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OEF Veteran Talks About Experiences

May 11, 2004 -- WASHINGTON - In pre-deployment briefings, Afghanistan is often compared to Texas. But geographic size is about the only characteristic that the country and the Lone-Star state share, an Operation Enduring Freedom veteran told staff at the Deployment Health Support Directorate in a post-deployment briefing.

U.S. Army Maj. (Dr.) Mary V. Krueger, former deputy surgeon Civil Affairs - Afghanistan, described a nation with numerous health challenges. The mountainous, land-locked country lacks modern infrastructure. There are few roads and then, only 13 percent are paved. Telephone capabilities are extremely limited - about one telephone for every 1,000 people. If available at all, electricity is primarily provided by generators. Health care is extremely limited and life expectancy is estimated at 40 years.

Elements of the 48th Combat Support Hospital deployed to this austere environment in November 2002 and returned home June 7, 2003. In that six-month period, the staff treated approximately 9,200 patients at sick call and responded to Coalition mass casualties about once a month. From the outset of the operation, the medical staff began recording lessons learned to improve future deployments.

"One of the biggest lessons I learned with serving in Afghanistan was the importance of pre-deployment screening, not just with military personnel, but also with contractors," Krueger said. "We do not want to put people in an environment where we will be unable to care for them."

The more common non-trauma diagnoses in soldiers deployed to Afghanistan were diarrheal illness, respiratory illness, fevers, heat injury, kidney stones and dental problems. Many could have been prevented with proper education and better pre-deployment screening, she said.

Diarrheal illnesses among deployed troops were the number one problem seen. Soldiers were advised to drink bottled water and to avoid eating food on the economy, but Krueger learned that is easier said then done. In Afghanistan, communication first begins with drinking tea. While working within the local communities and discussing business with the village leaders - the Shuras and Mullahs - she learned that in order to gain respect and get information, sharing Chai was essential.

"I learned to watch the water and make sure the tea was steaming hot before I would drink," said Krueger.

Afghanistan's climate is arid and semi-arid and for the past 10 years has suffered a severe drought. Add to that the spring-time "120 days of wind," and you have a very dusty environment, Krueger said. These conditions led to many respiratory health problems.

"I estimate that about half of the respiratory cases we saw in one day were due to irritants such as the sand," said Krueger.

Some preventive measures involved issued equipment, while others were homegrown.

"As long as you wrapped a scarf around your face and wore your goggles, you were good to go," she said.

Krueger said that this was one more instance where pre-deployment screening is very important. Prior to deployment to areas like Afghanistan, the severity of allergies and asthma need to be determined. Moreover, while environmental conditions can cause an increased risk for soldiers with previously diagnosed respiratory problems, proper medication can provide some relief.

The dry, dusty environment also contributed to numerous preventable eye injuries. Soldiers were advised to not wear contact lenses while in theater, but the rule was not widely enforced, she said. Many soldiers continued to wear contact lens in theater despite the conditions.

"Imagine trying to put a contact lens in with wind and dust blowing all around you, and you probably have not washed your hands real recently either," said Krueger.

Health consequences resulting from the dry dusty conditions were expected, but the unexpected occurred as well. In particular, Krueger said kidney stones turned out to be an unexpected problem. The combination of dehydration, high altitude, a high protein diet typical of the MREs proved to be a significant burden for medical evacuations. She estimated that during her time in the emergency department, one person a week had to be evacuated out of theater.

This is another area where pre-deployment screening and education can make a difference, she said. In particular, pre-deployment health assessments should screen for previous kidney stones to help educate those service members about precautions they should take.

Poor dental health was another area of concern. Soldiers were sometimes kept from going into the field because they needed treatment of routine cavities, which should have been identified and treated before deployment. Krueger said that many of the dentists who worked with her unit were frustrated that so many of the problems they saw should have been addressed prior to arriving in theater. Dental problems proved to be a significant challenge for Reservists and Coalition forces that had not had previous dental work in a long time. The deployed dentists were kept busy providing routine dental care.

Common traumatic diagnoses seen at the 48th Combat Support Hospital included injuries from landmines, sprains and strains, limb crushes and venomous bites. She and her team used an active education effort to inform deployed soldiers about potential environmental problems and the need for work-safety standards to minimize the number of traumatic events.

Afghanistan is the most heavily mined country in the world and landmine injuries were the prime cause of traumatic amputation. Soldiers involved in a landmine or improvised explosive device attack were also at risk for a ruptured eardrum or loss of sight. The briefings helped educate the soldier as to what to be on the look out for and to take the necessary steps to avoid stepping on a landmine.

Sprains and strains in the lower extremities accounted for approximately 50 percent of the musculoskeletal injuries seen by 48th CSH personnel, Krueger said. In Bagram, the paths are lined with rocks to help prevent flooding, which made it very challenging for walking. Treatment for sprains or strains often consists of crutches and aircasts, but due to the danger of navigating rocky paths with crutches, aircasts were often used alone. These orthopedic devices use pre-inflated air cells and which wrap around the injured area providing support and stability. Ensuring the hospital had the right size wasn't always possible. When the supply of air casts was depleted, Krueger said the CSH providers became very creative with the resources that were available to them.

Emphasis on the use of safe practices was a constant effort. The majority of crush injuries occurred with heavy equipment operators, Krueger said. Some solutions were relatively simple, such as ensuring that soldiers worked together when moving heavy equipment. Others involved changing bad habits. For example, some soldiers would put their foot outside of their HMMWV to stop it from hitting another vehicle, not fully realizing the potential catastrophic consequences of such an action.

"We tried to reiterate to soldiers the importance of team work and the normal safety procedures to prevent these injuries from happening," she said.

And there were other hazards. Rodents were a problem at camp, not so much for disease but for the predators they attracted - snakes. Afghanistan has 270 varieties of snakes and 52 are poisonous, including the aggressive Saw-Scaled Viper. A bite from this snake could prove fatal. Soldiers received strong and consistent guidance regarding the storage of food in their tent that could attract rodents and, subsequently snakes.

Bites from spiders and scorpions added yet one more concern. These bites tend to produce a painful bee like sting, but are not fatal in a non-allergic patient. The risk comes from getting a subsequent infection. Again, Krueger stressed the importance her team placed on educating the soldiers about checking their boots before putting them on in the morning and their bedding before going to sleep to make sure that there were no spiders hiding in them.

While assigned in Afghanistan, Krueger said some of the most rewarding work for her was working with the local physicians.

"Some of the diseases we saw in the local populace have pretty much been eliminated from the United States, but not in Afghanistan. Local physicians were able to determine right away by looking at a patient if they had typhoid or malaria. American physicians rely heavily on laboratory and radiological tests. It was very educational to see these physicians make diagnoses with only the physical exam and patient history as guides," said Krueger. "I developed great respect for my Afghan colleagues."

What was her greatest learning experience? Krueger said the actions that take place prior to deployment are crucial to a successful deployment. The medical and environmental briefings ensure soldiers are aware of and prepared for the risks in the theater. The prevention efforts in country then build on that knowledge. And finally, she says there is no substitute for ensuring that those who deploy are physically ready for the challenges of deployment.

"You really do not realize the importance of pre-deployment screening until you are there."