Meet our Docs: From an American OR to a tent hospital in Iraq, Dr. Lee Warren recounts his time as a combat surgeon
By Kristy Bleizeffer Feb 9, 2016
W. Lee Warren, Jr., M.D., joined the U.S. Air Force, in part, to help pay for medical school. In the long years of peace that followed, he never dreamed that he may be called to war.
But he was called - six months before he was supposed to be discharged. Dr. Warren became only the second U.S. Air Force neurosurgeon deployed to a wartime hospital since the Vietnam War. He spent 125 days performing combat brain and spinal surgery in a tent hospital in Balad Air Base during Operation Iraqi Freedom. Balad troops nicknamed it Mortaritaville for its high frequency of rocket and mortar attacks.
“Most days, we were working 24 hours and we’d grab a few hours of sleep where we could. There were many days when we did 10 to 12 cases in a 24-hour period,” said Dr. Warren. “We were pretty much on call 24 hours a day, seven days a week. That’s why the Air Force only deployed us for four months at a time.”
Dr. Warren is a board-certified neurosurgeon at Wyoming Neurosurgery and Spine in Casper and a retired major of the U.S. Air Force. In this interview, he talks about how those four months as a combat surgeon made him the doctor he is today.
When you aren’t deployed to a combat zone, what does an Air Force neurosurgeon do?
Until I was deployed, I was at the Wilford Hall Medical Center in San Antonio, a big military hospital treating mostly retirees and civilians.
We had a peacetime mission until 2001. At first, they said that we were never going to deploy neurosurgeons. We all had this mindset that we were going to be rear echelon because the idea was that if you got hurt on the battlefield, you would not have time to get to a neurosurgeon. As the trauma system got better, they found out that they could get people from the battlefield to the tertiary care hospital and theater in less than one hour.
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Then, they said they needed all the medical specialists in the war zone. In late 2004, the Air Force decided to deploy neurosurgeons, and I was the second one to go.
Where did you grow up, and when did you become interested in medicine?
I grew up in a little town called Broken Bow, Oklahoma. There were no medical people in my family, I just felt that the Lord put the desire to be a doctor in my heart. My parents say that it’s all I’ve wanted to do since I was a little kid.
I went to college at Oklahoma Christian University and then medical school at the University of Oklahoma. I was fortunate to be chosen for the Air Force scholarship to pay for medical school. I was on reserve status in the miliary from 1991 until I finished my neurosurgery training in 2001. I was on active duty with the Air Force after that.
I went through U.S. Officer Training School in Maxwell Air Force Base in Alabama and then school for advanced medicine to be a flight surgeon. I decided I wanted to be a neurosurgeon during the course of medical school.
What made you go that direction?
I thought I was going to be a primary care doctor. I was actually the president of the Family Medicine Club in medical school, and I thought I would go back to my small town and do that. Then, my son came along in my third year of medical school, and I needed to change my schedule to be off when he was born. The only thing I could switch to was neurosurgery.
I walked in the first day and they let me drill a hole in somebody’s head. I thought, ‘Wow, this is cool.’ Within about two weeks, I knew I was going to be a neurosurgeon. There were lasers and computers and all kinds of unanswered scientific questions, along with just really delicate work. It was really impactful.
Had you considered joining the military before deciding you wanted to go to medical school?
I grew up playing soldier, and I loved airplanes. My parents were private pilots as a hobby. When I got close to deciding to go to medical school, I looked at options to finance it. I heard about the military scholarships and it just seemed like a great idea
The ironic part is that it was peacetime when I signed up and there was no thought in my mind that I would ever go to war. It just was not in my paradigm. When I was taking my oath in 1991, I remember being at the recruiting office with my hand in the air. Over the guy’s shoulder, the television was on and the U.S. was bombing Iraq in the first Gulf war.
Then, we had all those years of peace as I went to medical school and did my training. I got out of my residency in 2001 and then was sent to San Antonio in August. In September, it was 9-11 and, suddenly, we were at war.
How did that change things for you?
It became this big culture shift within the military medical board, especially in San Antonio where we took care of retirees with back pain and some civilian trauma and that sort of thing. Never was it in their thought processes that we might get deployed to a military hospital. In 2001 to the first part of 2004, the Air Force was just supporting the mission.
In early 2004, I got sent to Germany to Landstuhl Army Medical Center to help with casualties that were coming out of Iraq and Afghanistan. We would stabilize them enough to get them back to the United States. Then, in August of 2004, I was informed that I was going to Iraq as a deployed neurosurgeon to a tent hospital at Balad Air Base. At the time, they called it “Mortaritaville” because it was the most attacked base in the Iraq theater. We had an average of one to two mortar and rocket attacks a day on the base. In the four months that I was there, we had 120 mortar and rocket attacks.
Tell us about the hospital at Balad.
At that time, the hospital was made from eight tents lanced together. I went from providing tertiary neurosurgery in San Antonio to working in a tent hospital while being shot at in a combat environment within just a couple of days.
What types of injures were you treating in Iraq?
The vast majority of the people we saw were victims of mass casualty situations such as IEDs, truck bombs and that sort of things. We had a lot of penetrating brain injuries, closed head injuries, spinal injuries and those types of things. I did more than 200 craniotomies and brain surgeries while in the tent hospital. We had a fairly large number of combat and noncombat-related accidents like roll-over truck accidents. It was the kind of trauma you would see back in the states with broken necks and backs.
We also did a little civilian care. If an Iraqi family had a baby that had some problems, they would walk up to the gate and ask if we could take care of the child. From time-to-time we got permission to do that. I took a brain tumor out of a 13-year-old Iraqi girl who was having seizures. I did a spina bifida myelomeningocele repair on an Iraqi infant. The parents just literally walked this kid up to the gate with the spinal cord hanging out of its back and said, “Can you help our baby?” We got permission from the State Department to operate on the kid. At the time, it was the first myelomeningocele repair ever done in a deployed hospital in the world.
Explain the differences between working in an American operating room and a tent hospital in a combat zone.
The combat-related cases usually involved many injured people who would come in with bad brain injuries, with fragments in their heads, skull fractures, broken necks and small-arms wounds and burns. Many patients had multiple traumas. It was routine to have a neurosurgeon, an ENT, general surgeon and orthopedist operating on a patient at the same time. It was crazy.
We had four operating rooms, each with two beds so we could have eight people undergoing surgery at the same time. More than once, we were mortared during surgery, so we would be in the middle of an operation and the lights would go out. It took about 30 seconds for the generators to kick in, so we would all just hold still and wait until the lights came back on. We were operating with flack-jackets and carrying weapons in the operating room. It was a totally unique experience.
What was the hardest thing about practicing medicine in a war zone?
I guess the thing that was the hardest was learning how to deal with losses that we never had to deal with in the United States. The most common thing was somebody bleeding to death. In most American hospitals, patients hardly ever die from bleeding to death as we can just get more blood products. You can decide to let somebody go if they are not salvageable, but you are not going to lose them because they are bleeding out and you cannot stop it.
In Iraq, if we had 20 marines in the ER, and one guy was so badly injured that he was going to use up all the blood, we had to decide to let him go so we could save somebody else with that two units of blood that we had left. Sometimes, they would call over the speakers and say, “We need O positive blood,” and everybody of that type would run to donate their blood for use in the next five minutes.
You got used to being mortared, you got used to being shot at because you could not control that. You got used to terrorists blowing somebody up and having to deal with taking care of both the American and the guy that hurt them. You got used to all that, but it was really hard to get used to just not having enough blood, platelets, or something else to actually decide whether this person is going to die and you have stop the care. We almost never have to do that in the U.S.
Do you think the experience changed you as a doctor?
It absolutely did. First, I learned how blessed we are to have the gross excess of resources that we have available to us in the United States, and also how most of the time we do not need everything that we have. I learned to not be a prima donna in the operating room. It started making me mad when I would hear somebody in the U.S. say, “I cannot operate under these conditions. I cannot work without this $3,000 pair of scissors,” or whatever. I would say, “Really? I took out a brain tumor with a spoon in Iraq.”
We had to learn how to severely manage limited resources, and we did well. We had good outcomes and very low infection rates.
Second, I learned, I think, how great a blessing it is for somebody to be the patient in America. We have tremendous healthcare. Not only from the basic things like immunizations and dental care, but when you are hurt, there is somebody who can take really good care of you here. That is not true elsewhere.
Was it a difficult adjustment leaving that kind of environment?
I learned in Iraq that caregivers are subject to a lot of stress and strain. We came home, and it was ill-defined at that time, that the non-combatants sometimes had a higher incidence of PTSD and struggles with combat stress-related injuries than some of the combatants did. It has been well studied now, but when I was leaving nobody thought about us. If you were a combatant, on the average you would see one or no active combat engagements the whole time you were deployed. Most people never fired a weapon.
Healthcare workers were exposed to extreme stress with people dying in front of us, having to make decisions to let somebody die or not, and taking care of the enemy sometimes 24-hours a day.
We also had mortars hitting the base and were being shot at, and we had no ability to fight back. We learned over time that the providers in that environment really had a very high incidence of trouble. When I came home, all the stuff I deployed with literally stayed in trunks in my garage and I never talked about any of those experiences or opened those boxes. Then, about five years after I got home, I had a real bout with PTSD.
How did you work through those issues?
My wife, Lisa, and I were watching TV one night and “Generation Kill” came on HBO. It was a show about the Iraq War and they were following soldiers from the battlefield to the hospital where I had worked. The stories were kind of reenacting what I saw as patients came off the helicopter.
A couple days after that, I started having nightmares and just was really having a hard time for a couple of months. Lisa said, “I do not think you every really dealt with all this stuff that you went through.” I talked with a psychiatrist friend and he said that I needed to write a journal about it. He said I needed to unpack all those trunks in my garage and tell the stories.
In the process of unpacking, I discovered a file of about 5,000 photographs that I had taken in Iraq in the operating rooms. One of the soldiers in the photographs had been blown up by an IED and had the worst head injury that I had ever seen. Somehow the guy survived after four hours of surgery with a bunch of us operating on him. By the time we transported him back to Germany, he was still alive. Lisa said, “what happened to him?” I didn’t know. Once we sent somebody away, we really never did have any followup. She Googled him and there he was on the CBS News, alive and well in the U.S. and still alive. He had a job and was kind of a normal guy. We contacted him, and I actually got to meet him in 2010. I met his parents. That story kind of led me to write the book, “No Place to Hide.” It basically got me back to being kind of a normal person again.
That really connected with the military community and the PTSD community, and it has been a real blessing to get to know them. That really has led to me blogging and Podcasting and doing all the other on-line stuff I have been doing, connecting with the group of people out there who need to learn how to work through hard things that they have been through.
Tell me what it was like as a doctor to have to treat the enemy?
You know, it was hard at first because they did not tell us that we would have to care for al-Qaeda terrorists. What we found out was that our medics are extraordinary heroes in that when they landed on a battlefield, they would pick up anybody who was hurt, which of course sometimes was the enemy. They would bring them back with our soldiers, side-by-side on the same helicopter, and we would take care of all them.
The first week I was there, there was a guy who came in with a lot of injured marines. The soldiers told us that it was the actual guy who had off the bomb that injured all our guys. We were taking care of him alongside all the victims of his terror. When he was recovering in the ICU, you could see that everyone was caring for him medically, but nobody was being super-nice to him.
About a week or later, the soldiers came back in and said, “Oh. By the way, we misidentified that guy. He was not the bad guy, he was just standing there.” It was remarkable to see how everyone’s attitude changed around this patient. The nurses were a little nicer to him, and everybody was kind. We actually talked about it a lot. All of us kind of made the same decision that it was not our job to judge somebody based on the stories we heard about them. It was our job to take care of them as we would any other patient in front of us. It relieved us of the burden of having to decide if somebody deserved our care or not. It just put us in the position of just love everybody and take care of everybody. Even if they are a terrorist, and they have been raised to think that Americans are hateful, then they will see that that was not true. It made a huge difference in quality of life and peace of mind, and sense of duty and all those things. If you came in with a neurosurgery problem, I was going to take care of you.
NPR’s Snap Judgment podcast recently interviewed about having to choose to treat and American or an enemy soldier. Tell us a little about that case.
In Iraq, we had four sets of neurosurgery instruments available to us, and it took three hours to re-sterilize them in the autoclave that we had. There was one day when the weather was bad, and we had been told that we were not going to get resupplied that day. We knew that whatever we had in the hospital was going to have to last us a couple of days.
A bomb went off and a bunch of people showed up at the hospital at the same time. My partner and I ended up doing four craniotomies in a very short order. He took the third patient to the OR with the third set of instruments, and I got the fourth Marine. I was about to start operating when a bad guy came in with an equally bad injury.
So, I had one operating room available and one set of instruments. I had to make a decision that one of these two guys was going to die because he was going to have to wait for surgery for two hours. I decided that the other surgeon was going to be about 30 minutes, so I decided that we were going to take both of these guys back to the operating room and prep them for surgery. We were going to operate on the American, and as soon as we were done with those instruments, we were going to pour alcohol on them and operate on the bad guy.
It worked out that they both did alright. You never would have to make that decision in the United States. That was so different. You went to bed at night and felt like you did your best, and that is what we had to do for those two people. I did not feel bad about using them on the American first. That was our mission.
You retired from the Air Force as a major. Why did you decide you wanted to return to civilian life?
The Air Force offered to promote me to Lieutenant Colonel, but they wanted me to go back to Iraq instead of getting out in June 2005. But my kids were young, and it was just too much. I felt like I had done what I needed to do. I felt this was the right thing for my family.
So, you joined the Air Force to help pay for medical school, but it sounds like it had a profound effect on shaping you as a neurosurgeon and a doctor.
Without any question, it was the defining period of time in my professional and personal life. It is the thing of which I am the most proud professionally, and I think it defined me as a surgeon more than any other thing I went through as a human being. I served my country, and when I had moments when I felt like I did not do enough, I had to realize that the vast majority of people will never go at all.
At the end of the day, I know that when my country asked something of me, I did it and I did my best job that I could do. I feel good about that.
Dr. Warren is a board-certified neurosurgeon and a retired major of the U.S. Air Force. After serving the country for 14 years, including a deployment as a combat surgeon in Iraq, he retired as chairman of neurosurgery at Wilford Hall Medical Center in San Antonio. He is founder of the Air Force’s Comprehensive Epilepsy Management Center and the Center for Minimally Invasive Neurosurgery. He also served as Director of Cerebrovascular, Skull Base, and Neurotrauma Surgery. In his spare time, he writes and podcasts about the influence of neuroscience on mental wellness and personal development at his website www.wleewarrenmd.com.