From battlefield to bedside—and back again

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Members of Dr. Cole's FRSS on sand dunes in Morocco

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Dr. Cole in the OR.

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Dr. Cole in the trauma bay at Advocate Good Samaritan Hospital.

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Lt. Cdr. Johnny Sacco, CRNA (left) and Dr. Cole in southern Morocco, April 2012

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Dr. Cole’s FRSS team supporting Exercise African Lion in the Sahara desert, Morocco. The team treated four severely injured Marines.

On April 4, James Cole, DO, FACS, boarded a commercial plane in Chicago, IL, for the 36-hour journey to the Far Western Desert, Morocco, an expanse of the Sahara in the southeastern part of the country. As a U.S. Navy Commander and the senior member of a mobile forward resuscitative surgical suite (FRSS) attached to 4th Medical Battalion, 4th Marine Logistics Group, Dr. Cole and his 15-person surgical team were called upon to provide support to a bilateral live-fire training exercise between the U.S. Marine Corps and the Royal Armed Forces of Morocco.

Over the last two decades, the 47-year-old father of four has been deployed to 10 countries as a military physician, often living in conditions that are spartan and, at times, hostile. Dr. Cole, who was recently promoted to the rank of Navy Captain, says his abiding interests in trauma care stretch far beyond the hospital walls he inhabits as a civilian surgeon. “I love trauma surgery, and I like the military, so that is sort of the perfect mix for me, being a trauma surgeon in a very austere environment,” he said. “It’s like pushing the trauma operative experience to a new level.”

The trouble with trauma

In his memoir, Trauma: My Life as an Emergency Surgeon (published in 2011), Dr. Cole tells the story about a particular U.S. civilian trauma so horrific that the patient did not survive.* In one passage, the author describes how he and his trauma team desperately tried to save the life of a young woman who had been gunned down by her estranged husband with a semi-automatic machine gun.

He writes, “Unfortunately, adversity is the very nature of trauma. Members of a trauma team get what’s handed to them. In our situation, it was a young woman who tried her best to avoid trouble, but trouble sought her out. And now she was dead.”

This, he said, was the first time he was faced with a patient who had so many injuries that he didn’t know where to get started. “I had plenty of experience dealing with people shot by someone, but that was the first time I was trying to treat someone shot 30 times by an automatic weapon,” he said.

In his book, Dr. Cole talks about this and so many other memories that he couldn’t shake off. He recalls his residency at William Beaumont Army Medical Center, El Paso, TX, averaging 120-hour work weeks honing his surgical skills to perfection, and one rotation so grueling he felt for certain the relentless stress of being put on endless call would lead to his own demise.

Looking back, he feels fortunate for his training in the military, especially under the direction of Col. Stephen Hetz, MD, FACS. “He was just a great leader, an awesome surgeon, and a great human being,” he said. “He was also a field surgeon, so he specifically prepared us for war, and I’m grateful for that.”

Even with that preparation, however, there were difficult, trying moments over the years. Seeing children die, operating for lengthy sessions, and breaking the news of lost loved ones to devastated family members were some of the pressures that had often left Dr. Cole physically and emotionally drained.

In the 15 years since he became a surgeon, some of the memories that have haunted the surgeon the most were the trauma injuries afflicted on children—the attempted murders of innocents. One such memory that didn’t fade with time was that of a little boy who was delivered to his trauma table with a screwdriver lodged into his chest, dying before his eyes.

Spurred on by family and friends to share his stories, he began writing about these and other events. “I wrote about experiences that had weighed on me over the years, especially from when I was in training and when I was in Iraq and Afghanistan,” he said. “I wrote about things that I had thought about over and over and over for a long time. I was sad for some of these patients who were so traumatized.”

For Dr. Cole, completing the book proved to be cathartic. After transcribing the details of every disturbing memory that continued to live on in his mind, he was finally able to release these powerful emotions and find peace. “It was as if my mind would not allow me to let go of the memories, but writing this stuff down cleansed a lot of my thoughts,” he said. “It was strangely therapeutic.”

Another benefit was that he gained new insight into his ever-evolving role as a physician. “Many trauma patients are substance abusers, mentally ill, or criminals. Many of my patients’ family members don’t even want them to return home. At times, I feel like a social worker,” he said. “But I realized that I had been given a great gift over the years, and this has allowed me to spend extra time without losing my patience to offer solutions, support, and alternatives to my patients’ difficult social lifestyle problems.”

Labor of love

Another reason the self-described “working stiff” put pen to paper was to provide a real-world view of the day-to-day life of surgeons and other health care professionals. “Not only did I want to just tell the story, but I also really wanted to set the record straight, or at least let people know what we have to go through to get our board certification in surgery and the responsibilities of the job we have chosen,” he said. “I think, unfortunately, a lot of people have the wrong impression of what being a doctor is all about based on TV shows that make it look a lot more fun and relaxing than it is.”

In truth, learning every aspect of Dr. Cole’s surgical trade during residency often meant subsisting on a diet of sugar-laden snacks and caffeine-rich beverages, living in a sleep-deprived, semi-comatose state and being separated from his loved ones for long periods. “What we need more of in health care—and I’m talking doctors, nurses, technicians, providers of every variety—are people who really want to care for patients and have the intestinal fortitude and commitment to drive on,” he said. “We need people who are willing to put their hands in blood and are willing to handle the stress of people dying. I want the right people to get into health care, and hopefully this book might inspire a few people to do that.”

In the trenches together

On the military front, Dr. Cole was active as a U.S. Navy officer from 1991 to 2000. Then, in July of 2004, he got his orders to ship out to southern Afghanistan, his first deployment since rejoining the U.S. Navy Reserve following the terrorist attack on the World Trade Center on September 11, 2001. For Dr. Cole, a sense of duty brought him back into the military fold after a nearly three-year hiatus. “I felt a sense of obligation and even guilt for not being in the service when our country was at war, knowing that I had friends who were already deployed, and young soldiers and Marines and sailors that were in this combat zone getting injured. I thought, ‘this is my duty, I’m a surgeon, I’m supposed to be there taking care of these people,’” he said.

At the Bagram Air Base in Afghanistan, he was assigned to the U.S. Special Operations Command medical team. An expert rifleman, paratrooper, and Navy diver, he had been attached to this elite group several years prior to this assignment. For the next five months, Dr. Cole wore two hats: first, as the task force surgeon, supervising all health care matters related to the Special Operations Task Force, and second, as a member of a forward surgical team providing support to Special Operations commandos.

At the base, commandos were deployed every night to capture or kill Taliban and Al Qaeda fighters. Flying numerous missions, Dr. Cole was required to accompany the commandos armed as any other combat soldier, wearing body armor and weapons weighing 60 pounds. With just a few hours notice, the medical team would pack their gear, board a heavily armed helicopter, and lift off into the black of night. Departing from the safety of camp, they would then touch down a distance from a battle scene and wait to receive gravely injured soldiers. During one mission, Dr. Cole sensed a danger so palpable that he readied himself for ambush by encroaching adversaries.

“My typical day was a typical night. We always did all of our briefings, missions, and travels at night,” he said. “Every two to three days we would go out to the hinterland and support some sort of combat mission, and come back and decompress, then sleep during the day, and start the cycle all over again.”

At various makeshift surgical sites throughout the southern region of the country, Dr. Cole operated on injured U.S. servicemen and United Nations personnel, as well as captured prisoners, performing chest surgery, abdominal surgery, and extremity surgery. “Land mines were an especially precarious enemy of the soldiers I treated, and were the primary reason why I performed so many completion amputations,” he said. He performed approximately 10 amputations in the combat zone.

Despite the challenges of living in this desiccated wilderness, Dr. Cole says he took great satisfaction from knowing that he and his colleagues were able to have a hand in saving the lives of soldiers on the battlefield. “It’s really heartbreaking when I see these young kids,” he said. “I feel good that we are able to do something for them, but a lot of the time I never know their definitive outcome because they get sent to another echelon of care, and eventually back to the United States.”

Desert hot spots

Dr. Cole didn’t know what to expect when he got another set of military orders to deploy with the U.S. Marines of the Second Marine Expeditionary Force to Al Anbar Province, Iraq, in support of the military surge—the worst of the fighting in Iraq. But in April of 2007, the civilian surgeon dropped what he was doing, and readied himself for the next mission.

At the outset, he was assigned to the surgical hospital aboard Camp Taqaddum, which was one of several surgical facilities established close to the combat zones. Many of the military personnel suffered injuries from improvised explosive devices; therefore, the surgical team often operated on multiple body parts simultaneously.

“In civilian trauma we do have some very devastating blunt traumas, but typically the penetrating traumas are pretty straightforward to deal with: one or a couple of holes from a fairly low-energy weapon, whereas in the military environment you have these blast injuries where a casualty is peppered with 30, 40, or 50 rounds from an explosive device of a massive charge that just blows them up,” he said. “It’s pretty overwhelming to deal with sometimes—one person blown almost apart with numerous holes.”

Dr. Cole was also put in charge of a mobile FRSS. His handpicked medical team used equipment they brought with them to follow Marines as they moved through the Iraqi desert. The suite—including two 15×18-foot tents, a portable oxygen generator, portable ventilators, cardiac monitors, two electrical generators, and other medical equipment—could be set up or broken down within one hour.

“When you are in the field, you literally have to do everything yourself, from setting up the tents to opening all of the containers. There’s a lot of minutia that needs to be directed,” he said. “If all your equipment is not set and the generator is not working right, you can’t do your job.”

The mobile surgical unit lived out of tiny individual tents, sleeping on the ground, with their rifles and other weapons always close by. As time wore on, and mostly no way to bathe, they stayed coated with dirt and sand. The highest temperatures of 120 degrees did not offset the freezing temperatures they shivered through at night.

Altogether, Dr. Cole spent nearly one year in Iraq. “It’s tough to be away from home, away from my family for long periods of time,” the husband of 25 years said. “The military Medical Corps is getting smaller, and people are voluntarily separating because they are getting tired of the repeated deployments; so there are fewer of us left and, as a result, we are getting sent on these overseas support operations more often.”

By the time his assignment was up, Dr. Cole was glad to return home to suburban Chicago, IL. “The transition home was strange. I had this heightened sense of awareness for a while, hyper-perceptive to various sounds, wondering what that noise is outside,” he said. “It took me a while to get used to the flowers and the trees, and so forth. It was like going to Disney World.”

When it comes to making a smooth transition, Dr. Cole offers this advice to other servicemen returning home: avoid big welcome home receptions for awhile and take a few weeks off from your regular job. Give yourself time to adjust to the sights and sounds of your surroundings. And, to families and friends: try to avoid overwhelming your loved one with lots of questions about the war zone. “I know that I regressed socially for a while, but time and gradual reintroduction to everything brought me around,” he said. Dr. Cole credits these feats and more to his wife, “an amazing woman who supported me through it all.”

Surgeon without borders

Stateside, Dr. Cole is the assistant director of trauma services at Advocate Good Samaritan Hospital in Downers Grove, IL, where he treats victims of accidents, shootings, stabbings, and other trauma. Throughout his career, he has operated on a few thousand patients, as both a civilian and military surgeon.

Not surprisingly, he believes that his deep experience with combat medicine and other sufferings over the years taught him to think differently. “I think a lot of times we can just be frustrated by our trauma patient population. But being in Iraq and being one of them, a homeless person essentially, made me feel more compassion for them. When you go without for a long period of time—I’m talking food, shelter, warmth, and protection—it brings you down to a lower level,” he said. “I’ve learned that all people pretty much want to live another day. And they want to be treated compassionately.”

The response is golden

Years have passed since his first major trauma casualty. On that day, a four-year-old boy, who was critically wounded by a shot in the head, arrived at the hospital just after midnight. “I was a very junior surgeon, and of course I thought there was no way that anybody could survive this. And as a matter of fact, I was told that this is a non-survivable injury, a trans-cranial gunshot wound,” he said. But the child did survive, and a year later the bashful boy walked into the intensive care unit alongside his mother to thank the trauma team, and throw a foam baseball Dr. Cole’s way.

Trauma teams see sad endings. And miracles. “I take care of devastatingly injured patients, but it’s a lot more than a surgeon and a surgeon’s team that does save these patients’ lives and cures them,” he said. “I have seen patients get better when I thought it was not possible from the perspective of medicine and science.”

A man of faith, Dr. Cole has maintained a steady dialogue with God. “I tell my patients’ families in a very, very horrible situation that I think the likely outcome is going to be ‘X,’ but I never say always, and I never say never, because every once in a while the unexplainable happens,” he said. “So, I say, don’t ever lose hope, and don’t ever lose faith.”

*Cole J. Trauma: My Life as an Emergency Surgeon. New York City, NY: St. Martin’s Press; 2011.

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