Military surgeon Rob Lim must perform surgery in the middle of a sandstorm in Iraq.
Robert B. Lim, MD is a General Surgeon on active duty in the United States Army. He specializes in Advanced Laparoscopic Surgery, which includes robotics, single-incision laparoscopic, and bariatric surgery. He did his fellowship training at Beth Israel Deaconess Medical Center/Harvard Medical School. His academic career focuses on obesity care, surgical education, surgical simulation, and patient safety. He is on the Board of Governors at the Society of American Gastrointestinal and Endoscopic Surgery and holds the rank of Associate Professor at the Uniformed Services University of the Health Sciences. Dr. Lim founded the Society of Military Surgeons and produced the first ever tri-service military surgical symposium in 2014. He has been deployed to the combat zone 5 times including the initial invasion of Iraq in 2003. He has served on Forward Surgical Teams, in the Combat Hospitals, and on the GHOST-T surgical team (Golden Hour Offset of Surgical Trauma-Team) with the Special Forces. He helped revitalize the Excelsior Surgical Society, which is a tri-service military society that originated during World War II under the guidance of Winston Churchill.
Story Transcript
My story starts out around November in 2002—this is right after 9/11—there was more talk about Saddam Hussein not complying with the United Nations mandates, and things like that, and we're talking about invading Iraq, and there was weapons of mass destruction talk. I was assigned to a forward surgical team, and a forward surgical team is a twenty-person surgical unit, made up of nurses, and doctors, and techs. It's designed to be highly mobile, so when the troops went somewhere, we could follow right behind them, and if they got hurt, we could do surgery right away. Oftentimes within an hour. A relatively new concept in the military.
I get assigned to this team, thinking, "Well, people get assigned all the time, they never really go to combat.” Then around November, they said, "Hey, we need you to be in Miami in a couple of days.” In Miami is the Army’s trauma training center, and you go there and you do two things. One, you meet your team and you get to see who you might deploy with if you go. You get to have little a personal interaction, know their backgrounds, that sort of thing. It's good team bonding. But it's also to learn some surgical skills that you may have not done for a while.
As a general surgeon, we fancy ourselves as being able to take care of any part of the body, but we're not as fast if we're talking about head trauma, or chest trauma, or something like that, so it's a good refresher type of course. There was also a new concept called “damage control surgery,” which we needed to learn. Damage control, just in a nutshell, is basically you do whatever you can do to save the life. If someone has a badly damaged leg, for instance, you could try to spend hours sewing it back together, putting the vessels back together, but that takes a lot of time. If that patient is—if you're doing that type of operation in the desert somewhere, in a tent, the longer you spend in surgery, the higher the mortality is, so you wouldn't want to do that.
You would just basically cut that leg off, say, "It’s an amputation, but we did save your life.” The other part of that is you'll likely have other patients to take care of, so you can't waste all of your supplies on one patient trying to save the leg when you could cut the leg off, they'll be better, the next patient will be better. Damage control topics have been around for about a decade before that, but never really used in the military setting. So we were learning this stuff and revising it as we prepared to go off to war, at this point not knowing we were going to go anywhere. After that trauma training, which was in November of 2002, I went back to Fort Huachuca, started being a general surgeon again.
I felt pretty confident that things were going well, but then around January time frame, it really started to heat up. Saddam Hussein was not listening to anything that the United Nations had to say, and we had more troops going over there. I called my commander for the fast team, and I said, "Hey, have you heard anything?" "Nope, don't worry about it.” This was on Monday. On Wednesday, he calls back and says, "Hey, don't schedule any patients for February.” I said, "You know that's like in two weeks away?" He goes, "Yeah, yeah, don't.” "And so I'm I coming there?" He like, "No, no, no. Don't worry about it, but don't schedule any patients for February.” “All right, fine.”
At that time, I actually covered two hospitals, so I would round at one hospital and then drive back to my main hospital and do my work. So on Friday morning, I usually do some minor procedures, so I came in to the pre-op area and there's no patients. I looked at the nurse and said, "Where are my patients?" and they said, "Well, the chief medical officer cancelled all your cases for you.” I was like, "Er, Okay.”
The surgeons know that's not a good thing normally, so they imagined it's something bad. They said, "He wants you to go to his office.” So of course I'm thinking, "What did I do wrong?" On that two-flight walk up to his office, I’m thinking, "What could I possibly have done wrong? I've been here for like six months.” I get in his office and he's kind of glum. He's looking at me and he says, "Your forward surgical team wants you there tomorrow.” I said, "What?" He goes, "Yeah." It's Friday, and he goes, "They got a plane, they're going to send you a ticket, they want you be there by tomorrow, so you can start training.”
I said, "You're kidding, right?" He goes "No, no. I'm going to call them back and see if I can get you a couple more days, but you need to go home now. You need to start packing, you need to tell your wife that you're leaving likely within twenty-four hours.” I was in Fort Huachuca and my team was actually in Fort Hood. So what did I do? I did the only logical thing that anybody would do in this situation. I went to where my wife was—or, at that time, my fiancée—was working and I said, "Hey, we need to get married.” [Laughs] She said, "Well, I guess you're getting deployed.” I said "Yeah.” My wife is a very strong woman, so she had a good cry for about five minutes and then said, "Okay, why don't you go home and start packing. I'm going to make some arrangements.”
I went home, started getting all my gear together, started to get my will and things like that together and all the things you need to worry about. She comes home with a wedding dress, and says, "All right, call the chaplain. We got a time at six o'clock tonight.” I called a couple of people, and we got some witnesses. That night, we got married and then my friends in the hospital threw us a little wedding. They bought a wedding cake, and we had a nice little wedding in Sierra Vista, Arizona, Fort Huachuca.
I still hadn't gotten a call back for the DC CS (deputy commander for clinical services), [but then] he tells me I got a couple more days, so I can report there on Monday. We do everything the last couple of days, and then I report to Fort Hood and get ready to go to deploy. Two weeks later, we land in Kuwait and there's forces building up on the border. We don't know when we're going in, or if we're going in, or what's going to happen. There’s a big political fight. Saddam was not backing down, and we're not backing down, UN is not backing down.
We're hanging out in the desert, and they say, basically our mission at that time was to prepare, just practice. We had ten vehicles, ten trailers, twenty of us, and we each carried a certain thing. My vehicle was the oxygen tanks and the refrigerators that kept our medications. In the rest of the trailers were our tents, our operating room tables, our gowns, our saline—everything else you need to do to run an operation. What we would practice is setting up our tent. We'd be there, and the commander's like, "Hey go set up a tent,” and he would time it, someone would take charge. He's like, "Okay, this guy's dead. You go take charge.” By the time we were done, after a couple of weeks, we were pretty fast and all at setting up that tent. We could set the whole thing up—two ward beds, two anesthesia machines, a covered tent, generators, saline, electricity, all that kind of stuff—in less than an hour. And this is doctors and nurses, all right?
We like to think we're tough as surgeons, but we're not really manual-lifter tough, we are more of stay-up-all-night tough, so this was a big deal for us. I think about February eighteenth, we got the call that we are going to go to border of Iraq, and if Saddam hadn't backed down, we're going to go in. Shock and awe was going to happen.
So we all lined up on the border. We turn off all our lights, because you couldn't really have lights on, right? Because that just means that's what the enemy can shoot at. We're counting down. Is this really happening? We're counting down. We saw the planes go over, we heard the artillery fire, it's happening. I turned to one of my buddies, and I was like, "How do we do our laundry?" He looked at me and said, "Well, I don't really know, but we'll figure something out.”
The plan from our commander is we need to get up to Baghdad, which from the Kuwait border was about three hundred and fifty miles. We were estimating a five-day trip. Five days, even on the non-pay roads. We left February eighteenth, about that time, went into Iraq, and eighteen days later, we ended up in Baghdad. During that time, you have nothing. Unless there was surgery going on, which there wasn't quite for every day, there's no really no sort of purpose for us. We were just one of the many people in this convoy. You were really dependent on the person in front of you, because, again, you couldn't put lights on, you couldn't follow the big green signs that said, "Baghdad this way.”
You had these night vision goggles, and night lights on the vehicles. There're these two little red lights in the back of the vehicle in the dusts that you’re driving in the desert, and you basically follow those for hours and hours, going about five miles an hour, because you just couldn't really go very fast. No one was going to say, "Hey, bathroom break" to go to the bathroom. If you got hungry, you couldn't stop at a 7-Eleven to go get a soda. I brought about five T-shirts and five uniforms, and I realized you can't change every day because you'll never have enough stuff. When it got down to one uniform, we'd all take turns doing laundry with the laundry bucket and shampoo, because nobody brought laundry detergent, or if they did, it went out pretty quickly. And we didn't shower over eighteen days.
Finally, though, we got into Baghdad, at the airport; we're on the tarmac. If you remember Baghdad Bob... I'm bringing back lots of bad memories, I know, but so there's a good picture of me brushing my teeth on tarmac at the airport, and we're listening to the short-wave radio that one of our guys brought. Baghdad Bob was saying that the US troops are dying—"They’re dying at the gates of the airport; they are not getting in.”
I looked around as I was brushing my teeth and I said, "If I'm on the tarmac of the airport, I'm pretty sure we had taken the airport" because if the doctors are there, that means everyone else is already gone through there. Then we set up our tent and we were ready to go. We were ready for things to happen. Along the way, though, before we got into the airport, we had this one particular night. We had drove about thirty straight hours between that one night and the next day, and so we were all pretty exhausted. I fell asleep in the front of my vehicle. During that time, as we were driving, we had our body armor on, and we had our chemical protective gear on, because they were still a threat of chemical weapons during that time. If you've ever worn those, they're horrible. They are these carbon-base things that are really thick. By the time you put all of your gear on with your pro-mask, and your weapon, you really can't move, and it's super-hot, right? It's the desert.
During the day it's about a hundred and ten. You're sweating and it's enough to get your water bottle up to your mouth so you can drink, and after that you're just like, "If there’s a patient here, let me know. Otherwise I'm just going to be here in the shade trying to stay comfortable." I fell asleep in the front seat of my Humvee, and I woke up and it was dark orange out. I looked around and I had a little microphone, and I was like, "Anybody else on our team out there?" I actually thought that we had gotten chemically attacked because of the orange. After a couple of minutes, someone finally called me back and said, "No, we're expecting a very bad sandstorm.” If you've been in a sandstorm—I know some guys who are from my team here have been deployed—it turns pretty calm and bright orange, before the sandstorm hits. Then it turns super windy, you can't hear anything, and it's just pitch-black.
They say, "No, stay in your vehicle, don't try to get outside, because any minute now ..."What they meant was likely in the next twenty, thirty minutes, there was going to be a horrible sandstorm. So just hunker down, stay there, don't try to go out. But then, a minute later, we get this in that we have three casualties. I do the right thing. We run out and there's three causalities. One of them has a gunshot wound to his abdomen and his intestines are in disarray—they're hanging out. He's got to go to the operating room. He's a little hypotensive and you know, he's not doing too well. Pretty easy decision to make—we have to go to the operating room.
The commander says, “Okay, let's set that thing up,” but now it's getting really windy. It's getting really windy, and visibility is kind of low. We broke a record. We set it up in about twenty minutes. Everyone was just flying around, we had it done. By the time we had our tent set up though—because we had to have light on the tent; it had to be protected from that—by the time we had a tent set up, it was pitch-black outside. You couldn't hear or see a thing; it was howling. One of our guys actually started sort of screaming through his mic and said, "Hey, hey, where are you guys? I can't find you, I can't find you!” After about five minutes, someone said, "Look, you just got to stay there. Don't bother moving because you can't see us, we can't see you, we can't go out to find you. Just wait till the storm is over.” Some of us thought, "This is not good, he might not make it.” I know that's what I was thinking, but I'm happy to tell you he made it because he's sitting right over there, that's our XO.
We got gowned up, and we had to keep our chemical gear on, and had to keep our body armor on, just in case. The anesthesiologist put the patient to sleep and we were ready to go. We heard some long-distance fire coming, or sound. If you're close to it, it shakes the ground pretty good. Our tent is shaking, we're kind of shaking, and we kind of look around and go, "Well, do we keep operating?" I guess we do because the patient is dying, and it was probably our guys firing outward, but still, it was pretty impressive.
Then we heard small arms fire, which usually means people are within a hundred yards of you. I was thinking, "Well, who are they shooting at?" Because it's pitch-black outside. Just don't shoot towards the tent and I'll be okay. I was the lead surgeon in this particular case. I got scalpel and as I was about to cut the patient in, I actually felt pretty good. It was hot, it was windy, I couldn't hear and I had to yell, but now I was going to do something that I was good at. I knew what was going on, that I didn't have to worry about following the red lights. I didn't have to worry about, do I wear this gear or whatever? I had to do the operation.
We opened the patient up, everything was going well, and I'm a big believer in God, but I think he has a funny sense of humor. The first patient we operated on was malrotated, so for the people [who aren’t] surgeons in the room, that happens about one in every five hundred people, where the intestines are not where they are supposed to be. This person's colon was all on the left--hand side, and this person's small bowel was all on the right-hand side. Normally, the small bowel is in the middle, the colon goes around it. We just laughed. We opened up and go, "This is unbelievable, right? The first case in Iraq, sandstorm, indirect fire, nearby direct fire, and the guy is malrotated.” But, again, medical training took over, we felt pretty good, did the case, the guy did well, we got out of there. During that time, my first time, we did about thirty cases. We recorded all data and all that kind of stuff, just more for [posterity], I think at the time, but we thought we were pretty good, that we were great guys. I remember thinking back to when I was at ATTC (Army Trauma Training Center), there's a lot of very powerful surgeons who are at those training centers. Very accomplished, well-published academic people who I looked up to and thought, “If they published it, it must be a great study, it must be vetted, and these are the giants telling us what to do.” The people who invented or put the damage control part into the military thing, then these are the senior-level surgeons of the military. They must have great experience. They're responsible; this is what it is. I remember thinking about these cases, "This is all wrong. A lot of stuff doesn't make sense. We got the wrong equipment in some cases, we sort of deployed in the wrong areas.” The surgery part is okay; it was more of the system that was wrong. The deployment ended and I came back, and they actually invited us to go back to Miami to talk about things. And in Arizona there's a local medical school up at Tucson, and they invited me to come talk about the experience.
Talking to some pretty accomplished trauma surgeons in both places, they couldn't hear enough about it. They wanted to know more about it. They were pulling me inside, "What did you guys do for this?" "What did you guys do for this?" "How did this go?" Along the lines, I realized that what's published out there and what people there, what may be their best honest effort, and it may be good, but it's often dependent on the kind of data that you have. Here I was, one year out of my residency training, and I have a little bit more experience with some of this combat stuff than some of the more published trauma guys did. That's not to discredit them; it's just that we hadn't been in the war like this for a while, so this was hot news. The use of the forward surgical team and the damage control was a big deal.
They were looking for my opinion and I thought, "Well, this ought to be better, this ought to be better>” Those of us who've been deployed know that, we get these big after-action reports, any time we go on a mission, to try and see where improvements can come from. What I realized is that there's people who are big writers and researchers, but you still need the data to come from somewhere. It's great when people can put both of those things together; those are some of the best researchers that we have.
I find myself in this position where I could actually start to do that. So even though my board scores were terrible, and if you had met any of my professors at the time I was a resident, none of them would think that I would be somebody who might publish someday, and be more in tune to doing academic-type stuff, but here I am.
It's always a big kick for me to come back to the American College of Surgeons, because I see my professors and my mentors and things like that, and say, "I know they didn't see this in my future, but here I am, and it’s sort of where opportunity met what’s out there. I realized that even at this younger level or less experienced level, you can still see things that make things better, it can make change. That started me on a path of saying, "I need to keep my eyes open. I need to find where we can make things better. I need to look and see ..." We believe this because some super smart guy twenty years ago said this is true, but it may not have a trial behind it, or something like that. That brought me to where I think I am today.
I like doing surgery; I still love it. I like taking care of patients and feeling like I'm making a connection with them and making them better, but I really like looking at the data and trying to make changes, and trying to improve it for the next guys, so that the next person who does it, even the next army officer who has to go in the combat zone, feels a little bit better about going in there. That's my story, thank you for your time.