In any armed conflict, military surgeons work close to the front lines, treating injured soldiers and civilians. But most military doctors are trained during peacetime and have seen few seen combat wounds, like those they are now treating in Iraq.
Few doctors or medical corpsmen have seen penetrating wounds caused by large caliber, high speed bullets. Recent armed conflicts involving the United States have, thankfully, been short, and just as frontline surgeons become experienced, the fighting has been over.
The Pentagon came to realize that during the Gulf War, and has since formed partnerships with three inner city hospitals - in Baltimore, Miami, and Los Angeles. The Navy chose the medical center operated jointly by the University of Southern California and Los Angeles County, because of its reputation and its volume of patients. It is the busiest trauma center in the country. Dr. Demetrios Demetriades is trauma chief.
He said patients come by ambulance, car or helicopter, with the kind of injuries usually seen in battle. Like war wounds, many are caused by the military-style assault rifles favored by Los Angeles gangs.
"We see a lot of gunshot injuries, including those from high velocity automatic weapons. So we do see situations very close to the military situation, patients coming with seven, ten bullets all over the body. We see, of course, a lot of knife injuries, but of course, a lot of car accidents, a lot of industrial accidents, a lot of suicides, you name it," Dr. Demetriades said.
Commander Peter Rhee heads the Navy program here. Since September, more than 100 surgeons, nurses and medics have been through the one-month courses. He said newcomers often find the atmosphere disturbing, especially the need to make stark choices in the operating room.
"One of the nights that we were on call here, we had a mass casualty type of situation, five people shot coming in at one particular time, and so it's very similar to a battlefield zone environment. And one of the patients, we had to let go because we had to pick and choose who we were going to focus all of our attention on," Commander Rhee said.
USC trauma chief Demetriades said surgeons learn to make those life and death decisions instantly. "This is a field of medicine where every minute, I would say even every second, counts. You make the wrong decision, you might lose a patient. You make the right decision at the right time, and very often that time to make a decision is only a few seconds, then you can see miracles," he said.
The trauma specialist said one difficult part of the training for trauma surgeons and nurses is learning to learn to deal with their emotions.
"Very often, the inexperienced person, especially when he or she deals with somebody dying in front of his or her eyes, somebody bleeding, or you have multiple casualties, often the health-care giver gets paralyzed, stops thinking. We want to accustom them to this environment," he said.
Trauma workers are trained as a team, consisting of a trauma surgeon, an orthopedic surgeon, an anesthesiologist, nurses with various specialties, and paramedics. Commander Rhee says they are taught to work with colleagues as a unit.
"Here, they will get to operate with them, they will get to work together, and they get those subtle nonverbal communication skills down, the nod of the head, a movement of the hand, that tells them what they need," Commander Rhee said.
Most who have finished the Navy program are now in the Persian Gulf, in either fleet surgery teams or forward resuscitative units on the front lines. "They're in very portable tents, which can be set up, meaning a fully operational operating room is set up within an hour, and can be moved within an hour as well," he explained.
Most Americans are monitoring the conflict in Iraq by television, and some of the images are distressing. But trauma chief Demetriades says others are inspiring. He has seen graduates of the Los Angeles Navy program interviewed from the front lines.
"And we are very proud to see them taking care not only of the American soldiers but also civilian injured people. We are extremely proud of that, and even enemy soldiers," Dr. Demetriades said.
Navy Commander Rhee said this trauma program helps the military, and also the hospital, by providing extra doctors and nurses, paid for by the navy, who are helping out in an urban combat zone.