What the Casualties in Iraq Taught Me About War

A U.S. Marine with Combat Logistics Battalion 24 (CLB), 24th Marine Expeditionary Unit (MEU), carries a simulated casualty out of a CH-53 Super Stallion at a mass casualty exercise during Realistic Urban Training (RUT) at Camp Lejeune, N.C., on Oct. 8, 2020. Cpl. Isaiah Campbell/U.S. Marine Corps photo

Commentary

I deployed to Tallil Air Base, Iraq, in September 2004 as a U.S. Air Force (USAF) Operating Room (OR) nurse with the 407th Expeditionary Medical Group. At the time, there was still hope that Operation Iraqi Freedom might live up to its namesake. The United States was ostensibly still looking for weapons of mass destruction (the U.S. Iraq Survey Group issued its Final Report on Sept. 30, 2004), the Second Battle for Fallujah in November hadn’t yet taken place, and preparations were being made for the coming Iraqi elections in January 2005.

Tallil is about 12 miles from the city of An Nasiriyah in southeastern Iraq, the country’s fourth largest city. While there had been significant fighting in the area during the initial 2003 invasion, by September 2004 most of the violence was concentrated in the north: Baghdad, Tikrit, Mosul, et al. From an OR/surgical perspective, we were a small footprint consisting of a general surgeon, orthopedic surgeon, anesthesiologist, nurse anesthetist, two OR nurses, and two surgical technicians. Our job was to stabilize surgical patients who would either return to duty or be transported via aerovac to the central level III echelon facility in Iraq: 332nd Expeditionary Medical Group/Air Force Theater Hospital at Balad Air Base. Balad, 40 miles north of Baghdad, had a robust medical footprint. From there, patients either returned to duty or were aerovac'd to Landstuhl Medical Center in Germany.

First, a few caveats. Tallil, even in 2004, was not considered a “hot spot.” Our small medical footprint was appropriate given where we were in Iraq at the time. Also, I never left the base. Although I was part of an MFST (Mobile Forward Surgical Team), the medevac and aerovac infrastructure was in place to bring patients most efficiently to fixed locations throughout Iraq. The only time leaving Tallil was even a possibility was when the powers that be considered sending some of us to reinforce Balad in preparation for the Second Battle of Fallujah (Operation Phantom Fury). High numbers of casualties were expected and there was concern it might overwhelm the existing medical assets in Balad. While the battle proved to be the bloodiest battle involving U.S. troops since the Vietnam War, the casualties weren’t as high as feared, and no 407th EMEDS (expeditionary medical support) surgical assets were sent to Balad.

Also, our deployment was only four months. In fact, the AF had just increased combat deployments from 3 months to 4 months beginning our deployment cycle. This was during a time when Marines deployed for 7 months and regular Army units deployed for a year at a time. I even met some Army National Guardsmen while at Tallil whose deployments were extended to 18 months. I carried a great deal of guilt about this (a separate article in itself).

While there was always a risk of a suicide bomber, like the one who blew up the DFAC (dining facility) in Mosul that December, traveling in Iraq posed the most danger. We were all keenly aware that the year before, a suicide bomber had killed 18 Italian soldiers in An Nasiriyah, injuring 20 more along with 80 Iraqi civilians. I was thankful that my job kept me “inside the wire” and appreciated those who protected us. Simply put, their pointy spears kept us from getting killed and I never forgot that. If they didn’t do a thorough search or kill the bad guys, we’d be an easy target for a “patient” to arrive with a hidden bomb or weapon. I don’t recall ever receiving mortar fire either. If memory serves, Tallil’s ECPs (Entry Control Points) were so far out, our camp was beyond insurgent mortar range.

Nevertheless, the threat of death hung over everything like a heavy, invisible curtain. I often thought about those outside the wire—how vulnerable they were and how brave they were. I often wondered how I’d fare facing what they faced. I’d seen plenty of gunshot wounds (GSW), burns, and mangled bodies, ironically mostly as a civilian nurse. At this point, I’d worked in ORs for nine years, including a level I trauma center, and was very aware of what fire and metal do to flesh and bone. You’d be surprised at what people can live through. I also turned 32 years old a few weeks after arriving, so there were no youthful illusions of invincibility. Perhaps that’s why I was more afraid of being maimed than being killed.

We arrived in Tallil at night in a C-130, descending the rapid downward spiral of a “combat landing.” As the steep descent began, I prayed that if it was my time, that it be quick. This was followed by a demand that if I was to die in Iraq, let it be now and not on the way home after making it through the deployment. After landing, our unit was briefed by an OSI agent (U.S. Air Force Office of Special Investigations) dressed in civilian clothes. There was fear in the agent’s eyes as he spoke in an animated tone, uncharacteristic in the military. I recall two things from his briefing. First, he informed us that multiple RPGs (rocket-propelled grenades) had been fired at our plane as we descended, which was not a normal occurrence at Tallil. He went on to say that while the chances of being hit were remote, it had been possible. The agent emphasized that although most of the fighting was well north of us, we were still in a dangerous combat zone.

Capt. Ryan Murphy, 40th Airlift Squadron pilot, and Capt. James Wishart, 40th AS co-pilot, land a C-130J Super Hercules, at Pope Army Airfield, N.C., during Battalion Mass Tactical Week, on Jan. 24, 2023.  Airman 1st Class Ryan Hayman/U.S. Air Force photo

Secondly, the OSI agent warned us not to ever find ourselves alone or separated from our troops. There was a standing terrorist bounty paid for any captured U.S. soldier, with the reward being higher for females—particularly blondes. At that time, Americans in Iraq faced the prospect of torture ending with an all-too-slow beheading with a blade. For the highly sought-after female, the only thing worse might be adding rape to that equation. I had made a point to never watch a beheading (and never will); I knew I’d never get the image out of my mind if I did. It wouldn’t be the quick kill of an executioner’s axe or guillotine—but an even more brutal, violent act that doesn’t bring death fast enough.

Arriving in Iraq was like going back in time to an age of barbarism. We had females in our unit. We had blonde females in our unit. In a world of barbarians, you need guns to protect them as well as yourself. And we weren’t issued any weapons. Our leadership decided it best to keep them secured in an armory for the duration of the deployment. Why? Our camp was well-protected in the heart of Tallil Air Base, and we were surrounded by coalition forces, which included U.S. and Italian soldiers. Our leadership also assessed the risk of accidentally discharging a round was far greater than the chances of needing to use it. Also, we couldn’t lose a weapon we were never issued. Not that it mattered, but I agreed with the decision. It was one less item to keep up with. To my mind, if I, as a nurse, needed to use an M9—we’d already lost.

407th Expeditionary Medical Group unit photo (2004). Michael Warnock is in the back row on the far right just under the ambulance cross. Michael Warnock

This made us 100 percent reliant on others to protect us. I was shocked that our camp was filled with Iraqis and Third Country Nationals (TCNs) that did our laundry, served us food, and cleaned our makeshift bathrooms. I thought about how easy it would be for any one of them to poison a vat of soup, sprinkle toxins in our clothes, or for a suicide bomber to blow themselves up. I had imagined doing our own laundry, eating MREs, and using porta-johns. Instead, we dropped off our laundry, ate hot food in a DFAC, and had shed-like bathrooms that permitted 90-second “combat showers.” A single, security forces airman augmentee escorted groups of 6 to 8 Iraqi workers as they performed various duties around our camp. I remember thinking, “What’s one person going to do if these guys attack.” They’d quickly overpower a single individual.

Almost immediately, my attitude became fatalistic. As we set up our OR, I remember telling my colleagues, “If I’m hit and lose more than one limb, don’t try too hard to save me.” Again, my biggest fear was being maimed—which included being seriously burned, paralyzed, blinded, or losing the ability to walk. Again, you’d be surprised at what people can live through. We were also told to break open our gas mask filters (stored in cans) and check our gas mask seal weekly. The risk of chemical or biological attack was also ever-present.

I’d trained extensively in MOPP gear (“Mission Oriented Protective Gear” designed to protect from biological or chemical attacks) and knew how unrealistic it was to pretend we could do our jobs while wearing it, and how impractical it would be to wear them in the desert heat. Covered from head to toe and wearing a gas mask, the thick, charcoal-lined garments worn over the uniform, gloves, and boots were hot, heavy, and cumbersome. They’d soon have to come off or else we’d cook to death inside them. If we ever needed MOPP, I saw it as only delaying the inevitable. I never opened my gas mask filter or checked my gas mask seal. If a chemical or biological attack came, I didn’t want to suffer and then die. I also didn’t want to live long enough to watch others die around me without being able to do anything about it. Let’s just skip that first part.

We took our first casualty as we were still setting up. An airman electrician, working on a generator, hadn’t properly grounded himself and was electrocuted. The electricity arced through his face causing third-degree burns. His face was a swollen, burned pulp and without securing an airway, he’d suffocate as the swelling compressed his trachea. He was intubated and aerovac'd out, there wasn’t anything more we could do for him. As I watched him get carried out on a stretcher, I couldn’t help but think his face looked like a pile of bloody cornflakes. It was like something out of a nightmare. I remember thinking how ironic that an airman was our first casualty and that it was an accidental injury. I expected our casualties to be mostly soldiers with combat-related injuries. But that’s just not how it was.

Our first few weeks there were busy. In addition to motor vehicle or HUMVEE crashes, a UH-60 Blackhawk crashed critically injuring four Army National Guardsmen. We lived and worked in tents, and our OR tent had two beds in it. This was the only time we used both simultaneously. As we worked on the crew, all our surgical resources were engaged. I remember hoping the other injured wouldn’t pay a price for waiting as we worked on these guys. The prospect of someone being further harmed or dying because we couldn’t get to them always weighed heavily. I don’t remember if we operated on all four of them or not.

Regardless, we stabilized the four soldiers who were aboard the UH-60, one of whom had a broken back, and they were aerovac'd out. I thought about what their lives might be like from here on out. They were part-time soldiers but would live with full-time injuries. Later that night I remember catching a bit of CNN at the MWR tent. As the newscaster bantered on about something, across the bottom of the screen scrolled the words (something like): “4 U.S. service members injured in Blackhawk crash in Tallil Iraq.” That was it. It seemed so innocuous to me. Just another information blip lost in the news maelstrom. Most Americans would never know what these soldiers, and those like them, sacrificed to serve our country.

I thought about the OSI agent’s warnings about the RPGs fired at our plane a few weeks earlier. I don’t recall the cause of the crash ever being disclosed.

Local safety officials inspect the wreckage of an Army UH-60 Blackhawk crash at Tallil Air Base, Iraq. All four soldiers on board were rescued from the helicopter by members of Tallil's 407th Air Expeditionary Group and 407th Expeditionary Medical Squadron, on Sept. 21, 2004. Airman 1st Class Jeff Andrejcik/USAF photo

The last day in September, we performed surgery on an 8-year-old Iraqi girl who’d been bitten by a poisonous snake. Her leg had swelled to the point that her tissue was necrosing and she was dying. She received antivenom, several units of blood, and eventually recovered. Her father was awestruck that she received this care without having to pay anything. He would have had to pay money just to see a nurse in An Nasiriyah, then more to see a doctor, then more money for them to administer the antivenom—which they likely wouldn’t have. The little girl was discharged with so many gifts from our unit that our commander ordered that it not be repeated. It attracted too much attention. The girl’s family could barely cart it away. It spoke to the universality of love for the innocent and compassion for a level of poverty unfathomable to most Americans. It also seemed like we were overcompensating for what we’d done to their country.

After October, the OR was fairly steady, with ebbs and flows of cases, but thankfully we weren’t busy. I was surprised at the lack of gunshot, shrapnel, or combat-related injuries. That’s what I had been expecting. Most of our cases were the result of accidents (mostly bone fracture fixations) and I’m sure we did an appendectomy or two, removed a gallbladder (cholecystectomy), and/or repaired a hernia. The only GSW we operated on (that I recall) was a U.S. Private Military Contractor (PMC). Something else that surprised me as soon as we arrived was how many civilian contractors were present. Halliburton was ubiquitous. The U.S. military was clearly not self-sufficient. There was such an infusion of civilians, it begged questioning how many millions of dollars these companies were making and how much of this war might be influenced by profit.

But privatizing a war also had its advantages. PMCs weren’t counted among U.S. casualties; they weren’t awarded Purple Hearts. They didn’t receive VA disability. When we stabilized and aerovac'd that PMC contractor with the GSW, I remember thinking “That guy’s eventually going to get a bill from Uncle Sam.” I was thankful to be covered by the military’s socialized medicine and to be an American with access to good medical care. I wondered how that PMC contractor was going to afford his medical bills. How expensive was it to aerovac from Tallil to Balad to Landstuhl and then to the States? But at least he was going to have access to medical care. For the Iraqis, it was a different story.

For example, our ER received an unresponsive woman who had essentially been dumped by her family in the hope that we could save her. We attempted resuscitation for several minutes but soon ceased—she was DOA. The Iraqis I saw were all short, undernourished, and looked at least a decade older than they were. The disparity between our worlds was stark.

Iraqi Army (IA) 4th Battalion (BN), 1st Brigade (BGDE), Iraqi Intervention Force (IIF) soldiers lock and load their weapons as they prepare to walk a field patrol on the outskirts of the village of Al Taji, Baghdad Province, Iraq (IRQ), looking for a suspected mortar launch site during Operation Iraqi Freedom, on July 19, 2004. SSGT Ashley Brokop/USAF via NARA & DVIDS Public Domain Archive

The battlelines were always muddled because we treated everyone the same. Our mission wasn’t to kill. Our mission was to save. That’s what we did, no matter who came through the door. Once someone entered our EMEDS, there was no “us vs. them.” It was a strange place to be in Iraq.

Our last casualty was an insurgent who’d inadvertently blown himself up trying to attack the base. He had a severe head injury (among others) and was unconscious. All we could do was stabilize and intubate him. He too was sent to Balad. I thought, “Even if this guy lives, where’s he going to go?” Balad wasn’t going to keep him forever. Iraq didn’t have the medical infrastructure for follow-up care—even if he had the money to pay for it. To me, it seemed like all we’d done was delay the inevitable.

But that’s what you do. Whether it’s a service member, civilian contractor, Iraqi, TCN, or insurgent. Everybody bleeds the same. Whatever their role in the war, once crossing into our world everyone becomes a “patient.” Our rules of engagement are simple: save lives. It was an odd feeling to look at someone intubated, now both harmless and helpless, who’d just tried to kill us. And we were expending costly resources to do it. Whether he lived or not, he had no future. The word “fruitless” came to mind, i.e., useless; unproductive; without results or success.

That was my overall sentiment of the war by the time we left. In the context of 9/11, Saddam Hussein’s aggression, and WMD shell game, we had legitimate reasons for invading Iraq. But as we redeployed home in January 2005, the Iraq War was morphing into a costly, fruitless meatgrinder chewing up blood and treasure. And all this while we were also fighting in Afghanistan. Despite the emphasis placed on the elections in January 2005, the country was falling apart—not coming together.

(Tallil Air Base, Iraq, 2004) I'm in front of a Medevac Blackhawk after getting to ride along as a practice patient strapped into a stretcher. It was the only time I ever flew in a helicopter in Iraq. The (U.S. Army) pilot did his best to make this Air Force “Zoomie” puke—but I found respite in the experience. Like the C-130 flight that got me there, I was forced to let go and accept my life was in someone else’s hands. That can be especially difficult for medical professionals because we’re used to it being the other way around (and why typically we're terrible patients). Michael Warnock

Prior to leaving Iraq, we were interviewed by one of our docs. One of the questions he asked was if we had any health-related concerns about our tour. I told him that I was concerned about the amount of pesticides we’d been exposed to. Leishmaniasis, a potentially fatal disease transmitted by sandflies, was a serious concern in Iraq. Consequently, we were told pesticides were regularly sprayed to reduce the number of sandflies. Several times throughout the deployment, our camp was filled with a fog so thick you couldn’t see much more than a few feet. It lasted hours. It was everywhere and there was no getting away from it. You were stuck. We all were. I recall thinking, “I hope breathing this stuff doesn’t come back to bite me.”

The doc told me, “I’m not as concerned about the pesticide as much as the smoke from the burn pits. The way the winds blow here, it would just sit in the middle of our camp.” He then said words to the effect: “People are going to be getting sick in the next 30 years.”

I assumed the fog was pesticide—but it was burn pit smoke.

So, in 2020, when I was diagnosed with thyroid cancer that had spread to several lymph nodes in my neck, that doc’s words came back to haunt me. Did exposure to burn pit smoke cause it? I don’t know, but I think the answer is “probably.” Does that make me a “casualty” of the Iraq War? Maybe. And if I am, then I’m just one of thousands of Americans who are—and far more Iraqis. I had expected more casualties during my deployment to Tallil and after the PACT ACT was passed in 2022, it seems there were.

Brielle Robinson, daughter of Sgt. First Class Heath Robinson, listens as her mother, Danielle Robinson, speaks during a signing ceremony for the "Sergeant First Class Heath Robinson Honoring our Promises to Address Comprehensive Toxics (PACT) Act of 2022," in the East Room of the White House, on Aug. 10, 2022. The legislation allowed for delivery of more timely benefits and services to veterans who may have been impacted by toxic exposures while serving in the U.S. armed forces. Sgt. First Class Heath Robinson died from lung cancer as a result of toxic exposure. [Author's Note: military families with a spouse deploying during the global war on terror will recognize Brielle holds a "daddy doll"—a doll with the picture of her father affixed to it.] Jim Watson/AFP via Getty Images

I underwent a total thyroidectomy and neck dissection which removed 40 lymph nodes from my neck, which was then followed by radioactive iodine treatment. Without a thyroid gland, I take a Synthroid pill every morning that keeps my body from slowly shutting down, eventually slipping into a coma and then dying. I received medical interventions that saved my life. I have access to Synthroid that keeps me alive and well. I have access to endocrinologists who will monitor my health for the rest of my life.

My prognosis is good, but once again, the threat of death hangs like an invisible curtain. No, it’s not as heavy, or as dark as the one in Iraq but it’s naggingly there. I have a 15-inch scar down the right side of my neck and numbness that reminds me anytime I start to take something for granted. Appreciate life. Live in the moment. You never know when your time is up. Though I can expect a normal life expectancy, these are no longer merely aspirational platitudes.

Perusing the list of presumptive diseases and conditions covered under the PACT Act is overwhelming, so I make a point not to look at it anymore. It’s hard not to make comparisons to Agent Orange exposure, which likely killed my dad’s brother (who I never met) in 1981. It’s history repeating itself.

I’m incredibly fortunate for so many reasons. I’m alive. I’m now healthy. So many sacrificed everything. I think about the Second Battle of Fallujah, which killed 110 coalition troops and wounded more than 600. I think about the four national guardsmen and their life-altering injuries. I think about the disfiguring burns suffered by that airman. I think about those Iraqi civilians. And I think of the countless others that they represent. So many lost so much more. My deployment was only four months in a less dangerous part of Iraq; so many had risked so much more and for much longer.

I’m still here. I have a beautiful, loving wife and three wonderful children who I’m getting to see become adults and forge their own lives. I have great friends in my life; friends who are family. I’m independent: I can feed myself; go to the bathroom by myself, I can walk, I’m not in chronic pain, I’m not covered in burns, I don’t have PTSD. I’m not a burden to my family. Medical bills won’t bankrupt us. I have a future.

What did the casualties in Iraq teach me about war? Answer: things we’ve all heard and read before. It’s just one thing to read about it and another to experience it:

• 
  
• More casualties are caused by disease and nonbattle injuries than combat.
  (e.g., from Sept. 1, 2004, through Dec. 1, 2005, there were 13,460 casualties treated or evacuated through the 332nd Expeditionary Medical Group/Air Force Theater Hospital at Balad Air Base, 3,096 (23 percent) with battle-related injuries.)
• Far more civilians than military personnel become casualties of war.
  (e.g., U.N. estimates 90 percent of war casualties are civilians)
• Methods of injury (mental or physical) can be insidious and not become apparent until years later.
  (e.g., an estimated 300,000 veterans have died from Agent Orange exposure—almost five times as many as the 58,000 who died in combat.)
• The full costs of war can never be calculated.
• In general, Americans are insulated from the casualties of war, including those with the power to wage it.
  (e.g., Frank Pauc’s article: “Afghanistan was Background Noise, and Soon Will Be Again”)
• The Military Industrial Complex is an inextricable part of our country. It is far more powerful and generates more wealth than most people can imagine.
  (e.g., On Sept. 10, 2001, then U.S. Defense Secretary Donald Rumsfeld disclosed that his department was unable to account for roughly $2.3 trillion worth of transactions.) As of 2023, although DOD’s spending makes up about half of the federal government’s discretionary spending, and its physical assets represent more than 70 percent of the federal government’s physical assets, it remains the only major agency that has never been able to accurately account for and report on its spending or physical assets.

The appearance of U.S. Department of Defense (DoD) visual information does not imply or constitute DoD endorsement.