Stephanie Streit, MD, FACS, Lt Col, USAF, MC: 7 years Active-Duty Service

I knew nothing about what getting deployed meant until it actually happened. I knew I had to get on a plane in Baltimore on a Tuesday evening. I didn’t know where that plane was going to land or when. I knew I would go to Qatar to “get the rest of my gear” but nothing beyond that. I didn’t know how or when I would get to Afghanistan. I didn’t know what would happen when I got there. I didn’t know I would live in the hospital and that I wouldn’t leave my 8 × 10 ft room, even just to use the restroom in the middle of the night, or get out of uniform for the next six months. I didn’t know that having that 8x10ft room to myself would be such an immense privilege and it would be the one thing that would keep me sane.

One might be thinking, “well, why didn’t you ask?” Honestly, I knew so little that I didn’t even know what to ask.

I went to Commissioned Officer Training the summer between college and medical school. The next summer, I went to San Antonio for 10 days to learn about Aerospace Medicine. Upon returning, I packed my battle dress uniform (BDU) into a giant plastic box, never to be worn again. I matched into a deferred general surgery residency, then Civilian Sponsored Trauma Fellowship. Only then did I get my first assignment in the real Air Force.

It had been 10 years since I had worn a uniform or learned what it meant to be an officer. I spent the first 4 weeks on active duty walking around with a checklist in hand, trying to decipher the new language of “alphabet soup.” I said the words, “I don’t know” and “what does that mean” more times than I had since intern year.

And as it turned out, when the dust settled, I wasn’t in the unit that I had been told I would be in. I found out the hard way when, after 5 months of working entirely at our civilian partner trauma center, I got the call from my squadron commander. I was getting deployed, and I was leaving in one month. I was going as a general surgeon to the role 3, not as a trauma czar like I had been preparing for the last 11+ years. Nothing was how it was “supposed” to be...

The four weeks between the call and the flight were a total whirlwind. New uniforms. Shooting guns I wanted nothing to do with. Gathering gear I would never need. Endless CBTs (computer-based training). A fishing trip with my dad and brother that we had been planning for months. Canceling all the plans I had for the summer. Then, all of the sudden, it was time to go.

When I arrived in Qatar, I had no idea what day or time it could be. We were “in-processed” but all I could say was, ”what is happening?” Everyone around me seemed to be taking it in stride, so I tried to follow the pack. I managed to get my essentials into a small pack, find linens and then a bed. When I woke up, I had a horrific headache.

Four check-ins later, I was called out and sent to the airport to get in a different line. This started several days of waking up, packing everything, turning in linens, trekking across base to the airport, checking in for standby, waiting the whole day, not getting a flight, going back across base, getting new linens, and finding a new bunk to try to sleep only to inevitably get woken up in the middle of the night when a new unit showed up. It was 5 days of this routine before we were actually in the air.

Once we got to our destination, it all started again - in-processing in the middle of the night, shuffling bags, meeting strangers, finding a toilet, and my 8 × 10 box. By then, the headache was unbearable, and there was no sleep to be had. And then...

“IN-COMING IN-COMING IN-COMING”

And then…applause?

The cheers, I later learned, were from the people who were about to go home, because that meant they got one more month of hazard pay. I couldn’t even begin to wrap my head around that at the time. Honestly, it's still tough now.

The next several days I spent climbing perhaps the steepest learning curve of my life. Don’t wear this, wear that, put your hair up, why are you so quiet, don’t sit there, don’t talk like that, talk less, get some rest, that’s not your role, you should get out more, relax. I couldn’t sleep. All I could do was sleep. I cut 12 in off of my hair to try to get the headache to go away.

I was sure I couldn’t do it.

Of course, I did get through it, but I would be lying if I said I thrived. Patient care was the easy part. I seemed to continuously offend people by not knowing how I was “supposed” to act or speak.

I went days, sometimes a week, without leaving the building. My 8 × 10 box, the one thing in that country that was mine, shared a wall with the ICU doors. Every time these doors opened or closed, I woke up.. Did they need me? I couldn’t tear myself away from the patients. I was certain the moment I left the immediate area, something bad would happen. It took me 6 weeks to allow myself to go to the soccer field a 10-min drive away. Sunday soccer ended up being my favorite time of the week, eventually.

People assume that trauma surgeons are tough, unflappable even. People assume that because I project confidence in the trauma bay, I must have things figured out in general. Perhaps I also struggle to ask for help, to ask more questions.

So what does this have to do with being a female military trauma surgeon? I find myself wondering if any of my struggles had to do with my gender. In my more self-conscious times, I feel like if I had just been better, smarter, calmer, and less emotional, maybe things wouldn’t have been so hard for me. But I doubt that would make up all of the difference, and I know that is how women get gaslit in academia.

Ultimately, I learned that there are many ways to lead in the deployed setting, but not everyone needs to be a leader all the time. Great leaders need good followers, too. I didn’t need to be “in charge” to contribute. The unit didn’t need me to be the loudest voice. The unit didn’t need me to be at the front of the room. The unit didn’t even need me to be the best surgeon there. In fact, I was arguably the least necessary surgeon in the unit. What the unit did need was for me to find ways to unburden the surgeons at the front of the room. To do the less glamorous stuff that keeps the machine moving- put in lines, change wound vacs, put in feeding tubes, tinker with ventilators, go to clinic. Talk less. Listen more. Ask questions, even if those questions would lay bare my inexperience, my lack of confidence, and my vulnerability. I know I wasn’t always successful, but I know I am a better doctor and officer for every minute of it.

Katherine Wrenn-Maresh, MD, CDR, MC, USN: 15 years Active-Duty Service

“So the key is to tuck the sleeves in your pockets, then ‘Harlem Shake’ to slide it down, but make sure it doesn’t fall so far down that it touches the floor.” 26 years of uninterrupted formal education, followed by a two-year stint as a staff surgeon at a hospital, and at the time, this felt like the most practical, essential thing I had ever learned. How to successfully pee while wearing coveralls in a tiny ship restroom, aka head. I was never more grateful to have two enlisted teammates take me under their wing and teach me how to survive and eventually thrive, on a warship.

I was in the Navy Reserves during medical school at a civilian university and had been on active duty for 8 years by this point. Five years were in Navy residency training and two at a small, but high-acuity, overseas military hospital, and now I had just joined Fleet Surgical Team (FST) 9 for my second assignment as a surgeon. FST-9 was going to be different from any of my prior experiences, and I felt wholly unprepared for the military officer part of my job.

My overseas tour had been hugely formative for me as a surgeon. I benefited from a solid case volume, including trauma, and the steadfast mentorship of a senior trauma surgeon and friend. By the time I left, I was confident in my abilities as a surgeon. What I wasn’t confident about was anything on the ship outside of the operating room.

Everything about a ship is confusing to an outsider. Basic route-finding is anything but basic; the different levels connect in unexpected ways, and you often find yourself going up to go down. Nothing keeps the same name: floors become decks, walls become bulkheads, drinking fountains become scuttlebutts. Added to the constant state of physical disorientation is the byzantine system of traditions and customs. Just boarding the ship is a multi-step process fraught with potential embarrassment.

A Navy FST is a small medical unit of about 18 people designed to provide initial resuscitation, surgical, intensive care unit (ICU), and en-route care capabilities to ships that are equipped with operating rooms and an ICU, but don’t carry the staffing as part of their organic personnel. The goal is to provide stabilizing surgical treatment of wounded patients and get them to a higher level of care as quickly as possible.

The heart of the mission is surgical, so the surgeon carries a significant leadership responsibility, in addition to the weight of their rank alone. The team was welcoming to me from the beginning, but it was a month later, in our first training exercise underway that I really bonded with them.

Rank is an interesting dynamic in the military, particularly with respect to physicians. At the time, I was a Lieutenant Commander, which on a ship the size of the one we were on put me in the upper echelon of officers. But I was brand new to the “real navy,” still learning port from starboard. Because I felt confident in my capabilities as a surgeon, I felt no shame in embracing my “new to a ship” role and asking for guidance every step of the way. I genuinely needed my teammates to help me find my meals, the medical spaces, and the weather decks to get some much-needed sun.

I spent the next 2 weeks underway on a deliberate curiosity offensive: see as much of the ship as possible and learn as much as I could about what each space does. I was surrounded by experts, regardless of their rank or age, and they loved being given the chance to teach an officer, let alone a surgeon, what they do to get after the ship’s overarching mission. At times I felt like a novelty. My unit commander and I were the highest-ranking women on board on several occasions and many sailors had never met a female surgeon. But once I let them show me their expertise, the awkwardness dissolved and the connections were made.

Through it all, I kept teaching, explaining, and answering questions. I had plenty of medical knowledge to trade for their ship knowledge, and it became easier for me to navigate the physical spaces as well as the customs and traditions. Carrying that knowledge back to the hospital has helped me build rapport and understand my patients’ daily lives and how that impacts my surgical care.

I have since spent time on seven different ships and deployed to a combat hospital in Kandahar, and now find myself back at that small, relatively high-acuity, overseas military hospital, several years older and most certainly wiser. I was recently appointed the Director of Surgical Services, sitting on the hospital Board of Directors and supervising the operating room (OR) and all of the surgical subspecialties, making this assignment anything but a rerun and challenging me in new ways. I carry with me those experiences that were successful, like the one described above, with others that were less so.

Many might say that cultivating relationships, showing gaps in knowledge, and deferring to outside expertise aren’t typical traits associated with surgeons. But I would argue that the incidents I see as missteps in my career are times when I was trying to be too brazen, too directive, too abrasive, in a word, too “surgeony.” Each time felt like swimming upstream, fighting my strengths and highlighting my weaknesses.

Throughout my career as a female Navy surgeon, I feel fortunate that when it comes to the surgery part of my job, I have not felt that my gender is a factor. There are still patients who assume that I am the nurse when I walk into the room or nurses who focus their questions on the plan with the (male) resident when I am standing right there as the final authority. Or even the patient who told me “I’ve never had a female surgeon before, and you actually did a great job!” Those incidents occur in the civilian world as well, and they seem to happen less and less frequently to me.

I feel grateful for the first military surgeons who have blazed the trail. While I have felt the small signs of progress, the numbers are still telling and there is still much room for growth. As the profession of surgery has grown incrementally more diverse in gender, ethnicity, and other measures, space has opened to allow a diversity of leadership styles. Surgical leadership, whether in the military or civilian realms, does not require a stereotypically masculine, caustic approach. Surgeons are trained to make difficult decisions with immense consequences, but that doesn’t mean that humility and a willingness to ask for help indicate a lack of competence. Or that we can’t cultivate our own authentic leadership style to guide our approach, whether that is more “masculine” or “feminine.”

Above all, as I gain more experience and more perspective, I have realized that leadership outside the OR is crucial to succeeding in the OR. Even in the military, rank or title by itself doesn’t get things done. However, building relationships and a collaborative environment pay vast dividends. Surgery is a team sport, but it isn’t a pick-up game. Everyone has to buy into the bigger mission and be ready and willing to succeed in their role. Perhaps even more so in the austere, potentially perilous environments military surgeons find ourselves. Residency teaches us how to supervise, but does it teach us to lead? For that, I needed my time with FST-9 and my unwavering teammates. Without them, I might never have figured out those coveralls or the “real navy.”

Mary Stuever, Lt Col, MC, USAF: 14 years Active Service, 3 years Guard

I am a trauma critical care physician in the US Air Force assigned to the Center for Sustainment of Trauma and Readiness Skills (C-STARS) Cincinnati. I received my initial commission in the US Army as part of the Kansas Army National Guard as a physician assistant. I then had the opportunity to cross over the blue and entered the Air Force on an HPSP scholarship. After completing a combined military-civilian residency affiliated with Wright-Patterson Air Force Base, and a surgical critical care fellowship at the Ohio State University I was assigned to C-STARS Cincinnati. Our primary mission is to train and validate critical care air transport teams (CCATT), in preparation for deployment. I also have a clinical component to my duties as part of a trauma critical care team in the division of surgery at the University of Cincinnati.

In May 2020, I was sent on my first deployment to Afghanistan serving as the trauma czar, for the 455th Expeditionary Medical Group at Craig Joint Theater Hospital on Bagram Airfield, Afghanistan. This hospital opened in 2006 as part of Operation Enduring Freedom. Many trauma czars have preceded me in service to Bagram Airfield and Afghanistan. I faced the same challenges that other trauma czars have faced on deployment. Trauma czars are on call 24/7 for the deployment duration, which requires a lot of mental resilience, support from your deployed team, and your friends and family back home. The most common injuries that I saw were gunshot wounds and blast injuries. A vast majority of the trauma patients we treated were Afghan National Army and Afghan National Police. As the medical facilities and resources in Afghanistan were very limited, one of the greatest deployment challenges was learning how to facilitate post-injury rehabilitation for local national patients.

During deployment, I was very blessed to have a command that was supportive of the trauma program and deploy with other incredible medical professionals. I felt as if I were part of a family and had a home away from home. We usually went to meals together, jokingly calling it family dinner. If one of us was not able to go to the dining facility, we were always able to get each other food. Even though I missed numerous meals due to clinical care, when I came back from the operating room, a member of my deployment family would tell me that my food was in the refrigerator.

My particular deployment was challenged by the additional unanticipated effects of the COVID-19 pandemic. Prior to my arrival, the staff had put in place plans for responding to an anticipated surge of patients infected with COVID-19. Upon my arrival, they had only treated two patients, one of which was critically ill with COVID-19. By the time I left country, in November 2020, we had treated over 80 COVID-19 patients, many of whom were critically ill. As the only intensivist in theater at that time, I was challenged to develop protocols and practices to treat COVID-19, which changed daily, as our knowledge of COVID-19 changed. The pandemic added many challenges to daily operations including patient movement, and restrictions on transporting patients out of theater resulting in longer lengths of stay for our patients, with the longest treatment course being 25 days. During this time, I had the opportunity to work with the most talented group of clinicians, nurses, and technicians I have ever encountered. Our supply lines were also affected greatly due to the pandemic and plans for retrograding the Air Force base during the drawdown plans for Afghanistan.

Morale during my deployment was somewhat affected due to the limits of COVID-19 as most of the scheduled activities during a typical deployment for morale were canceled. This was a great challenge, particularly for those of us who are used to engaging with others. However, I did not experience any issues with being a female in a leadership position. All of the airmen, non-commissioned officers, and officers I worked with respected me, and there was a collegial atmosphere throughout my deployment.

My deployment is also unique in that my husband and I are both active duty Air Force. He supported me and our three children during my deployment. Throughout our careers, we have experienced numerous episodes of separation for various changes in duty stations, deployments, and training opportunities. In our 21 years of marriage, we have lived apart for 7 years. My children have been very resilient through all of the changes in a military family. I was home for six months, and in April 2021, my husband began his 6-month deployment. So now it is my turn again to be the home “single” parent. These experiences have allowed my husband and I to have more empathy for one another as both of us have been in each other’s position. Being in a military family comes with many challenges and requires advanced planning as well as the support of your local community and your command structure; we are lucky to have had both in our experiences.

Danielle B. Holt, MD, MSS, FACS, LTC(P), MC, US Army: 18 years Active-Duty Service

Being an army general surgeon has taught me foremost the importance of adaptability and divergent thinking for surgical leadership, particularly in the deployed environment. Even if fortunate to prepare with the team or unit, deployed surgical care involves flexibility with equipment, medical supplies, capabilities, and most often expectations of “how” things get done. Surgical leadership instead requires focusing on the goals of therapy as impacted by the operational environment, resulting in a shift of thinking from “what we would do” to “what we can do with what we have” to achieve the desired effect. Innovation often happens at the seams between disciplines which requires humbleness to listen and incorporate what others know, regardless of their position in the medical or military hierarchy. As the surgeon, you must be approachable without inflicting intimidation or fear, so you can accurately assess your team’s capabilities. More importantly, when making difficult decisions in resource-limited and rapidly changing conditions, the surgeon must demonstrate cautious optimism to forge the path ahead as the informal leader of the medical team.

Military general surgery has highlighted the tension of increasing sub-specialization in American medicine juxtaposed by the broad range of surgical skills needed, particularly in austere environments. As a critical wartime specialty, general surgeons along with nurse anesthetists and physician assistants are some of the most frequently deployed medical personnel [10]. Clinical readiness of the general surgeons is the most difficult to maintain because the deployed combat casualty care mission including trauma and critical care varies from elective general surgery practice performed in the military treatment facilities (MTFs) [11•]. As a result, I have had the opportunity to rethink notions about scope of practice, access to care, standards of care, and quality outcomes while balancing surgical confidence and humility. The unrelenting push for improvement is the cornerstone of surgical leadership. I’ve appeased feelings of surgical technical inadequacy by embracing “what I can safely do” by considering as many viable options as possible and selecting a course based on sound surgical principles.

In leading surgical teams in remote environments, providing highly specialized procedures limits the availability and reach of surgical care which is largely influenced by context and environment. One example while deployed to southeast Afghanistan in 2012 involved the care of an Afghan girl who had been struck by a US armored vehicle resulting in a crush injury to the skull. Upon arrival at our augmented role 2 facility (we had access to computed tomography and small ICU holding capability), the patient displayed signs of impending herniation. We contacted the neurosurgeon in Bagram; however, it was clear the patient would not survive transport. We proceeded with a decompressive craniectomy using predominantly the Emergency War Surgery textbook as a guide with real-time advice prior to the procedure from one of my neurosurgery colleagues via a messenger application.

Postoperatively, the girl remained in our small ICU as challenges with the cultural context of her care began to unfold. Her father had been brought to our facility and refused to speak with me as the surgeon because of my gender. Through asynchronous conversations with the interpreter, I learned of his frustration that surgery had been performed because of his inability to care for his daughter. I made multiple attempts to update the father when he would visit, but he would only talk to the male Afghan interpreter in private. Eventually, she was transferred to a local children’s hospital, and I do not know her eventual clinical outcome. Discussions with the interpreter suggested regardless of what we did for this child, she would likely die once she left the hospital because family resources could not be allocated for her. Although her case reaffirmed my service as a military officer to uphold the democratic ideals of justice, liberty, and equality, it highlighted the ethical dilemma of doing “everything you can do” without respect for the clinical context and operational environment.

Adaptability in this case applied not only to the technical aspects of performing a neurosurgical procedure as a general surgeon, but also the ethical decision to perform the procedure, principles of beneficence and non-maleficence, parental medical decision-making, non-combatant injuries in war, cultural competence, and reconciliation of personal values. These complex decisions require tremendous leadership to understand not only the impacts on the patient, their family, community, military mission, and diplomacy but also the surgeon and surgical team with the risk of moral distress and injury in cases with poor outcomes [12]. Surgical leadership requires “skin in the game” to understand what it means to deliver unwanted news or tell a patient’s family or military teammates the worst possible news that the patient didn’t make it. Such leadership requires trust that medical teams were capable of doing what could be done with what was available, that resources were allocated based on the best available information, and that individuals on the team were giving their “all.”

Surgical leadership to do the right thing in response to complex adaptive systems such as casualties on the battlefield requires divergent thinking. Divergent thinking, or the creation of many solutions rather than a single solution, requires breadth across disciplines rather than depth to find interconnectedness. As medical knowledge has exponentially increased, healthcare has responded by increasing specialization and narrowing scopes of practice, which has led to increased discomfort when solving problems outside of one’s primary specialty. General surgery provides breadth across the spectrum of healthcare that grooms adaptive leaders who practice across the entire healthcare landscape. Divergent thinking requires diversity of thought, or at least the willingness to persistently question what you don’t know both from a medical and operational context.

Military surgeons may want to shy away from formal leadership roles to limit responsibilities outside of the operating room. I would argue military surgeons are well prepared and most suited to carry the burden of leadership because we are often saddled with enough “skin in the game” to relentlessly push for “the best we can do with what we have.”