MILITARY MEDICINE, 169, 10:810, 2004

Lessons Learned: Operation Anaconda

Guarantor: CPT George S. Midla, SP Contributor: CPT George S. Midla, SP

With the recent long deployments of our military, a review of experienced by our battalion or myself directly. There were lessons learned becomes a vital part of mission success and many other units and supporting elements that took part in this helps to shape our forces for future conflicts. This article engagement, but I am not at liberty to discuss possible lessons examines some medical issues that were experienced by the learned on their behalf. Topics of discussion will include nutri- Raider Rakkasans of the 101st Airborne (Air Assault) Division tion, altitude sickness, medical evacuation (MEDEVAC) re-

during Operation Anaconda in Afghanistan. Topics include Downloaded from https://academic.oup.com/milmed/article/169/10/810/4283548 by guest on 01 October 2021 nutrition, altitude sickness, medical evacuation requests, and quests, and the transport of patients on resupply platforms the evacuation of wounded on resupply platforms (back-haul- (back-haul). ing). When nutritional aspects of war fighting were discussed, an emphasis was placed on making a greater variety of field Nutrition rations accessible to the force with the addition of a multivi- tamin to each ration. Also, a meal high in caloric content Nutritional aspects of premission planning are often over- before infiltration and an education/inspection program to en- looked. Units are usually busy with rehearsals, equipment sure the maximum benefit of each ration was reviewed. The maintenance, and thorough inspections, as we were, when pre- use of acetazolamide to combat altitude sickness was also paring for an operation. Sleep is often given a higher priority discussed. Dosing of 250 mg BID 24 hours before a rapid than diet, but as troops are readied for bed, they are often assent, then 125 mg BID for 4 days was suggested. Line three anxious and thus have difficulty falling asleep. This could cause of the medical evacuation request was also reviewed for report- the force to be both fatigued and ill-prepared nutritionally at the ing inaccuracies. Complete physical examinations and direct onset of the mission. Once on the ground, the first 24 hours are dialogue between medical personnel and commanders was the most demanding. Operational awareness has to be gained, stressed. Last, a standard medical package to accompany any resupply during hostilities was advised, instead of releasing movement to a base or position must be accomplished, devel- ground medical personnel to attend the wounded when using opment of gun emplacements, and much more must be ad- this for an evacuation platform. dressed before a chow/rest program can be implemented. During Operation Anaconda, the first 2 days were very de- Introduction manding. Our unit was challenged with the enemy’s direct fire weapons, shoulder-fired rockets, and mortar rounds while hav- he U.S. military’s most recent involvement in Afghanistan ing to maneuver over some very rugged terrain. No one had the T began in the latter part of 2001. By 2002, U.S. and coalition opportunity for a leisurely brunch and after 2 days of little rest forces were well established in the country and many military and food, our operational sharpness began to dull. I will also add operations had been conducted, with additional missions being that we were not thinking of our meals. That is, some ate be- planned. One of these operations was code-named Anaconda. cause they knew they needed to for performance, but being shot Its mission was to destroy or capture al Qaeda and Taliban at really does curb one’s appetite. forces in mountain positions located in the Shahi-Kot Valley and As time progressed, the initial rations that we carried in were Arma Mountains southeast of the city of Zurmat. finally consumed. Resupply then became a problem. Most of our Operation Anaconda began on March 2, 2002. At the comple- unit was not able to acquire additional meals and thus went tion of this mission, U.S. and coalition forces had been involved without food, in some cases, for days. Historic records from with the longest battle in U.S. history since the Vietnam War. World War II support this finding. The Marines at Guadalcanal Anaconda was also the highest elevation engagement ever re- went through extended time periods of not being able to eat corded by the United States. because of logistical problems. The acquiring of the enemy’s Before I begin, let me state that I am the battalion physician food became a major part of some of the men’s diet during this assistant for 2/187 Infantry Regiment (Raider Rakkasans) of the campaign.1 101st Airborne (Air Assault) Division. I infiltrated the Shahi-Kot The newest version of the combat ration is the meal ready to Valley on March 2 in a CH-47 (Chinook) helicopter as part of the eat (MRE). It has been designed to be a high-caloric meal to help first force on the ground. On this aircraft, I accompanied a support the soldier on the battlefield.2 A single ration contains a platoon of our C Company, a command element, a small number variety of foods. These foods are dispersed in multiple pouches of Special Forces Soldiers, and an Air Force Enlisted Terminal throughout the MRE. For the soldier to benefit the most nutri- Attack Controller team. I spent the next 12 days in multiple tionally, he/she needs to consume all or at least some part of locations throughout the battlefield. My comments concerning each individual pouch. This brings up another nutritional issue: lessons learned will be restricted to medical issues that were our troops often do not sample each portion, thus defeating the maximum benefit of the field ration. Instead, many individuals Walter Reed Army Medical Center, Cardiothoracic Surgery, Perfusion Service, 6900 get bored with the finite selection of meal choices. They then Georgia Avenue NW, Washington, DC 20307-5000. This manuscript was received for review in July 2003. The revised manuscript was attempt to function on a diet heavy in the desert items, which accepted for publication in November 2003. are more palatable and located in every meal. Examples of these Reprint & Copyright © by Association of Military Surgeons of U.S., 2004. foods include pound cake and the candy “Skittles.” These sol-

Military Medicine, Vol. 169, October 2004 810 Lessons Learned: Operation Anaconda 811 diers may feel comfortable in their diet choice of eating just the huge concern, especially during air assault operations that are sweets from the meals. This reassurance is gained over a 1- or conducted at increased elevations. 2-week field exercise at their previous duty station where they Reaching altitude by vehicle or foot allows a slower assent were able to complete a given mission on such a diet. During with the ability to stop at various contour lines to acclimate, if overseas deployments, I have often had a nutritional regiment needed. At the very least, medical personnel can evaluate those strictly made up of MREs for 2 to 3 months before ever seeing developing signs and symptoms related to elevation changes the next step up in the Army cuisine, which is the tray ration and can act accordingly when using ground techniques. None of (T-rat).2–4 The T-rat is delivered in a flat rectangular pan and these luxuries are offered during insertion by helicopter (air does not require refrigeration. This ration is prepared by simply assault). submerging it in hot water, opening, and serving. Because of its During our air assault, we were and typically are shoulder to design, T-rats can offer a hot meal with a kitchen appeal to large shoulder and knee deep in equipment flying in a CH-47D. and small groups of soldiers. Even with the introduction of the Within minutes, we were at altitude and then disembarked the

T-rat, on some of my deployments, the MRE was the major part aircraft and conducted combat operations with full packs in the Downloaded from https://academic.oup.com/milmed/article/169/10/810/4283548 by guest on 01 October 2021 of my daily dietary intake. This scenario is not uncommon. Our snow. Because of these expected issues, we examined the pos- troops are often not eating properly secondary to a weary pal- sibility of combating altitude sickness by pharmacological ate.5,6 means. We now must reexamine my previous comments on soldiers After our preliminary map reconnaissance of the area of op- being nutritionally depleted before a major operation and then eration (AO), an initial altitude of approximately 11,000 feet was not being able to get resupplied during conflict. Compile these determined to be our step-off point. A decision was made at that two points with the possibility of 1 to 2 months of poor eating time to premedicate for altitude sickness. Medications and dos- habits (the pound cake and Skittles diet), and we may determine ages for this illness vary. We settled on a regiment of acetazol- that part of the fighting force may not be able to give a 100% amide (Diamox), 250 mg BID, 24 hours before infiltration. That effort. dose was changed to 125 mg BID upon landing and was con- To help attack this nutritional challenge on the battlefield, a tinued for an additional 4 days, and then terminated. Diamox is multiple approach should be examined. First, a greater variety usually started 48 hours before a planned rapid assent. Our of meals must be offered to the soldier. This should be our decision to begin this medication only 24 hours before infiltra- biggest priority. If we are unable to deliver those rations in a tion was decided on because of our mission constraints. timely manner, the purchase and distribution of foreign Army Weather changes, current intelligence reports, and the political rations should be investigated. It was always a treat for our climate can quickly halt a mission. Starting and then stopping troops to acquire a Canadian, Portuguese, or Australian ration pharmaceuticals never goes over well with the troops, but a while in Afghanistan. Also, the foreign forces that make these “thumbs-up” 24 hours before usually means that the mission trades also appreciated the variety. As an additional note, I just will be conducted. returned from Iraq and one of my most enjoyable lunches was a Acetazolamine is a carbonic anhydrase inhibitor, effective in yellow-bagged humanitarian aid meal that I was given to sam- the control of fluid secretion.9 This effect of increased urination ple. The lentil stew was not of a better quality than our standard was considered during our planning phase. We decided that at rations, just different. such a low dosage, diuresis would not be a health issue. Dehy- A multivitamin should also be added to the MRE. For the dration, as expected, was minimal at this scaled-down measure soldier who does not eat properly or is unable to because of and thus was not a factor. At the end of this operation, we had mission constraints, this addition would be a great help. I sug- zero individuals complaining of or needing MEDEVAC for alti- gest a sweet chewable to satisfy those who have difficulty swal- tude-related illnesses. lowing pills and to increase compliance. The most common side effect of Diamox experienced by our The next step in operational nutrition should be an education force was a tingling sensation of the extremities, lips, and program directed at our force. This can be done at all leadership tongue. A premedication brief was conducted and these possible schools for the commissioned and noncommissioned officers. side effects were reviewed. I strongly believe that if this had not The stressing of a banquet of rations before a mission in prep- been done, those experiencing these symptoms would have cer- aration for an unavoidable fast is paramount. Also, inspections tainly had an increase in anxiety at the start of this particular during the consumption of daily meals should be reviewed with mission. the highlighting of nutritional benefits when all portions are ingested. I have presented the previous dietary notes at our battalion meetings. These suggestions were always welcomed MEDEVAC Requests and, when applicable, were enforced. When requesting for MEDEVAC, a structured report is trans- mitted. This MEDEVAC request or “9-line” has been standard- Altitude Sickness ized to aid in the quick and complete relaying of information. The report is as follows:10 High altitude illness is experienced by approximately 20% of all those ascending above 9,000 feet.7 The percent affected con- Line 1: Location of pickup site. tinues to rise with increased elevations. Conditions experienced Line 2: Radio frequency, call sign, and suffix. may vary between acute mountain sickness, high-altitude pul- Line 3: Number of patients by precedence: A—URGENT, monary edema, high-altitude cerebral edema, retinal hemor- B—URGENT-SURGICAL, C—PRIORITY, D—ROUTINE, rhaging, and peripheral or facial edema.8 These illnesses are a E—CONVENIENCE

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Line 4: Special equipment required: A—None, B—Hoist, hours, to plan or wait until nightfall is often crucial when flying. C—Extraction Equipment, D—Ventilator Many of the division’s AH-64 (Apache) attack helicopters were Line 5: Number of patients by type: Litter and/or Ambula- damaged during this operation. Sending in an unarmed MEDE- tory. VAC aircraft, even with an escort, is never an easy decision. Line 6: Security of pickup site (use this version of the line The second event happened to me directly. A call came over during wartime): N—No enemy troops in area, the radio stating that one of our soldiers was “unstable,” al- P—Possible enemy troops in area, T—Enemy troops though a field medic was administering some type of care. The in area (approach with caution), X—Enemy troops in patient was 2.5 km away over some very tough terrain. I re- area (armed escort required). quested that the medic be put on the radio or have someone Line 6: Number and type of wound, injury, or illness (use this relay information for us. I was hoping to talk him through version of the line during peacetime). treatment because I knew I could never get there in time. With Line 7: Method of marking pickup site. A—Panels, B—Pyro- no response back after several minutes, I contacted the unit and technic Signal, C—Smoke, D—None, E—Other. received the same report that he was still unstable and nothing Downloaded from https://academic.oup.com/milmed/article/169/10/810/4283548 by guest on 01 October 2021 Line 8: Patient nationality and status. A—US military, B—US else. I left my position, commandeered a gator (a gator is a civilian; C—Non-US military, D–Non-US civilian, E— variety of garden tractor with a “go anywhere” attitude), and Enemy prisoner of war. drove with a small security element to the base of the mountain Line 9: NBC contamination (wartime). N—Nuclear; B—Bio- where they were positioned. An uphill run followed, while I was logical, C—Chemical. carrying a very large trauma rucksack. When I reached the Line 9: Terrain description (use this version of the line during soldier, he was quite stable and resting easily. The field medic on peacetime). the scene was surprised to see me and stated that at no time was the individual’s health uncertain. My next point relates to the caregivers’ tendency to issue I do not have the answer to correct this concern except to patients a higher precedence (line 3 of the MEDEVAC request) make others aware of the problem. At a minimum, I must stress than is warranted. After speaking to others who have been the completion of a primary and secondary survey before a involved with operations for some time, I found out that this is MEDEVAC is requested. Also, leaders need to speak directly to not an uncommon occurrence. I determined that the motivation medical personnel before requisitioning this type of evacuation. for increasing the severity category is related to multiple factors. This dialogue would correct any confusion that may develop First, the individuals calling in the request may want the from the multiple “word of mouth” transfer of information. wounded to get the best care possible and receive that care quickly, therefore an upgrade in status of the injured is issued. Back-Haul This upgrade also allows for the termination of the many obsta- cles faced while having to conduct a mission, possibly on foot, The evacuation of wounded is normally carried out by a UH- and simultaneously performing the duties of moving, securing, 60A (MEDEVAC) helicopter. This occurs in a perfect world. Dur- and caring for a patient. Another possible cause related to the ing Operation Anaconda, things were not quite perfect. The increase of precedence of wounded has to do with the stress command had to make a decision that vacillated between letting experienced during an operation. The first impression of a bat- the MEDEVAC helicopters fly and possibly risk additional tlefield injury usually is rather shocking. An accurate examina- equipment damage and personnel injury or to evacuate the tion needs to be completed before a MEDEVAC is called. The wounded on the Chinook aircraft that had to resupply the U.S. military uses a two-stage model in the examination of the ground forces with additional men and equipment anyway. This trauma patient.10 The first part is called the primary survey. technique of MEDEVAC is referred to as “back-haul.” The Chi- During this examination, the standard airway, breathing, circu- nook helicopter is the workhorse of the 101st Airborne Division. lation approach is used to identify life-threatening wounds. The In some cases, the decision was made to back-haul the wounded second stage or secondary survey is a more thorough examina- on the Chinooks instead of putting a greater number of helicop- tion to identify nonlife-threatening injuries. A request may be ters and their crews in harms’ way. placed before the completion of a secondary survey in some This brings up the point of medical assets, or the lack of them, situations. Also, a commander may get word passed up that he on resupply platforms. Doctrine would have us believe that has wounded. This information gets twisted as it is relayed from when back-hauling the wounded, they should be supported by soldier to soldier. A call is then placed based on that false report, releasing ground medical personnel. The decision to attach this which may have initially been founded on an incomplete exam- support would depend on the severity of the injuries. In reality, ination. I know of two examples pertinent to these issues. nothing could be worse. Having a platoon or company medic, The first example was a problem that developed from a previ- battalion physician assistant, or physician leaving his unit while ous patient upgrade. I learned of this issue while monitoring a under hostilities is bad medicine. This action has great psycho- radio. An individual made a call for the evacuation of a soldier logical repercussions on the ground force and the medical per- who was diagnosed with a form of altitude sickness. Higher sonnel identified to attend those injured. Additionally, a section command questioned the need for that request before imple- commander will lose all or part of his medical team. menting a plan. The hesitation was a result of an earlier incor- Medical personnel and equipment should accompany addi- rect prioritization of wounded from the same unit. I do not tional troops and supplies that come in during conflict. Future chastise the command for their actions. Releasing a MEDEVAC plans should include the standardization of this medical sup- platform in a hostile situation means that they are putting port. This would ensure that the wounded being extracted others in harms’ way. Having the time, if only a few additional would be cared for without removing ground assets.

Military Medicine, Vol. 169, October 2004 Lessons Learned: Operation Anaconda 813

Conclusion phase of their missions. It is my deep belief that it is everyone’s duty to present his/her lessons learned at the conclusion of all This article has been a review of nutritional issues, altitude major operations. In the future, I hope to see additional notes sickness, MEDEVAC requests, and the use of resupply plat- from within the ranks, at all levels and in all disciplines, that forms to evacuate the wounded as experienced during a combat took part in this conflict. There is still much to learn. engagement in Afghanistan. Nutritional aspects of premission planning are often overlooked. To ensure that our troops are References eating properly, a greater variety of meals, a multivitamin, in- 1. Russ Z: Textbook of Military Medicine (War Psychiatry). Washington, DC, Office of creased caloric intake just before infiltration, education, and the Surgeon General at TTM Publications Borden Institute, Walter Reed Army inspection of the ingestion of all parts of the field ration were Medical Center, 1995. 2. Hasenauer H: From Horse Blood To Hot Pockets. Soldiers 2002, December, pp suggested. To combat the physical threats of altitude sickness, 24–9. acetazolamide was prescribed. The dosing use during this op- 3. Alspach R: New and improved T-ration and MRE development. Quartermaster eration was 250 mg BID 24 hours before infiltration, and then Professional Bulletin, December, 1988, pp 1–3. Available at http://www. Downloaded from https://academic.oup.com/milmed/article/169/10/810/4283548 by guest on 01 October 2021 125 mg BID upon landing with continued dosing for an addi- qmfound.com/mre_tration.htm. 4. Motrynezuk P: The Army Family of Rations. Quartermaster Professional Bulletin, tional 4 days. Line 3 of the MEDEVAC request was examined for Autumn, 1991, pp 1–3. Available at http://www.qmfound.com/army_family_ reporting inaccuracies. This line determines the number of pa- of_rations.htm. tients by precedence. The precedence is often inflated, which 5. Wenkam N: Energy and nutrient intake of soldiers consuming MRE operational causes time constraints and air management problems during rations: physiological correlates. J Am Dietetic Assoc 1989; 89: 407–9. combat operations. Complete physical examinations and the 6. Carter J: Anthropometric, psychomotor, and hemodynamic changes during twen- ty-one continuous days of eating only meals, ready-to-eat (MREs). Milit Med direct dialogue of medical personnel with commanders was 1992; 157: 536–9. stressed. Last, the use of resupply platforms to evacuate the 7. Berkow R: The Merck Manual of Diagnosis and Therapy, Ed 16. Rahway, NJ, wounded was discussed. A standard medical package to accom- Merck Research Laboratories, 1992. pany additional troops and equipment into battle was advised in 8. Auerbach P: Wilderness Medicine, Ed 4. St. Louis, MO, Mosby, Inc., 2001. 9. Acetazolamide Package Insert, Taro Pharmaceuticals Industries Ltd., Haifa Bay, lieu of ground medical personnel leaving their units to treat Israel. those wounded. 10. Whitlock W: Special Operations Forces Medical Handbook. Jackson, WY, Tenton I hope that this review benefits those during the planning NewMedia and The Geneva Foundation, 2001.

Military Medicine, Vol. 169, October 2004