Reflections of Service in Afghanistan: USAF Col (Ret) Max Lee

Dr. Andrea Austin interviews Dr. Maximillian Lee on the impacts of the current events in Afghanistan on the physicians who served in that theater of war.  Col (ret) Lee is the former Air Force Special Operations Command, Chief of Aerospace Medicine  and an influential leader in the development of our current physician forward operating stance. He deployed to Afghanistan multiple times as an emergency physician, on  Critical Care Air Transport Teams and also in Forward Surgical Teams. 

Transcript

Narrator: 1:09

Welcome to the government services chapter of the American College of Emergency Physicians podcast. GSACEP represents emergency physicians who work in the federal government, including active duty military, National Guard, and military reserves, as well as the Veterans Administration, Indian Health Service and other federal agencies. Our mission is advancing emergency care for America's heroes. In this podcast, we bring you lectures and conversations with leaders in federal emergency medicine, to help you better care for your patients and lead your departments. The views expressed on this podcast are personal views, and do not represent the views of the Department of Defense, any branch of the military, or the federal government, and they do not constitute endorsement of any product by any of these entities.

Andrea Austin: 2:02

So welcome to this episode of the GSACEP podcast. I'm your co host, Andrea Austin, and I am also the immediate past president of the GSACEP chapter. Several of us have been talking in the last few weeks about the events unfolding in Afghanistan. And while I didn't personally serve in Afghanistan, I served in Iraq, I have many friends that have and the collective feeling is that there's a lot of angst about what's going on right now. And I've heard many of my friends question what their service meant, and have some memories brought up that have been really hard over the last few weeks. And as we're recording this podcast right now, it's not lost on us that there's continued suffering happening. And most recently, 13 US service members died, doing their jobs at the Kabul airport, trying to get more Americans and other people evacuated from Afghanistan. So our hearts are with the service members and their families that have been affected by this very long conflict. And we understand that there's still service members on the ground doing their job, and we're really thankful for their service. Part of why we wanted to record this episode today is less than 1% of Americans have served in Iraq and Afghanistan. So for those of us who have been there, it's a really small group. And as the years go by, you know, for me, I've been home for four years, I don't see a lot of the people that I deployed with, sometimes we still text, but sometimes it's hard to find an outlet or find somebody to talk to about your experiences that really know what it was like. So we hope this episode provides a chance for you to reflect on your service. And if you're having some feelings that are hard to process right now, we hope you reach out to your colleagues, to the people that you served with to the people you're working with now. And we also understand that you may need to reach out and have professional help. There's lots of different resources available. But I just want to quickly mention that if you're currently in the military, Military One Source is a wonderful resource, and one that many people choose to use because Military One Source connects service members with civilian mental health professionals, and it's outside the military system. So if confidentiality is a concern for you, I would highly encourage you to access Military One. And you can just search Military One in any search engine, and you'll be directed to those resources. If you're a veteran, you can call 1-800-273-8255. And you can also check va.gov. For more resources, there's a plethora of resources available for veterans. And if you're a civilian physician listening and not currently in the military and not a veteran, but you found this episode, because it was forwarded to you from a friend and you wanted to learn more about our perspective as being servicemembers and veterans. And this triggers something in you and you'd like to speak to a mental health professional. The American College of Emergency Physicians provides a service in which physicians can access a physician support line at 88840901 for one, and that is staffed by psychiatrists. So this has been a tough time between the events and Afghanistan the ongoing pandemic We want you to reach out and get the help that you need. Now, I'd like to introduce our guest, retired colonel max Lee. He is had a fascinating career that has spanned many different positions that an emergency medicine physician can do in the Air Force from working the traditional emergency departments that we're used to seeing whether you're in the military or civilian setting, and the very high speed world of working with the Special Operations community. I'm going to turn it over to max for him to give us a little bit more about his background and welcome him to the show.

Max Lee: 6:44

Thank you very much, Andrea. First and foremost, thank you for being the voice for our colleagues and our service members. They're the ones that really deserve all the praise and support that we are here to try to provide. I have to state that my experiences and opportunities maybe slightly different than many others, because of some of the unique positions that I've held. And I certainly am not an expert in any of these fields. So I would encourage and welcome the dialogue, and the discourse we can have about these very important and challenging issues at hand. Very briefly, my background in Afghanistan started in February of 2002. As a newly assigned F at Wilford Hall Medical Center, I was trained up to be a seacat team lead as an emergency physician and deployed to Bagram Airfield in Kandahar, from February to June of 2002. Fast forward a few years later, deployed, then as a cervical resuscitation team, emergency resuscitation provider in December of 2006, through the spring of 2007. This will become a little bit more pertinent and important as we discuss some of the challenges we face in in regards to going and coming back from Afghanistan, and what that may mean for different members who have deployed there and have returned, along with the recent events that are occurring. Because in a smaller microcosm, I felt there were some issues that I had to work through during that first surgical versus resuscitation deployment. And then I deployed again, as a surgical resuscitation team provider in December 2007, to late spring of 2008. There I saw ballroom developed from my initial base, where, you know, I actually helped lay the initial tests to bring in the 810 squadrons who are based out of Afghanistan and bogra, to a fully functional portal of entry for coalition forces in full logistical hub, many years down the road. So thank you. And that's my background in Afghanistan.

Andrea Austin: 9:09

Wow, that's just such an amazing career. And I think it's just fascinating how you saw so many different aspects over, you know, a number of years. And I think you brought up a great point as well. And I just want to be clear to our audience, this is a really complex topic. And one deployment to Afghanistan is one deployment to Afghanistan. And we're gonna have other guests on the show that are going to talk about their experiences. So you are now retired. And you had several deployments to Afghanistan. And now you're watching what's unfolding, through a retired perspective. And I'm wondering, as you're seeing the events in Afghanistan now, has that affected how you feel about your time and your service?

Max Lee: 10:08

Yeah, thank you for the question I dread that is part of my soul searching to understand the purpose or meaning of what I've accomplished or attempted to accomplish in Afghanistan. I think there are many mixed emotions and feelings, compounded by the stressors of everything else that's happening in the world currently. And so I I had to take a deep look into kind of the emotions and what I was bringing to my experiences and how I was processing this. So to go back to the relevance of my return from the second deployment to Afghanistan, I returned slightly earlier than the scheduled time because my unit at asked me to come back to assist in preparation for a operational readiness inspection. So, on the day that I returned to the United States, I found out that the helicopter that I mainly flew out of with my teams crashed, and there were eight fatalities and 22 casualties. For Sumo 44. This was obviously a huge shock to me. And immediately, I felt a huge sense of survivor guilt. You know, could I have been there to assist more if I, if I didn't return? Should I have fought harder to stay in theater? rather than coming back for a inspection? What if I was on the aircraft and I was either injured or killed? How would my family deal with the aftermath of all that? So this was a very difficult time, and I had to really talk it over with the people that I worked with, to get a better sense of my purpose in my roles. The other aspect, and I think that's a microcosm and a small skill of what many people might be feeling. Why are we leaving? Is this the right time to leave? Did we prepare our coalition partners to successfully, you know, stand up and and with and hold up a government as we leave? So there are many questions, but in the way I've thought it through, I think there's some core correlation to this. And, and again, I've had to re approach my contacts from all 13 years ago to start this discussion again, because it has certainly opened some wounds that I'm still processing to this day.

Andrea Austin: 12:54

So I want to talk about that survivor guilt a little bit more. Knowing this is very sensitive, and I'm so sorry about the colleagues and friends that you lost. Because I think that has been triggered for a lot of people as they reflect on their time in Afghanistan. I know you said you talked with your colleagues. But is there any, any tangible tips you can give somebody that's dealing with survivor's guilt, or some of those memories have been brought up as they've been watching the coverage of what's unfolding in Afghanistan?

Max Lee: 13:34

Another great question, Andrea, as we discussed, sometimes, the process of venting and speaking and verbalizing the feelings that are happening, I found to be very helpful in getting to the core of why I may be feeling some of these survivor's guilt or some sort of retrospection and sometimes self flagellation. Right. So, as we think these through, for me, the most effective members who I can share these, you know, difficult past experiences were those who were in that situation, no matter, there are a lot of resources available. But for me, having spoken to people who were in similar situations, or in fact, in the same teams that I was, has really opened my eyes on how this is affecting a lot of people in many different ways. And that sense of camaraderie and, and team teamwork, really, I think opens up to a much more open and frank discussion on how this is affecting us, both personally and professionally. So I think speaking to peers has a lot of weight that should be utilized to the best extent possible. I'm not saying to exclude professional health, if you need that level of support, and help by all means I encourage everyone to seek support. But it's a complimentary and yet a slightly different way of approaching and processing these difficult situations and highly encouraged reaching out to your peers, because they'll have a level of understanding and the opportunity to speak frankly, about some of the maybe not necessarily classified but more sensitive issues that the non operational psychologist or other mental health care professionals may not be aware. I

Andrea Austin: 15:49

I think those are really important tips. And there's a lot of literature out there about when you're feeling emotional distress There is power in naming what that is. So trying to get more granular on if you're mad, or sad trying to add a few more words to actually describe what is making you feel mad? Or is it really more that you are feeling anguish or regret, and then you can explore that a little bit more in, you know, as we're going to see with whatever survivor guilt you have, you know, on a logical level, that, you know, you you really couldn't have been there, you really couldn't have done more. And I think, as emergency physicians, you know, it's it's not exactly survivor's guilt, but a little bit, we see a smaller sliver of that, when we have a bad outcome with a patient or an unexpected bad outcome, you know, we have those that those questioning emotions. So I also really liked how you highlighted the importance of peer support. And that is a program that the American College of Emergency Physicians is expanding, as we go through the covid 19 pandemic, that, you know, we really can draw on each other. And I think, as prior military, we recognize that, that the relationships you build that camaraderie that you alluded to, is very, very strengthening. So in this moment, where we are still dealing with social distancing, and dealing with some isolation, I would encourage people as much as you can to reach out, even if that is over a virtual platform, and maybe we are getting some fatigue from that. But instead of turning in Word, if you can connect with people, I think that's really important. So some of the discussions that we've been having is some emergency physicians didn't deploy to Afghanistan, but they were here in the United States. And they were taking care of people that came back from Afghanistan and one of my colleagues so that we know well, you know, described a story about being a medical student and taking care of, you know, so many patients coming back from Afghanistan with amputations, and that had a very profound impact on, you know, what she perceived military medicine to be. And, you know, I remember being an intern in the emergency department and starting ketamine infusions on a pretty regular basis on veterans returning with Phantom, you know, phantom limb pain. And looking back on that I now realize how unique that was that that became a routine thing for me that oh, we have, you know, a, you know, service member, that we need to start a ketamine infusion on which that's actually pretty unusual. So do you have any advice for people that, you know, didn't go, but now they're, they're watching the coverage, and they're like, gosh, you know, I took care of so many people, or I'm still taking care of them, I'm seeing them with their PTSD. And, you know, they're coming in the emergency department. You know, with the continued sequela of their injuries. Maybe they're coming in, after an episode of drinking, and they're struggling with alcoholism, there's just so many fallouts from this conflict. So I think a lot of us are just experiencing anxi over the continued trauma that we see from the sacrifices that were made.

Max Lee: 19:45

Thank you, Andrea, very important question, I think we'll see and continue to see many members affected by the recent wars. The closest thing I could relate to is having a, a championship level team that you work with, and you interact with and having them be affected in different ways. And you get to learn more about their both physical as well as psychological and social trauma that occurs. And the more we try to understand the kind of the inner workings and psyche of our warfighters who were previously deployed and those who have returned without potential external injuries, but certainly, both psychological and some people call it moral injury related to years of continued warfighting is important. We'll ask or one resource that we could look at. And a book that I recommend I need to my residents and people that I interact with is both by Eric and blehm. And the book's title, the only thing we're dying for, is a story of how we live and grow. For a spot for a new Afghanistan, right, so understanding the mindset and the teamwork that was involved to, to execute this mission is a eye opening account of how each team member, and not only values what they are able to contribute to the team, but how they rely on other people to be part of that team for team team and mission success. And when you look at it in that context, the death of a different teammate or another member, or even limitations due to both physical and or mental health issues is devastating. It's like taking out a key player on a baseball on an all star baseball team is how I can relate it to. So understanding the dynamics of how that team works and how missing parts of that team will affect the other individuals, I think is the start of deeper understanding into how our veterans are affected. There will be many hundreds of 1000s, if not millions of veterans, who will continue to get care in both our VOD and, and VA facilities. And there may be members who are in the community that are affected. So I would request our audience to take a moment of your time and talk to them about their experiences in in theater, and how it has affected them. I think we will learn much more about what what they are going through. But also it will be therapeutic in helping our our members in need, understanding that we're here to try to understand and to help them in the best manner we can, rather than just being a cog in the machine.

Andrea Austin: 22:57

I think that's so wonderful. And any of our of our civilian colleagues that are listening, I would just really ask that, you take that to heart. I think the hardest thing before I deployed was the disconnect between what I was going to do and the average person in the United States. And just to give some examples, before I left. So my non military friends said, Oh, we still have troops in Iraq. And that hurt because it felt like people don't even know that we're still there. And then somebody asked if my husband was going with me, you know, to a combat zone. So it's just like a level of complete disconnect between the sacrifices happening. And what I hear sometimes is, well, not that many people died in Iraq or Afghanistan. And, yes, if you compare the numbers to World War Two, or Vietnam, I understand that less people died. But the reason less people died was a ton of advances in both technology, body armor. Also, what we did, as resuscitation is in the advances that were made. The cost of that though, is more people survived. And people survived with trauma. And I use trauma in the broadest sense. So people had brain injuries, and the rate of brain injuries, you know, the force that people have gone through with these explosions, you know, whether they were in a tank, they still have injuries to their brain. So a lot of the wounds of the conflicts that we've gone through in the last 20 years are harder to see. But I want people to know, just because they're harder to see doesn't mean they're not there. And I do believe that all of us whether you work in the civilian emergency department of VA, the military center, you're going to see these veterans for the next 50 years, and having some concept of what they went through, I think is really important. And I think that's been the hardest thing for me personally, I don't know what your feelings are on that kind of that civilian military disconnect.

Max Lee: 25:19

I too feel sometimes that it's not from lack of wanting to understand, but there are a lot of nuanced military missions and purpose on why we deploy and where we go. And that can be lost in the big the big discussion. You know, these are high, very high level discussions. And we're used to a very abbreviated news cycle, and things that happened maybe even a few weeks ago, gets supplanted by another bigger news or something else that's happening. Sometimes. I also felt that The our civilian counterparts didn't didn't fully understand or appreciate some of the sacrifices that were being made. I don't think it was done in a malicious or intentional manner. I just think that the how quickly things are updated and how how many things that are also happening in the world makes it difficult for people who aren't living in that world all the time to fully comprehend. But taking that little time to connect with the either the patients or even your colleagues who may have experienced, you know, trauma and abroad, since, as you stated, I guess it shows a deeper interest in what it is that you're going through. And I think it's very sincere and genuine when approached in that manner, rather than in just a purely clinical manner. One of the most valuable lessons I think I was taught as a newly minted staff physician was, Hey, have you talked to this gentleman about his or her history in the military. And speaking to a world war two veteran who survived the Bataan Death March, I was amazed that the experiences in this person went through. And, you know, the gratitude I felt in being able to provide his health care. And it puts a whole different perspective to me on, on how to approach patient from not only an empathetic, but in a caring and loving way. And I think it's not only good for the providers, but it's also good for our patients.

Andrea Austin: 27:48

So I want to press on a little bit more of this concept of how, how we find meaning, and in what we did, and I'm going to tell you what my reflection has been in the last few months, and I'm interested in in your thoughts on it as we process what's going on. So I alluded to before I left for Iraq, I questioned what what we were doing, it was 2016, we This was going back into Iraq again, and that was to support the Iraqi military in their fight against ISIS. And I understand Iraq is very different than Afghanistan. So I'm only speaking from my personal experience. Before I left, I thought this is incredibly disruptive to my life, both personally and professionally. And it wasn't until right before I left that I was like, I could get hurt, or, you know, I could die. This is actually pretty serious. It was always kind of a very, like, far off thought in my brain till right before I left. And I was pretty angry right before I left. And then when I came home, I had some feelings of like, I don't really know what that meant, what I did, and now with some time and distance from it. And we see what's happening in Iraq as well. You know, I don't think it's an exaggeration to say that, you know, these are potentially failed states, Afghanistan, certainly going back under Taliban control is not what we envisioned. What I have come to conclude is my service was for my, the people in my unit, it was for the Iraqis that were injured, we took excellent care of them, we certainly saved their lives. And if we had not been there, it is not an exaggeration to say they would have died or had horrific outcomes that we truly helped those humans. So now, you know, five years later, looking back on it for me. I don't know about the geopolitical situation. And I honestly, I, I don't know what to think about that as a citizen. But what I do know is I did a good job as an emergency physician. And I take solace in that. So I wonder if that's a coping strategy that you're using right now is like focusing more on like, what you did, and the job you did, versus the whole time to connect that to a larger purpose.

Max Lee: 30:34

Yeah, Andrea, I think you hit it right nail on the head there. We are very used to being self critical. All right. We have morbidity and mortality rounds. We have stand ups, we have QA and all these things that occur to highlight the deficiencies and errors that we've made. But I also think we also need to take some time to say okay, what did we do with the resources and the knowledge that we had at the time and quite honestly And frankly, it is amazing that what our deployed military medics as well as physicians and our extended providers are doing out there with, because you can't train for every scenario or every situation, and you're going to be short on supplies and resupplies. And what they are able to do and save lives is amazing. And that should be acknowledged and celebrated. In many ways. I, when I entered the military and pursued medicine, my goal was to serve those who are in harm's way fighting for our nation. And that has that theme overall has carried through but how that is applied has made me morph during my career. And during each of my deployments, as a seacat. Doc, I probably wanted to understand and be a part of something that was new, a doctrine that was developing, how do we take care of a wounded injured in route rather than, you know, take them to one location and fix them up and then wait for them to recover, and then evacuate them. So it was a new way of doing business? And, and that was kind of exciting to challenge my clinical acumen. The second time to Afghanistan as a, as a member of the team in special operations. That was my first Special Operations deployment. And I wanted to kind of prove myself to see okay, you know, can I cut it in this field? Am I able to carry a rock Dinis missions in challenging environments and difficult situations? And really, to push myself? But I think it gradually evolved into, you know, what is it that I can contribute to the team into the fight, it became less me centric and more of a team centric approach. Part of the reason I volunteered to go again, a second tour in Afghanistan, was because I wanted to prove myself in missing out on that initial mass casualty as well, as you know, the challenges of, you know, why am I the guy who got out into there and didn't fly with a team that day. And it was almost in a strange way therapeutic, I got to think about it, talk over it with my medical team together. And when the opportunity arose. We had a mission. In the mountains of Afghanistan, during February, we had roughly 40 cold related injuries, whether it's frostbite or hypothermia, and then many multiple traumatic casualties, I will care about a time. And we were able to function as a team and I felt that I was able to contribute as a emergency physician and as a resuscitation specialist. And that mass casualty situation really was reaffirming for me that Yeah, I am part of the team. And I know I could grow and learn and adapt from difficult situations. So part of it, I think part of being an emergency medicine physician is putting yourself out there in unknown, undifferentiated resuscitation. reels, right. And that I think, extended into my pursuit of those challenges. But again, it wasn't initially I think it was more for me and understanding my limitations. But then I think it gradually morphed into how do I contribute to the team? So I hope that answers some of the concerns or questions regarding finding purpose in one's role as a military emergency physician or a member of the emergency medicine community supporting those who have fought in wars as a VA or government service position.

Andrea Austin: 35:06

So the last question I want to talk to you about is, I think a lot of us are struggling with what the fallout from Afghanistan is going to mean for many different groups. But you know, for me, as a woman, I'm very concerned about the women and girls left behind in Afghanistan. And it's hard, because I know the power of our military. I know, our military might, and that we were able to hold back the Taliban for about 20 years and life improved for women and girls in Afghanistan. So what would your advice be for for us right now in this moment, where we're just struggling with that, like, Are we really leaving all these women and girls behind and what is the role of the military When it comes to these situations,

Max Lee: 36:05

Thanks for the question, Andrea, we had a excellent team of surgical resuscitation specialists and emergency medicine providers. But one thing we did not do very well was a be able to treat and care for female casualties are female civilians. And we found having a male ID EMT or independent duty corpsman from the Navy assist in some of our humanitarian missions to be a game changer. So there is a unique role and a super versus sweet that I think our military medics who are female can contribute to the war efforts. Having said that, we have been very careful in my opinion in leading with the military, because as we've seen, that really fundamentally hasn't changed both the culture or the set expectations of the Afghan people. And in order to really start the nation building process with a inclusive, inclusive mindset. It has to be led by education, diplomacy, and economic means, so that the people in the culture fully understand and realize the benefit of engaging the whole entire human population of a nation to affect their goals, rather than just the military one. It can be said that, you know, if you live by the sword, you die by the forest sword and in that mentality, that's probably the worst way to go about affecting long term and lasting change that includes women, as leadership and as a valued member of society.

Andrea Austin: 37:51

I think a lot of people are struggling with how quickly the Afghan military fell, knowing that so many of our service members were involved in the training of the Afghan military. Are you surprised or What is your reaction to how quickly the Afghan military failed?

Max Lee: 38:11

The American way of fighting wars is very different than what has traditionally the way the wars have been waged, and Afghanistan. Americans, as a military fighting force rely on intelligence and agile combat logistics to get things done, right. If we don't have iosr, many of our missions do not happen in the first place. If we don't have ability to air up, ammunition, supplies, and air casualties out of the battlefield, it becomes severely challenging. So our mechanized and airlift capabilities is a huge part of our ability to wage Modern Warfare. Due to the terrain and the soldiers in Afghanistan, that becomes even more relevant. And without the intelligence support from Asr, or RPA. Without the mobile insertion or extraction of troops or injured from helicopters, fixed wing data sets that war, how they fight the wars becomes very challenging. I was listening to a different podcast where one of the Green Berets went on a mission with the Afghan Special Forces. The Green Berets got into their em wraps the armored vehicles that are designed to withstand IED blast, and the Afghanis got into their armored Humvees, which are much less capable in ID explosions. And in their discussions, the Afghans asked Danny, Special Operations leader said to the American greenbrae forces, would you go on this mission in the vehicles that we have currently? And the greenbrae, you know, was kind of shocked at that, because no, they probably would not. Yet we are expecting our members that were, that are in Afghanistan to fight a similar war with different tactics and different equipment than what we are used to fighting with. So that's a long way of going about and saying that they're it's a different type of a war and we Americans fight in the way Afghanistan is our people of Afghanistan are very different. So the infrastructure the the the way of thinking, the the not only the people fighting the wars, the people, fixing the equipment, and providing logistics, all those other things that have had to change to In my opinion, to to seamlessly turn over the world. warfighting and security details to the host nation. So I think there are certain opportunities to improve from this situation and learn from and that they a more phased and goal targeted or objective measures, as we ratchet down our presence may have led to a little bit more smoother transition.

Andrea Austin: 41:31

really complicated issue. And I think that's, you know, the the number one thing, this is a nuanced, complicated dilemma. You know, that's been one of my favorite things that I focused on this year that, you know, there's problems problems imply an easy solution. And then there's dilemmas. And this is certainly a dilemma in which nothing was going to be fully satisfying. And there was always going to be cost with every decision we made. Well, thank you so much for coming on the podcast today. As we close out, I'm wondering if you have any parting thoughts or any other advice you would like to give our listeners

Max Lee: 42:15

Thank you, Andrea, for having me. I certainly appreciate the the careful thought and, and efforts that you've provided in providing a service to our community and those that we serve. I would encourage our members and listeners to, to be engaged and to look for opportunities to maybe initially learn but in the future, contribute your knowledge and your experiences. And, and I fully believe that having a collaborative model in looking for novel ways to solve or approach some of these dilemma is critical not only in this context of what we're talking about, but for the future of emergency medicine, learn, get involved, and go in there with the mindset of helping others. And I know that we can come together as a community to to benefit the society as well as our patients. Thank you.

Andrea Austin: 43:23

Thank you for listening to today's episode. I hope it was interesting and thought provoking. Please give us feedback. You can email me directly at Andrea Austin md@gmail.com. You could also tweet at us We are at GSA CEP. Also please let me know if you want to be on the show. We want more people to share their perspectives, whether it's about Afghanistan or about other experiences you've had as a military or federal emergency physician. We're always looking for guests. So thanks for listening and thanks for all you do.

Narrator: 43:59

GSA Sep is proud to be the premier continuing medical education source for military and federal emergency physicians. To purchase the Emmy for the episode you just listened to please click on the link in the show notes. The government services chapter of the American College of Emergency Physicians promotes quality emergency care and enhances the development of emergency physicians who serve our nation from training through retirement. Learn more about our chapter@www.gsacep.org