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Cover Story


 

Battlefield Surgeon

By Marion Blackburn

His patients roll in, day after day, sometimes by the dozen, their injuries so horrific it could overwhelm even an experienced trauma surgeon. The young men may have stepped on an IED—an improvised explosive device—or taken a mortar hit. Often they’re barely breathing, their chests torn open, an arm or a leg nearly blown off.

If you are that trauma surgeon and your hospital sits in “Rocket City,” an American military base just over the Afghan border with Pakistan, you can’t lose your cool when their lives are at stake. And it’s always in the back of your mind that as a U.S. combat surgeon on the front lines of the Afghan war, you’re a target, too.

Saving lives under fire is sort of a part-time job for Dr. Paul J. Schenarts, known to friends and family as P.J. The Brody School of Medicine associate professor and ECU trauma surgeon is a lieutenant colonel in the U.S. Army Reserves. He’s just back from deployment to Afghanistan.

A respected teacher who has won the UNC Board of Governors Distinguished Professor for Teaching Award and the Master Educator Award from ECU, Schenarts also been called the best combat surgeon in the Army. That was the assessment of Col. Christian Macedonia, the military physician and medical sciences adviser to the Chairman of the Joint Chiefs of Staff.

He just returned from Salerno, the third-largest U.S. base in Afghanistan—a place where bombs, automatic gunfire and casualties are daily dangers. That’s not even his worst assignment. That might be serving as a surgeon at the notorious Abu Ghraib prison in Iraq, where he was assigned just months after guards were photographed abusing captives. His main duty is treating U.S. soldiers but his patients include local citizens, especially children. He also treats the bad guys, whether Taliban, al-Qaida or something worse.

“Somebody has to take care of those patients,” Schenarts says. “It’s like any other patient. We don’t have moral dilemmas taking care of drug dealers or drunk drivers. You treat people like people. But a lot of people say, ‘Did you really want to treat them?’ As a doctor, and as a human being, while they may have different political views or they might not like you, to say the least, your job is to take care of them.”

Schenarts returned in October from his sixth overseas tour and immediately stepped back into his dual civilian roles as a trauma surgeon and a teacher of medical students. He’s one of the most popular instructors at Brody; residents and fellows and others he’s training trail him on hospital rounds in a focused entourage. He came to ECU in 2001 a summa cum laude undergraduate and Vanderbilt-trained surgeon, and since then has juggled responsibilities as an active reservist, ICU attending physician and surgeon, instructor, husband and dad to son Spencer, 4.

He has been awarded a Bronze Star, Army Commendation and Achievement medals and a NATO medal. At Brody, he’s received the National Outstanding Teacher Award from the Association for Surgical Education and ECU’s Robert L. Jones Award for Outstanding Teaching. He expects to return for a seventh deployment in 18 months.

Whether teaching or serving as a soldier, he brings so much compassion to his work that even wounded enemy combatants have shared their secrets with him. After treating a prisoner’s burns at Abu Ghraib, the man turned over useful intelligence. “He said, ‘Hey, you saved my hands, I was misguided,’” Schenarts remembers. “Other times we save children of Taliban and they come by and say, ‘We’ve been told how bad Americans are but you saved my daughter, you saved my son.’ That happens quite a bit.”

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Field Camp

Two surgeons and a tent



Schenarts’ road to Greenville—and to Rocket City—began in 1994 when he was a second-year surgery resident at Maine Medical Center. That’s when he decided to enlist. “My joining the military is absolutely sincere,” he says, knowing it’s rare for someone with his specialized skills to enlist. “I think everybody needs to give something back. There are very few trauma surgeons in the military, and that’s why I decided to do it. I have not been disappointed.”

First he was a surgeon in the U.S. Army Hospital in Nashville, Tenn., and then he supervised Special Forces medics as they rotated through at Vanderbilt for advanced trauma training. He worked on a National Institutes of Health fellowship at the University of Texas, including time at the Shriner’s Burn Institute there.

A New York City native, graduate of Fordham and the University of Connecticut, Schenarts came to ECU for its national reputation. Its paradigm—all attending trauma surgeons take care of patients in rotation—has made ECU’s trauma service a model for the nation. “North Carolina is very well known in trauma surgery,” Schenarts says. “Most people don’t know it, but we are nationally very well known, very well respected.”

His first active military tours came in 2003 during Operation Enduring Freedom, with the 948th and 946th Forward Surgical Teams in Afghanistan, and in 2004 with Operation Iraqi Freedom, when he served at Tikrit, Abu Ghraib and Baghdad with the 933rd Forward Surgical Team. He was also a senior surgeon in Baghdad, working at Ibn Sina, which used to be Saddam Hussein’s personal hospital. A forward surgical team is a pared down, mobile unit designed to stabilize wounded soldiers before moving them to a hospital.

He’s a member of the Liberty Medics, formally stationed in Fort Dix in New Jersey, so not only does he think like a doctor, but like a soldier, too.

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Dr. Schenarts working in a busy hospital.

Medicine in the military has a unique perspective, he says. “The motto of the Army’s medical corps is not to save lives. It’s to preserve fighting strength. It’s very different than where medicine fits in the life of a surgeon [back home].

“On a military forward operating base [a frontline base], there are other things that take precedence—food, water, protection, ammunition. The doctor is almost second on the list, because there are many other things that are far more important to the life of the base than you. You learn where medicine fits in the grand scheme of things. I think the chaplain is last. So it’s a very different social structure.”

Every day means devising solutions to problems you never see in med school, and that’s different, too. On his first deployment to Kandahar, the hospital was in the airport. His first time at Salerno (near Kowst), the OR was “two surgeons and a tent.” Sometimes he works in medical settings right out of the 1940s. Although not a neurosurgeon, he once performed brain surgery on two little boys to save them.

His third tour to Salerno came in 2010, when he was deputy commander for clinical services at the hospital, which these days is an advanced battlefield medical center, with CT scanning and X-rays. Still, it’s a long way from home—and not just because of the technology gap. There’s a values gap, too, as some of his deepest convictions simply don’t apply in Iraq or Afghanistan.

“When you’ve been in a part of the world where there are no laws, and there are no rights, where there is no social safety net, you appreciate what you have here,” he says.

One of his most poignant stories describes a boy, badly burned not by an explosion but by deliberate abuse. For the first time in his medical career, he faced the unbearable choice of not treating the boy.

“There are no child protective services,” he says. “If you save these children, they go back to their families of origin. The child then represents a risk to his brothers and sisters. The child can’t feed himself. And if the child isn’t self-sufficient, it’s going to have a rough time.” Schenarts treated the boy, but he later died of his injuries.

In another case, a woman was shot at her husband’s second marriage. He treated her; she recovered. But her family “didn’t need her and decided it wasn’t worth it to feed her. She starved to death.”

It’s hard to imagine withholding treatment, but sometimes it’s an advisable, if regrettable, option. “We just can’t take all of them in, or send them here,” he says. “You have to recognize the context in which you’re practicing. You can get very frustrated to see a young lady you worked very hard to get out of the hospital starve to death.”

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Dr. Schenarts with a patient.

The home drill



As an attending surgeon at Pitt County Memorial Hospital, the medical school’s teaching partner and a Level 1 Trauma Center, Schenarts makes daily rounds in the intensive care and surgical critical care units, and takes care of incoming trauma patients. They’ve been in a car accident, been shot or knifed. It’s a considerable load: as the only regional trauma ED, the PCMH trauma center served nearly 70,000 patients in 2009. Of them, 2,700 had significant trauma requiring hospitalization. When the hospitals at UNC and Duke decide they’re at capacity and send patients elsewhere, they land here.

On a cold morning in late November, just a few weeks after coming home, he’s on rounds with a team of med students scrambling to keep up with him. The first patient is an older man hit while riding a bicycle. Not only does the patient have a punctured lung, requiring him to be on a ventilator, but he’s also at risk of complications including alcohol withdrawal. It’s suggested he should be given moderated alcohol while recovering, a response that shocks the medical students.

Schenarts reminds them that alcohol withdrawal can kill, and after a charged discussion, they agree he’ll receive medication and be watched for withdrawal symptoms.

Next they visit a patient in a coma after a car wreck, unaware for now that a family member has died in the same accident. Next, they must decide the next steps for a patient with a brain injury. He asks for their assessments, listens without interruption, and then presses them on the possible consequences of their decisions. He takes notes with a fountain pen, then looks up and says, “I’m asking you to predict the future. Because you’re going to be a doctor.”

An old man with broken ribs unsettles everyone. Each breath brings pain, but medication to help him will inhibit his breathing. What to do? Schenarts offers a framework, as he does for complicated cases: “Break it down to its simplest components.”

Before noon, they’ll examine an accident victim who may have cancer; a lady with a broken leg whose complications include diabetes and kidney disease; a woman who may have shot herself. These are high-acuity, high-stress situations that demand a choice. “We try to put students in decision-making mode, because when they’re done, they’ll be in decision-making mode from the day they start,” he says. Moreover, in trauma centers with this level of care, seriously injured patients must be seen within 15 minutes by a senior-level physician. The benefits are clear. “The complications are fewer at a teaching hospital,” he says. “It’s a team approach, and nothing is done without supervision.”

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Dr. Schenarts in a medical meeting.

His other OR



At Salerno, it’s another story. He often works alone. Once he struggled through a surgical procedure while the OR was on fire. He’s saved soldiers with grave injuries, who, years later, sought him out to thank him. Their families, too. He saved a young man who was dying of an unseen stomach wound and, “probably two years later, sitting at this very desk, the phone rang and it was his aunt who called to say, ‘Thank you.’ His mother called six months after that. They said his wife was pregnant, and he was doing fine. But he couldn’t call himself, because it was too emotional.

“We had a kid come in who lost a leg in an explosion, and who came into our hospital at Salerno, with no pulse, no blood pressure. We got him back, operated on him, and he’s now trying to re-enlist, with one leg,” he says. “I’m always embarrassed, because I get so much more out of the experience than I give. It always is a great experience.”

Soldiers have shown up at the hospital looking for the man who saved their life, says Dr. Michael Rotondo, professor and chair of the Department of Surgery at ECU and director of the Center for Trauma and Critical Care. “These are people who’ve come to find him, to thank him, for what he did for them,” Rotondo says.

“He has an amazing amount of integrity in everything he does,” Rotondo adds. “He has a high set of values to start from. He makes the most of whatever he’s been asked to do, to make it excellent in every way. And he pursues it with passion.”

During his deployments, other trauma surgeons pick up the extra work, and their support—along with that of the department, medical school and university—earned ECU the Secretary of Defense Employer Support Freedom Award. It’s the highest recognition given by the U.S. Government to employers for their support of their employees who serve in the National Guard and reserves. ECU is only one of only 15 chosen from about 2,500 nominees to win this honor.

“Being a Freedom Award winner means you’ve gone out of your way to work with the military, with those deployed,” says Steve Duncan, assistant vice chancellor for administration and finance and director of military programs. “It says East Carolina is out there as a distinguished institution. Of the honors we get, it’s one you can greatly respect. It’s truly earned.”

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Dr. Schenarts with his son.

Teacher, father and chef



When all is said and done, Schenarts enjoys teaching most of all. That dedication to “reaching down and pulling up” is evident when he respectfully asks residents to carefully consider every treatment choice—whether taking a patient off a ventilator, prescribing medication or sending someone home.

His likeability and high standards make him a remarkable mentor, says fourth-year surgery resident Dr. Michael Meara. “He’s a lot of the reason I’m at this residency right now,” Meara says. During his interview, they talked comfortably about being Eagle Scouts, and “it turned into the easiest interview I ever had.

“From a resident standpoint he’s our biggest advocate and stands behind you. He does that for better or worse. He’s also the first guy who, if you screwed up, will tell you how—and how to be better. It’s always very constructive.”

And while Schenarts brings an air of military discipline, it’s never at the cost of showing his soft side. “He’ll tell you about his experiences in war, then follow up with a story about wrestling with his kid,” Meara says. “He wants you to be 100 percent in what you want to do.”

Regardless of the demands, he’s a devoted husband and father to his son, often hunting dinosaurs in the backyard with him. He’s also an accomplished chef, whose specialties include ice creams and sorbets. He treasures his family time, because he knows about life on the other side of the world.

“My time deployed informs much of my decision-making here,” he says. Whether it’s Salerno or the trauma bay in Greenville, there’s going to be stress. “Sick people are sick people,” he says. But at the hospital ICU, he can count on his colleagues, as well as highly trained nurses and other professionals. As a combat trauma surgeon, working with reservists like himself in battlefield conditions, or with another surgeon in a tent, it’s a different story. “I don’t have a big team,” he says. “It’s just me.”
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Dr. Theodore T. Koutlas.

Dr. P.J. Schenarts is an embodiment of the Brody School of Medicine’s long and proud tradition of serving the military. Among other projects, the school’s Department of Surgery is engaged with trauma training for military doctors. Several faculty and administrators there have completed military service, including Dr. Paul Cunningham, dean, who was a major in the Army Reserve Medical Corps.

Dr. Theodore T. Koutlas, a pediatric heart surgeon, serves as a reservist and is currently on duty in Afghanistan as the surgeon in chief for the 909th Forward Surgical Team. He signed on in 2004 and is currently serving on his fourth deployment, his first in Afghanistan. He is working with a mobile medical base south of Kabul.

Like Schenarts, he treats the complex injuries caused by roadside bombs and is often under fire himself.

“Here it is almost all general surgery, nearly exclusively trauma surgery,” Koutlas said by e-mail. “Where I trained and went to medical school we had pretty robust trauma programs, so it has not been a real difficult transition. The main difference is the scope of military trauma compared to civilian injuries back home.

“The devastation caused by high-velocity weapons and IEDs (improvised explosive devices) is like nothing you ever see back in the States. It takes a little while to get used to, and even very experienced trauma surgeons from the United States have a learning curve when they get here.”

Military medicine has made remarkable advances during nearly 10 years of war in Afghanistan and Iraq. These advances will find their way into medicine back home, ultimately improving treatments for all patients.

“The Army has an excellent system in place for management of patients from point-of-injury to recovery at places like Walter Reed Medical Center,” Koutlas writes. “This system includes the widespread use of tourniquets and ‘combat gauze’ (bandages treated with a blood-clotting medication) by soldiers and medics in the field, having surgical teams like ours located in forward areas for damage-control surgery, very aggressive resuscitation and blood transfusion protocols and an incredible air evacuation system.”

As you listen to him talk about daily life as a battlefield surgeon, you see that even in the chaos of war, there is routine. “We are on-call 24/7,” he says. “Sometimes we go a day or two without any cases, some days we have eight–10 casualties brought in. Some of the time the injuries will be minor, but then we get some real bad cases.

“Most of the cases come in between 09:00 and 18:00, so we generally try to go to the gym early in the morning, then again in the afternoon, depending on if there are cases to do. We go eat at the chow hall two–three times a day. All these places, including our living quarters and the hospital itself, are tents. Occasionally we get cases late in the night. The rest of the time we either read or watch movies, hang out. We are a very tight unit (about 18 soldiers), and we enjoy hanging out together. You make bonds over here that you can never duplicate in civilian life.”