A Brain Surgeon’s Long Journey Home from the Iraq War

W. Lee Warren, MD, is a writer, neurosurgeon, inventor, and Iraq War veteran. His book No Place to Hide (2014) is a #1 Amazon bestseller. Now a retired major of the U.S. Air Force, Dr. Warren served our country for 14 years and was deployed to Iraq in 2004, during Operation Iraqi Freedom. He was the second neurosurgeon to be deployed since Vietnam. At the 332nd Air Force Theater Hospital at Joint Base Balad, Iraq, he was trained in a different specialty—surviving over a hundred mortar attacks and repairing the damages of a war that raged around every detail of every day. No place was safe, and the constant barrage wore down every possible defense, physical and psychological. Lee Warren’s story is an example of how a person can go from a place of total loss to one of strength, courage, and victory.

Dr. Warren practices minimally invasive brain and spinal surgery, develops new technologies with his wife through their company, Warren Innovation, and is an affiliate professor of biomedical sciences at Auburn University. In his spare time, he plays guitar, writes songs, and recently completed his first novel, Kill Switch.

Congress Quarterly: What inspired you to enlist in the Air Force and to become a neurosurgeon?

Dr. Lee Warren: I’m from a small town in Oklahoma, and I was looking for options to finance my medical education. The opportunity for a military scholarship came up, which was exciting to me, as there was some military history in my family. I was offered the scholarship in 1991, and was commissioned as a second lieutenant before I even started medical school. I went into medical school thinking I was going to be a family medicine doctor. In my third year of medical school my son was born, and I needed to change my schedule. The only rotation available was neurosurgery, which I knew nothing about. The first day the chief resident let me drill burr holes on a two-year-old sagittal synostosis patient. I was hooked from the first time I put the perforator in my hand. I did two more rotations in neurosurgery and was fortunate enough to match in neurosurgery at Alleghany Hospital in Pittsburgh.

CNSQ: You are involved in many things—your busy practice, your work in innovation, and your writing. What has inspired you to explore these different directions?

LW: I think I’m bent towards doing more than one thing. I’ve always had a lot of interest in writing and music, among other things. There has to be balance in life. I think we’re all spiritual, physical, emotional, and practical beings, who have all kinds of different skills we can develop. If you focus your whole energy on one aspect of yourself, then I think you tend to miss out on a lot of what’s great about life.

CNSQ: When you enlisted and joined the Air Force in medical school, did you ever think that you would ever be in a war zone operating?

LW: No, not at all, because when I enlisted in 1991, it was peacetime. The whole time I was enlisted, until 9/11, we were at peace. Even after 9/11, up to when I was ultimately deployed in 2004, the philosophy of the U.S. Air Force was that the people who are hurt badly enough in the field to need a neurosurgeon probably weren’t going to survive long enough to get to one. There weren’t very many neurosurgeons, maybe only 12 in the whole U.S. Air Force. The thinking at that time was that the neurosurgeons should be stationed in Germany or in the United States. Then, in early 2004, the Air Force realized that soldiers were getting to the field hospitals much more quickly with excellent on-the-ground care and medevac, and they needed all the specialists in theater to save lives. By the end of 2004, I was in the air. All of a sudden it was, boom, “You’re going.”

^{Wearing a holstered 9mm handgun in the OR. on Iraqi Election Day 2015, doctors were ordered to be armed at all times.}

CNSQ: What was going through your mind before you left for Iraq? What were you expecting and what did people tell you about what it would be like to be there in that capacity?

LW: That’s an interesting question, because we really had very little information about what we were getting ourselves into. The Army had been carrying the medical mission for Iraq and Afghanistan since the start of those wars. Then it was decided that the Air Force would take over the combat support mission. In September of 2004, the Air Force deployed Dr. Peter Lenners, who had a practice in Denver. He was the first U.S. Air Force neurosurgeon to be deployed to Iraq, and I was the second. So there wasn’t a lot of information coming back about what was happening. I really left without a clear sense at all of what I was going to experience once I got there.

CNSQ: What was an average day for you like in Iraq, if there was such a thing?

LW: We were in a war, so it was hard to have any kind of routine because the purpose and the mission of that hospital was to take care of trauma, and the very frequent mass casualty events. Whenever a bomb would go off or a battle would occur, we would get 10 to 30 patients in the ER at the same time. You never had a sense of knowing what a day might hold. But it was a typical hospital in the sense that we had operation rooms and ICUs and regular nursing pools. We made pre-operative rounds and had critical care rounds like you do in any normal hospital, except we’d be wearing body armor and carrying side arms and waiting for the next mortar to land.

CNSQ: You tell a vivid story on the NPR series Snap Judgement of having to make this very difficult decision. A Marine and an enemy combatant came in with severe traumatic brain injury at the same time and posed a dilemma. How do you recollect that experience?

LW: It was a really exciting and difficult day for all of us. Dr. Todd Abel was the other neurosurgeon that was there with me. Dr. Abel was operating on a soldier when two new patients, an American soldier and a terrorist, came in. They both needed surgery, and we only had one set of instruments left. I made the decision to take both patients into the operating room at the same time, hoping that by the time I got done dealing with one, Todd would be available to help with the other, and it turned out that he was. Since we had only one set of instruments, we shared them. The nurse would pour alcohol on them and clean them as best she could. I tried to do everything I needed to do with my patient before I handed an instrument off to him. We got both of those patients through it, and fortunately neither of them developed a brain infection or anything terrible.

That incident has remained as one of the most important lessons I’ve learned in neurosurgery. In America we have a gross excess of everything—all the blood product we need and every instrument available. In Iraq, despite the fact that we were limited, we were still able to do high quality work, which made me realize that none of us should be primadonnas about what we have, and yell and scream when we don’t have everything we want. You can do a good job with the instruments that you have available to you. Also, solving a complex problem is always possible if you put your mind to it. Todd and I collaborated and figured out what to do. We took care of those two gentlemen, and both of them survived. That’s a great lesson for all of us.

^{Medics unload a casualty from a Black Hawk Helicopter, Balad Air Force Theater Hospital, Iraq, 2005.}

CNSQ: What were some of the kind of cases you did there?

LW: Far and away the most common case was penetrating brain injury. We had all kinds of bombs going off. The American soldiers generally had body armor, protective gear on the torso, and usually helmets. Many of the injuries tended to be to the extremities, so the orthopedic surgeons were really busy. Even the ophthalmologists were really busy. There were a lot of projectiles coming from ground level that would penetrate through the facial bones and occipital bone and get under the helmet and penetrate into the skull. We had lots and lots of penetrating, low- energy projectile brain injuries.

One of the first things we learned is that the CT scan in Iraq doesn’t really tell the same story that it does in the United States. For example, most neurosurgery residents in the US think that a gunshot that crosses both hemispheres usually portends a poor prognosis because of the energy involved in a gunshot. However, the penetrating brain injuries in Iraq were from projectiles at a lower velocity. You would have CT scans that looked horrible, but the patients were awake and looked a lot better than you thought they would. We did a lot of retrieval of fragments, debridement of necrotic brain, a lot of complex cranial, facial fracture repairs, and CSF leak repairs. Those were routine cases for us. We also did a fair amount of spine trauma. Typically, for American soldiers, we would stabilize them and send them back to the U.S., but for the Iraqis and the terrorist and insurgents, we had to do cervical and lumbar fractures and more complex operations fairly frequently.

CNSQ: What was it like operating on patients who were fighting for the other side?

LW: It was really difficult. For example, there was a baby that the pediatric surgeons were taking care of that had been burned terribly all over her body after her house was fire bombed. The person that we thought was responsible was apprehended and injured in a firefight, and we were taking care of him also. It was difficult to justify taking care of him, but a few days later we learned that was just an innocent bystander. Here we’d been judging this guy and feeling bad about taking care of him, and he was actually innocent. It made me realize right then that it wasn’t our job to decide whether somebody deserved our care or not. It was our job to do our best. That set us free emotionally. We took care of whoever was put in front of us and let God take care of the judgment.

CNSQ: You’ve published this amazing book based on your experiences in Iraq, and it has been inspiring for so many people. How did your literary career affect your career as a neurosurgeon and vice versa?

LW: Writing taught me about the importance of story—you remember every good book you’ve read because it tells a good story. Taking that approach to neurosurgery, with every patient we encounter, we get an opportunity to step into their story and to change how that story plays out. Neurosurgeons can turn somebody’s life into a happy ending or tragedy and dramatically affect how their story plays out. I like to think about my career not as a collection of scans and patients with various pathologies to treat, but rather as human beings that are living out a story. I think that’s really affected how I’ve perceived my career. As a writer I try to craft a story that both moves and affects the reader, and as a surgeon I try to have the greatest positive impact I can in the patient’s life story.

^{Chapel at Balad Air Base, Iraq. Sandbags were for protection against mortar attacks.}

CNSQ: What drives you now, and what do you still hope to achieve?

LW: What I hope to achieve is to make the lives of my patients better and to leave behind some innovations that will help future generations of surgeons do things more safely or more efficiently. That’s why I like to develop instruments and physical techniques. The whole idea is that we should be more than practitioners who are earning a living doing something that somebody else taught us. We should actually be trying to advance the cause and the effectiveness of our specialty, and helping to educate those behind us. That’s the oath that we took—to help train those who come behind us as we have been trained by those in front of us.

CNSQ: Post traumatic stress and the mental health of our soldiers is something that is being recognized more. Did you have any of your own experiences after returning home, and how did you cope?

LW: I did. I used to be a person that stuffed difficult things down inside myself and didn’t really deal with them. I worked hard and ignored them. A few years after coming home from the war I had not even unpacked my bags. I had trunks full of all the stuff that I had in Iraq in the garage that I had never opened. I never talked to my family about it. One night, my wife and I were watching television, and a show came on HBO called Generation Kill. It was a story of U.S. soldiers in the battlefield in Iraq, and when somebody got injured they put them on a helicopter and flew them to the hospital where I had been stationed.

Within a few days of seeing that, everything started coming back to me. I started having dreams and nightmares, and everything I had stuffed down came out. Really, I started writing the book in response to the need (that my wife and family and psychiatrist identified) to get the stories out, to stop thinking about them all the time. Writing was my way to do that. What I found was that it helped a whole lot of other people, too. I’ve received so many letters from people all over the world, people telling me things like, “Reading your book made me be able to talk about what happened to me in Vietnam. I’d never told my family the stories. You opened that door for me.”

CNSQ: What advice can you give to residents and practicing neurosurgeons on how to contribute and serve, deal with stress, and find the motivation to continue doing interesting things with your life?

LW: You can contribute by never accepting anything just because you’re told, “That’s how it is.” Even when somebody hands you a Penfield 4 and tells you how to use it, you should ask, “Why?” Ask why it’s built that way, why it’s shaped that way, why it’s twisted that way. That will help you begin to think of how you could make it better. That’s what led me into the technician innovation—thinking about why Penfield designed that dissector the way he did. Those questions will lead you to discovering new ways to do procedures, new ways to build instruments, and new ways to solve problems.

You need to serve your patients’ interests above your own, always. Keep your family in mind. If you really want to serve your fellow man and your family, you have to be a human being who is also a neurosurgeon. You are not a neurosurgeon first. You’re a person first. That will help you find balance in your life. Remember that neurosurgeon is what’s on your coat, but it’s not who you are.

I know that dealing with stress is a difficult thing. Most of us, I think, are bent towards being top-heavy people, and we end up working all the time. There’s a reason God took a day off in the creation story. He was modeling for us the idea that you can’t be an effective person in any area if you’re not getting enough sleep, enough rest. Strive for balance in your life above all else, and that will help you manage stress. You’re going to see some difficult things in your career. You’re going to lose some patients, and you’re going to have some moments in your career where you have to deal with some very hard things.

If you’re a neurosurgeon or training to be one, you’ve been given an opportunity to do and see things that few people in the world ever will be able to do. It’s an incredible blessing to look through the foramen or Monroe into the third ventricle. It’s a blessing to be able to be in the CPA and see the cranial nerves and all those arteries. You should be motivated by that. There’s a verse in the Bible that says, “To whom much is given, much is required.” You’ve been given this amazing opportunity. Go out into your career and do something great, because something great has been given to you.

To hear Dr. Warren’s podcast Cross to Bear visit his blog:www.wleewarrenmd.com.