Ward Rounds

Rear Admiral David J. Smith, MD ’81, FACOEM, landed in Kabul, Afghanistan, in late October 2010 for a one-year assignment as the chief medical advisor for the International Security Assistance Force (ISAF). In this role, his primary duties include advising ISAF Commander General David Petraeus on medical issues, as well as overseeing the care of the men and women serving in Afghanistan. He and his team also help develop the health capabilities of the Afghan National Security Force and assist the Afghan Ministry of Public Health in their efforts to improve health care for the country as a whole. It’s his latest tour of duty in a 30-year military career.

Medical school, 1977

Smith, a native of Urbana, Ill., grew up fascinated by the Navy, sensing that it would offer him adventure and excitement. He enrolled in the Armed Forces Health Professions Scholarship Program, which paid for his medical school tuition, books, and other fees, and gave him a monthly stipend in exchange for a four-year obligation to serve.

Initially, Smith envisioned himself working in the private sector after fulfilling his contract, but the experiences available through the military had too strong of a pull.

“I certainly never thought I would stay longer than my four-year obligation to serve,” he says, “but the Navy continued to offer great opportunities and the satisfaction of serving our country.”

After graduating from medical school, Dr. Smith completed an internship at the Naval Regional Medical Center in Oakland, Calif., and participated in the Undersea Medical Officer training program at the Naval Undersea Medical Institute in Groton, Conn., where he earned the Surgeon General’s Award for Scholastic Achievement.

Following his residency, he served as the Occupational Health and Safety Official for the Defense Nuclear Agency (now the Defense Threat Reduction Agency) and as a Navy Medicine Exchange Officer with the Royal Navy in England.  As he gained experience, he progressed into larger leadership roles, assisting in the operation of Naval hospitals and the greater military health care system.  Four years ago, he began actively overseeing the health care operations of deployed troops around the globe before volunteering for his current position.

Rear admiral David J. Smith, MD, with General David Petraeus.

Battlefield Medicine

Dr. Smith says he gravitated toward the post in Afghanistan because of the diversity and complexity of the mission, as well as the enormous potential to make a difference.
About 9,000 medical personnel depend on Smith for leadership and guidance. The staff treats all injuries, no matter if the individual is a serviceman, member of the Afghan security forces, civilian, or enemy combatant. Nearly 95 percent of the patients they see have battlefield injuries, primarily blast injuries from improvised explosive devices and gunshot wounds.

Over the past 10 years, the military has developed a very sophisticated trauma system that Smith says provides some of the best, if not the best, trauma care in the world from point-of-injury through return-to-duty.

This system of care begins on the frontlines, where medics and corpsmen stabilize the airway and control bleeding within the first 10 minutes of injury. An evacuation helicopter then transports the patient to a surgical unit. Multi-specialty resuscitation teams greet the wounded on arrival and begin intensive, advanced trauma life support when necessary. If seriously injured, service members are evacuated from the theater of war.

“This system has resulted in a survival rate of around 96 percent if you reach a treatment facility alive,” Dr. Smith says. “That’s a remarkable testament to the trauma system in place.”

Battlefield medicine has also codified many clinical advances in trauma care, Smith says, such as resuscitation using a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets, the liberal use of tourniquets, and the need to prevent hypothermia even when the ambient temperatures exceed 130 degrees Fahrenheit.  In addition, major advances in rehabilitation, such as improved functionality from upper and lower extremity prosthetics have occurred.

The Joint Theater Trauma Registry, created by the Department of Defense, made these advancements possible. The registry captures all trauma cases in Iraq and Afghanistan that require hospitalization. To date, it includes more than 80,000 records. Thirty-four clinical practice guidelines have evolved out of this information, all of which are available online from the Institute of Surgical Research in San Antonio.

Kandahar Regional Military Hospital

Improving Health Care for Afghans

Working with the Afghan Ministry of Public Health, Smith and his team support the organization’s plan to help combat the country’s most pressing health needs.

“The biggest challenge to health development is the lack of resources, including deficient numbers and quality of health providers and a clear lack of financial resources to help support health measures for the Afghan population,” he says.

Afghanistan ranks among the bottom of nations in almost every health category, and has the lowest level of health of all countries in its region, which encompasses the Middle East and Northern Africa. The average life expectancy in Afghanistan is 42, compared with a regional average of 64.

Daughter Diana at my promotion to rear admiral

Still, the country has made considerable improvements since the overthrow of the Taliban nine years ago. For instance, access to basic health services, defined as a two-hour walk to care, has risen from 9 percent in 2000 to approximately 60 percent in 2010, Dr. Smith says. Officials aim to increase that number to 75 percent by the end of 2011 and to 90 percent by 2013; a significant challenge in a predominately rural population.

Leaders have also made maternal and child health priorities, as both were severely neglected under Taliban rule. In 2000, the mortality rate for children under the age of five (U5MR) was 257 for every 1,000 children, and the infant mortality rate (IMR) was 165 out of every 1,000.  The maternal mortality rate (MMR) was 1,600 maternal deaths per 100,000 live births. Regionally, the U5MR is 78/1,000, the IMR is 57/1,000, and the MMR is 420/100,000, according to 2008 data.

The Afghan government has set goal rates of 167/1,000 U5MR, 115/1,000 IMR, and 800/100,000 by 2013. A new Afghanistan Mortality Study – the most comprehensive health study of the country since 1973 – will offer insight into the progress made and the likelihood of meeting projected goals. Dr. Smith says he and his colleagues expect a favorable report.

“We are anticipating there may be good news, with Afghanistan exceeding the targets early,” he says.

Dr. Smith will continue to work on these and other issues as he completes his one-year tour of duty. Though challenging, Smith says he appreciates his time in Kabul.  Service members amaze him daily with their dedication and heroism and Afghans impress him with their warmth and resilience.

“My experiences in Afghanistan have been some of the most rewarding of my career,” he says, “and I have a lifetime of memories from this experience.”