1

Transfusion Medicine

Pediatric

Surgery and Medicine

for Hostile Environments

Revised

Borden Institute

Walter Reed Army Medical Center

Washington, DC

Office of The Surgeon General

United States Army

Falls Church, Virginia

US Army Medical Department Center and School

Fort Sam Houston, Texas
2

Pediatric Surgery and Medicine for Hostile Environments

The test of the morality of a society 

is what it does for its children.

—Dietrich Bonhoeffer (1906–1945)
3

Transfusion Medicine

This book is dedicated to the military medical professional in 

a land far from home, standing at the bedside of a critically ill 

child.
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Pediatric Surgery and Medicine for Hostile Environments

Dosage Selection:

The authors and publisher have made every effort to ensure the accuracy of dosages 

cited herein. However, it is the responsibility of every practitioner to consult appropriate 

information sources to ascertain correct dosages for each clinical situation, especially 

for new or unfamiliar drugs and procedures. The authors, editors, publisher, and the 

Department of Defense cannot be held responsible for any errors found in this book.

Use of Trade or Brand Names:

Use of trade or brand names in this publication is for illustrative purposes only and does 

not imply endorsement by the Department of Defense.

Neutral Language:

Unless this publication states otherwise, masculine nouns and pronouns do not refer 

exclusively to men.

The opinions or assertions contained herein are the personal views of the authors and 

are not to be construed as doctrine of the Department of the Army or the Department of 

Defense. For comments or suggestions on additional contents in forthcoming editions, 

please contact the publisher (www.bordeninstitute.army.mil).

CERTAIN PARTS OF THIS PUBLICATION PERTAIN TO COPYRIGHT 

RESTRICTIONS. ALL RIGHTS RESERVED.

NO COPYRIGHTED PARTS OF THIS PUBLICATION MAY BE REPRODUCED OR 

TRANSMITTED IN ANY FORM OR BY ANY MEANS, ELECTRONIC OR MECHANICAL 

(INCLUDING PHOTOCOPY, RECORDING, OR ANY INFORMATION STORAGE AND 

RETRIEVAL SYSTEM), WITHOUT PERMISSION IN WRITING FROM THE PUBLISHER 

OR COPYRIGHT OWNER.

Published by the Office of The Surgeon General

Borden Institute

Fort Detrick, Maryland, and Fort Sam Houston, Texas

Library of Congress Cataloging-in-Publication Data

Pediatric surgery and medicine for hostile environments / senior surgical editor, Michael M. Fuenfer ; 

senior medical and critical care editor, Kevin M. Creamer. -- Revised.

 p. ; cm.

 Includes bibliographical references and index.

 I. Fuenfer, Michael M., editor of compilation. II. Creamer, Kevin M., editor of compilation. III. Borden 

Institute (U.S.), issuing body. IV. United States. Department of the Army. Office of the Surgeon General, 

issuing body. V. US Army Medical Department Center and School, issuing body. VI. Emergency war 

surgery. Third United States revision. 2004. Pediatric version of (work):

 [DNLM: 1. Emergencies--Handbooks. 2. Wounds and Injuries--surgery--Handbooks. 3. Child. 4. 

Infant. 5. Military Medicine--Handbooks. WO 39]

 RD151

 617.9’9--dc23

 2013003735

Printed in the United States of America

18, 17, 16, 15, 14, 13 5 4 3 2 1
v

Transfusion Medicine

Contents

Foreword xi

Prologue xiii

Introduction xix

Resuscitation and Critical Care 1

1. Basic Approach to Pediatric Trauma 3

2. Anesthesia 13

3. Vascular Access 25

4. Mechanical Ventilation 31

5. Transfusion Medicine 37

6. Hemodynamics and Shock 43

7. Managing Intracranial Pressure 49

8. Aeromedical Evacuation 53

Surgery 61

9. Burns 63

10. Neurosurgery 77

11. Ophthalmology 93

12. Dentistry 121

13. Face and Neck 133

14. Orthopaedics 147

15. Thoracic Cavity 161

16. Vascular Surgery 171

17. Abdominal Wall, Peritoneum, and Diaphragm 181

18. Gastrointestinal Tract 197

19. Hepatobiliary Tract 233

20. Pancreas and Spleen 237

21. Genitourinary Tract 251
vi

Pediatric Surgery and Medicine for Hostile Environments

Medicine 271

22. Basic Fluid and Electrolytes 273

23. Nursing Assessment 279

24. Respiratory Emergencies 285

25. Status Epilepticus and Epilepsy 299

26. Care of the Newborn 309

27. Cardiology 323

28. Gastroenterology 335

29. Infectious Diseases 345

30. Endocrinology 373

31. Common Neurological Problems 387

32. Hematology and Oncology 397

33. Nephrology 413

34. Dermatology 419

35. Emergency Nutrition for Sick or Injured Infants and 

Children 451

36. Bites and Stings 459

37. Heat and Cold Injuries 465

38. Chemical, Biological, Radiological, Nuclear, and 

Explosive Injuries 469

39. Pharmacotherapeutics 487

Abbreviations and Acronyms xxv

Index xxxiii
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Pediatric Surgery and Medicine 

for Hostile Environments

Senior Surgical Editor

Michael M. Fuenfer, MD, FAAP, FACS

Colonel, Medical Corps, US Army Reserve

Pediatric Surgeon

Walter Reed Army Medical Center

6900 Georgia Avenue, NW, Washington, DC 20307;

National Naval Medical Center

8901 Rockville Pike, Bethesda, Maryland 20889;

Assitant Professor of Surgery and Pediatrics

Uniformed Services University of the Health Sciences

4301 Jones Bridge Road, Bethesda, Maryland 20814

Senior Medical and Critical Care Editor

Kevin M. Creamer, MD, FAAP

Colonel, Medical Corps, US Army

Chief, Pediatric Inpatient and Critical Care Services

Walter Reed Army Medical Center 

6900 Georgia Avenue, NW, Washington, DC 20307; 

Associate Professor of Pediatrics

Uniformed Services University of the Health Sciences

4301 Jones Bridge Road, Bethesda, Maryland 20814;

Pediatric Consultant to The Surgeon General 

for Pediatric Subspecialties

Borden Institute Editorial Staff 

Martha K. Lenhart, MD, PhD, FAAOS 

Colonel, MC, US Army

Director and Editor in Chief 

Ronda Lindsay 

Volume Editor 

Joan Redding

Managing Editor 

Douglas Wise

Layout Editor

Marcia Metzgar

Technical Editor
viii

Pediatric Surgery and Medicine for Hostile Environments

Note to Revised Edition

This revision includes an expanded dental chapter and minor wording 

changes.
ix

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Editorial Board

Dawn F. Muench, MAJ, MC, USA

Martin E. Weisse, COL, MC, USA

Cynthia H. Shields, COL, MC, USA

Shawn D. Safford, CDR, MC, USN

Kenneth S. Azarow, COL, MC, USA (Ret)

Marc S. Lessin, MD, JD

Brian F. Gilchrist, MD

Jeffrey R. Lukish, CDR, MC, USN

Debora S. Chan, PharmD, FASHP

Contributors

Karla Au Yeung, MAJ, MC, USA

Kenneth S. Azarow, COL, MC, USA (Ret) 

Hans E. Bakken, MAJ, MC, USA

Randy S. Bell, LCDR, MC, USN 

Paul L. Benfanti, COL, MC, USA

Richard H. Birdsong, COL, MC, USA

Scott E. Brietzke, LTC, MC, USA

Thomas R. Burklow, COL, MC, USA

Kathryn Camp, MS, RD, CSP

Wayne A. Cardoni, LCDR, MC, USN

Lisa Cartwright, LCDR, MC, USN 

Debora S. Chan, PharmD, FASHP

Theodore J. Cieslak, COL, MC, USA 

Bernard A. Cohen, MD 

Annesley W. Copeland, COL, MC, USA (Ret) 

James E. Cox, Jr., COL, MC, USAF (Ret)

Stephen J. Cozza, COL, MC, USA (Ret)

Kevin M. Creamer, COL, MC, USA

Arthur J. DeLorimier, COL, MC, USA

William C. DeVries, COL, MC, USAR

Robert L. Elwood, MAJ, MC, USAF

Nathan L. Frost, CPT, MC, USA

Charles J. Fox, LTC, MC, USA

Michael M. Fuenfer, COL, MC, USA

Satyen Gada, LCDR, MC, USN

Rebecca A. Garfinkle, MAJ, MC, USA

Curtis Goho, COL, DC, USA
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Pediatric Surgery and Medicine for Hostile Environments

Matthew D. Goldman, MAJ, MC, USAF

Gregory H. Gorman, LCDR, MC, USN

John Hanna, DDS

Patrick W. Hickey, MAJ, MC, USA

Alex Holston, LCDR, MC, USN

Nancy G. Hoover, LTC, MC, USA

Cheryl Issa, MS, RD, CSP, CNSD

David Jarrett, COL, MC, USA

Timothy K. Jones, COL, DC, USA (Ret) 

Matthew Kelly, MAJ, MC, USA

Ryan J. Keneally, MAJ, MC, USA

Brent L. Lechner, LTC, MC, USA

Martha K. Lenhart, COL, MC, USA

Rebecca B. Luria, MAJ, MC, USA

Robert Mansman, MAJ, DC, USA

Chad Mao, LCDR, MC, USN

Jonathan E. Martin, MAJ, MC, USA 

Donald R. McClellan, COL, MC, USA

Michael McCown, MAJ, MC, USA

Kathleen McHale, COL, MC, USA (Ret) 

Margret E. Merino, LTC, MC, USA

Michael H. Mitchell, COL, MC, USA 

Marisa G. Mize, DNP

Houman Motamen-Tavaf, LTC, MC, USA

Dawn D. Muench, MAJ, MC, USA

Harlan S. Patterson, COL, MC, USA

Philip L. Rogers, COL, MC, USA (Ret)

Shawn D. Safford, CDR, MC, USN 

Erik P. Schobitz, MD

Cynthia H. Shields, COL, MC, USA

Elizabeth Shin, DDS

Steven E. Spencer, LTC, MC, USA

Phillip C. Spinella, MD

Robert Steelman, MD, DMD

Allen I. Stering, MAJ, MC, USAF

Frederick J. Stoddard Jr, MD

Carolyn A. Sullivan, COL, MC, USA

Deena Sutter, MAJ, MC, USAF

Sarah K. Taylor, MAJ, MC, USA

Martin E. Weisse, COL, MC, USA
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Foreword

Throughout American history, military physicians have 

provided humanitarian care to civilians whenever possible. 

This was especially the case during the period of westward 

expansion in the 1800s, when, in many instances, Army doctors 

stationed at remote outposts represented the sole source 

of medical care for pioneering families. Today, officers and 

enlisted soldier–medics are deployed to over a hundred nations 

in all corners of the world. For much of the populace of these 

countries, especially children, these uniformed combat medics, 

nurses, physicians, and allied health professionals represent the 

only hope for modern and compassionate medical and surgical 

care. 

Now, more than ever before, large numbers of indigenous 

children with a wide range of acute and chronic medical 

conditions are presenting for treatment at US military medical 

facilities. Family members travel for days over rugged terrain, 

sometimes carrying children on their backs, in order to reach a 

US military facility, knowing that their children will receive lifesaving and compassionate treatment there. During my many 

visits to US military facilities in Iraq and Afghanistan, while 

participating in reviews of clinical research programs in Africa 

and Asia, or engaged in humanitarian missions in developing 

nations, I find few images are as heart rending as those of 

severely injured, ill, and wounded children. It is an unfortunate 

but irrefutable fact that the most innocent and vulnerable 

members of a society, its children, are often the first to suffer 

from the turmoil of an increasingly violent and unpredictable 

world.

Recognizing this state of affairs, my predecessor directed that 

the experience in pediatric care garnered by our deployed 

medical officers be incorporated into this book, Pediatric Surgery 

and Medicine for Hostile Environments. This manual will serve as 

a basic reference for military physicians and surgeons whose 

usual scope of practice entails limited exposure to childhood 

illness. To accomplish this objective, some of the most talented 

and experienced pediatricians and pediatric subspecialty 
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Pediatric Surgery and Medicine for Hostile Environments

surgeons throughout the active and retired ranks of the Medical 

Corps of the Army, Navy, and Air Force were enlisted as 

contributors. All are to be commended for an outstanding effort 

and remarkable final product. I feel this manual will contribute 

significantly to the success of the overall humanitarian mission 

of military medicine and will advance our collective efforts to 

mitigate the tragedy of violent conflict and, whenever possible, 

may prevent or arrest the spread of war.

Lieutenant General Eric B. Schoomaker, MD, PhD

The Surgeon General

US Army 

Commanding General

US Army Medical Command

Washington, DC

May 2010
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Prologue

Injuries to civilian populations are a tragic consequence of war. 

Unfortunately, the changing nature of warfare is resulting in a 

progressively higher proportion of civilian casualties. During 

World War I, civilians accounted for less than 20% of all deaths. 

In World War II, they made up 48% of all deaths. Civilians 

account for 80% of the war dead in more recent conflicts.1

 It is 

estimated that more than 2 million children perished as a result 

of war in the last decade of the 20th century, with over 6 million 

injured or permanently disabled.2 The current US military 

conflicts, Operation Enduring Freedom (OEF) in Afghanistan 

and Operation Iraqi Freedom (OIF) in Iraq, have also resulted 

in a significant incidence of pediatric trauma.

The primary mission of the deployed military healthcare 

system is to “preserve the fighting strength” by caring for sick 

and injured US military and coalition forces. Another vital role 

is to provide humanitarian care for the civilian population. 

Local national admissions to level III facilities, such as combat 

support hospitals (CSHs), are supported by US military 

doctrine if the patient is suffering from an illness or injury that 

threatens life, limb, or eyesight. The Center for Army Strategic 

Studies reports pediatric patients comprise approximately 

10% of all CSH admissions in Iraq and Afghanistan. Children 

comprised almost half of the humanitarian admissions in 

both theaters, and their length of hospital stay was roughly 

twice as long as that of all adult patients.3

 As of late 2009, it 

is estimated that between 5,000–6,000 children, many critically 

injured, have been admitted to deployed hospitals in Iraq and 

Afghanistan. Although nontraumatic and medical diagnoses 

were responsible for 25% of all pediatric admissions to CSHs, 

trauma injuries, of which 75% were penetrating, were the 

most common reasons for admission.4

 Traumatic injuries to 

children accounted for 12% of all occupied beds at CSHs, 11% 

of transfused and ventilated patients, and 13% of all combat 

hospital deaths.5 Although the primary mechanisms of injury 

in children are gunshot wounds (39%), followed by explosive 

injuries (32%), there are distinct differences between theaters 
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Pediatric Surgery and Medicine for Hostile Environments

(Tables 1 and 2, Figure 1).The length of hospital stay for these 

children averaged 7–15 days. On average, they each underwent 

more than two invasive or surgical procedures. The pediatric 

mortality rate has trended upward annually, and the overall 

mortality rate is 6.9% for children admitted to a CSH. This 

is significantly higher than for adults in both coalition and 

humanitarian emergency admissions, and more than double 

the reported pediatric civilian trauma mortality rate of 2.9%.6

Burns accounted for one third of inpatient deaths, followed 

by head injuries (75% of which were penetrating), at 25%. 

Infection and sepsis accounted for 10% of pediatric mortality, 

but when secondary infection was considered, it was evident 

that infections were a major factor in 30% of all pediatric CSH 

deaths. Head injuries resulted in the highest case fatality rates 

(20%), while pediatric burn injuries had a case fatality rate of 

16% at the CSH. In contrast, the case fatality rate for all other 

diagnoses was 3.8%.

The scope of the pediatric mission is a compelling reason to 

refine predeployment and deployment education to improve 

Table 1. Causes of Pediatric Injury by Theater

Known Cause of Injury Percent of Total Percent of Total

(Pediatric Inpatients) Injured in Afghanistan Injured in Iraq 

Gunshot wounds 21 56.6

Burns 14.6 5.8

Landmines 14.6 0.8

Motor vehicle crashes 12.5 6.8

Falls 12.3 1.5

Fragments 8.2 13.4

Blasts 7.4 8.7

Complications of previous 4.8 4.7

injuries

Environmental (drowning, 2.3 0.7

animal bites, cold, 

venomous bites/stings)

Poisoning 1.2 0.5

Stab wounds 1.1 0.3
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Table 2. Principal Pediatric Traumatic Diagnosis by Theater*

 Percent of Percent of Percent 

Principal Diagnosis Those Injured Those Injured of Total

(Pediatric Inpatients) in Afghanistan in Iraq Injured† 

Burns 16.3 10.1 13.3

Abdominal wound with 9.4 14.4 11.8

bowel/organ injury, 

penetrating

Lower extremity wound, 6.4 12.3 9.2

fracture, open

Lower extremity wound, 5.3 8.5 6.9

penetrating

Skull fracture, open 6.4 7.1 6.7

Upper extremity wound, 3.8 5.5 4.6

fracture, open

Lower extremity wound, 5.3 2.7 4.0

fracture, other

Skull fracture, other 5.7 2.1 4.0

Eye injury 5.8 1.6 3.8

Back/buttock/genitalia 2.2 5.3 3.7

wound, penetrating

Lower extremity wound, 5.5 1.7 3.6

traumatic amputation

Upper extremity wound, 2.8 4.0 3.4

penetrating

Face/head/neck wound, 3.7 2.5 3.1

penetrating

Upper extremity wound, 4.1 2 3.1

traumatic amputation

Head injury/traumatic 3.0 3.1 3.1

brain injury

Chest wound, penetrating 1.8 3.5 2.6

Upper extremity wound, 2.7 1.5 2.1

fracture, other

Chest wound, 0.9 1.7 1.3

pneumothorax

Vascular injury 0.9 1.6 1.2

Face/head/orbit fracture, 0.8 1.7 1.2

open

Face/head/orbit fracture, 1.7 0.5 1.1

other

Lower extremity wound, 1.3 0.7 1.0

other

All others 4.4 5.9 5.1

Totals (average percent) 51.20 48.80 100.00

*Most common injuries grouped and sorted by theater. †

Total number injured in Afghanistan: 787; total number injured in Iraq: 750; total number 

injured overall: 1,537.
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Pediatric Surgery and Medicine for Hostile Environments

outcomes in this vulnerable population. This manual was 

created in recognition of the clear need for pediatric emergency 

and humanitarian care delivery by the US military healthcare 

system in Afghanistan and Iraq during OEF and OIF.

Our intention is to provide military physicians, often practicing 

in an austere environment, with a current and concise reference 

for the basic medical, surgical, and critical care of children. It 

should be used as a pragmatic reference but not as a substitute for 

published textbooks, current peer reviewed articles, or reasoned 

judgment. Operative procedures performed on children often 

entail significant risk even under ideal circumstances, and 

should not be attempted without a complete assessment of the 

available resources and equipment, experience of the operating 

room team, potential complications, nonoperative options, 

availability of follow-up care, and an honest overall assessment 

of the risk to the child from the procedure to be undertaken. 

Figure 1. Distribution of injuries by anatomic region.

Lower extremity

wounds 24.8%

Head, face,

neck 6%

Eye 3.8%

Abdomen

12.2%

Brain injury,

skull fracture

13.7%

Chest 4.6%

Spine 1.4%

Back, buttocks,

genitalia 4.0%

Pelvic 1.0%

Upper 

extremity 

wounds 13.5%

Burns 13.3% Vascular 1.2%
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It is our ethical obligation to counsel the parent or guardian, 

if available, about the risks and benefits of a procedure, and 

to obtain their consent for nonemergent operations. Local 

custom and the family’s desires must be respected in all cases, 

lest what was intended to be a humanitarian gesture results in 

unintended consequences that negatively impact the success of 

the overall military mission. 

In many situations, the extent to which such aid can be rendered 

will be limited by operational considerations, lack of ageappropriate equipment and supplies, and limitation of other 

resources.

References

1. Aboutanos, MB, Baker SP. Wartime civilian injuries: epidemiology and intervention strategies. J Trauma. 1997;43:719–726.

2. Ursano RJ, Shaw JA. Children of war and opportunities for 

peace. JAMA. 2007;298:567–568.

3. Hassell LR, Wojcik BE, Stein CR. Overview of CASS studies 

and analysis. Paper presented at: Center for AMEDD Strategic Studies; June 7, 2007 (updated September 10, 2007); Ft 

Sam Houston, Tex. 

4. Creamer KM, Edwards MJ, Shields CH, Thompson MW, Yu 

CE, Adelman W. Pediatric wartime admissions to US military 

combat support hospitals in Afghanistan and Iraq: learning 

from the first 2,000 admissions. J Trauma. 2009;67;762–768.

5. Borgman M, Spinella PC. Profile of pediatric patients at US 

Army combat support hospitals in Afghanistan and Iraq. Crit 

Care Med. 2007;35:12s, A158.

6. Burd RS, Jang TS, Nair SS. Evaluation of the relationship between mechanism of injury and outcome in pediatric trauma. 

J Trauma. 2007;62:1004–1014. 
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Introduction

Caring for Children in War: Military Humanitarianism 

and Fourth-Dimension Warfare

Caring for children injured in combat or stricken ill by the consequences of war has long been a priority for American military 

medical forces. But the potential impact of “military humanitarianism” on the outcome of war is only now being recognized 

as a key component of the National Military Strategy, which 

encourages American military forces to promote peace and stability worldwide to “shape the world, not merely to be shaped 

by it.”1

Experts on modern warfare say that it has entered a “fourth” 

dimension. The first two dimensions encompassed war’s 

breadth and depth, but were limited by time and space. The 

third dimension began with the advent of airpower, which 

reached across the boundaries of distance and represented 

one of the major revolutions in warfare. Technology and the 

digital transformation have been referred to as warfare’s fourth 

dimension because the speed of information exchange allows 

for one warring faction to interrupt its enemy’s information–

decision–action (IDA) cycle.2

 However, this view of warfare’s 

fourth dimension is too shortsighted.

The ancient Greeks had different concepts of time. The idea of 

time as “chronos” defines physical time measured in a linear 

fashion, in which each moment is like the next. “Kairos” reflects 

the perfect season or quintessential moment that must be 

seized and acted upon to achieve a desired result. Physicians 

caring for children in austere or hostile environments are able 

to interrupt the enemy’s IDA cycle by affecting kairos time in 

the families and communities for which they provide care. They 

can be with the family at the exact moment of need, and can 

affect the family’s perspective for a lifetime. This is how military 

humanitarianism, particularly the care of children in wartime 

and in complex humanitarian disasters, embodies the fourth 

dimension of warfare. 
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Pediatric Surgery and Medicine for Hostile Environments

The impact of humanitarianism at these quintessential kairos 

moments can be seen throughout our history. The Lewis and 

Clark expedition, commissioned by President Jefferson, was the 

longest infantry patrol in US history. It traveled 8,000 miles in 28 

months, and military humanitarianism was one of the key goals 

of the mission.3

 Lewis and Clark acknowledged their mission’s 

success was in a large part due to the skill and leadership of 

their pregnant Shoshone guide, Sacagawea. Her knowledge of 

the geography and the languages and cultures of the tribes she 

encountered saved them on many occasions. When Sacagawea’s 

labor failed to progress, Lewis cared for her and administered 

two rings of a rattlesnake rattle, according to a local American 

Indian folk medicine tradition. Sacagawea’s child fell ill when 

he was 15 months old. On May 22, 1806, Lewis wrote, “The 

child . . . is very ill this evening . . . he was attacked with a 

high fever . . . and his neck and his throat are much swollen.” 

After treatment with cream of tartar and repeated application 

of poultice of onions, the fever broke.4

 The attentive care with 

which Lewis and Clark ministered to Sacagawea during her 

labor and to her son during his life-threatening illness was the 

kairos that won them her heart and her loyalty.5 

After the United States dropped a nuclear bomb on Hiroshima 

in 1945, a Japanese physician, Dr Hachiya Michihiko, was 

positively affected by US military doctors who helped him 

treat Japanese civilians wounded and sickened by the bomb. 

He wrote, 

They gave us great help, materially and 

spiritually, in the reconstruction of our hospital. 

Two doctors removed fear and hostility from 

our hearts and left us with a bright, new hope. 

The harsh winter that followed the autumn 

was less harsh for their having come.6

Military humanitarianism has also played a critical role in 

current conflicts. US Special Forces, focusing on engineering 

projects and delivering healthcare, helped radically improve 

the security on Basilan Island, Philippines. Over 4 years, this 
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“volatile, uncertain, complex and ambiguous” situation was 

made more secure by allowing the Philippine military to reduce 

its presence from 15 battalions to 2.7,8 The impact medical care 

had on young mothers and children—and, by association, 

future security—there remains to be seen.

In Afghanistan, humanitarian efforts may play an even greater 

role. In 2004, one in four children died before age 5, and one 

in twelve women died in childbirth. Afghanistan had been 

a training ground for enemies of the United States, and was 

far from becoming a developed nation. While talk in Iraq 

was about rebuilding, in Afghanistan, our efforts continue to 

be building from the ground up, and military physicians are 

deeply involved in this process. Caring for children is at the 

forefront of these efforts in military hospitals and in building 

host-nation capabilities.9–11

Although the nuances of fourth-dimension warfare are 

complex, the realities for doctors and nurses are much simpler. 

Service members caring for children in Iraq, Afghanistan, the 

Horn of Africa, the Philippines, Somalia, East Timor, and many 

other places around the globe focus their energies on building 

up nations’ healthcare systems so that infants there have the 

same chance at survival as infants born in the United States. 

If our enemies are indeed finite, it is possible to diminish their 

number by taking away their ability to recruit from the children 

of the next generation. For example, consider a child whose 

first memories of Americans are the faces of the doctors and 

nurses in uniform who struggle to save her after she stepped 

on a mine. What will this child and her parents think of the 

Americans they have met? Will their memories make them less 

likely to become our enemies? This is fourth-generation kairos 

warfare.12

In his address to the House of Commons on June 8, 1982, 

President Ronald Reagan said, “The ultimate determinant in the 

struggle that’s now going on in the world will not be bombs and 

rockets, but a test of wills and ideas, a trial of spiritual resolve, 

the values we hold, the beliefs we cherish, the ideas to which 
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Pediatric Surgery and Medicine for Hostile Environments

we are dedicated.”13 This book is directed at those engaged in 

this fight, and dedicated to everyone standing at the bedside of 

a critically ill child in a land far from home.

Colonel Chuck Callahan

DeWitt Health Care Network

Fort Belvoir, Virginia

Colonel Kevin M. Creamer

Walter Reed Army Medical Center

Washington, DC

Colonel Michael M. Fuenfer

Walter Reed Army Medical Center

Washington, DC

References

1. US Department of Defense. National Security Strategy 2008. 

US Department of Defense Defense Link Web site. http://

www.defenselink.mil/news/2008%20National%20Defense%20Strategy.pdf. Accessed October 10, 2009. 

2. Singh A. Time: the New Dimension in War. Joint Forces 

Quarterly. 1995/1996;10:56–61.

3. Ambrose S. Undaunted Courage. New York, NY: Touchstone 

Books; 1996.

4. Chuinard EG. Only One Man Died: The Medical Aspects of the 

Lewis and Clark Expedition. Glendale, Calif: The Arthur H. 

Clark Co; 1980: 405. 

5. Callahan C. The roots of military medical humanitarianism. 

US Army Med Dep J. 2001;PB 8-01-7/8/9:39.

6. Michihiko H. Hiroshima Diary. Wells W, trans. New York, 

NY: Avon Publications; 1955: 220.

7. McAvoy A. U.S. forces find model for beating terror. Washington Post. May 31, 2006. http://www.washingtonpost.com/

wp-dyn/content/article/2006/05/31/AR2006053100347.

html.

8. Shambach SA. Strategic Leadership Primer. Carlisle Barracks, 

Pa: US Army War College; 2004.
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9. Creamer K, Edwards MJ, Shields C, Thompson M, Yu CE, 

Adelman W. Pediatric wartime admissions to US combat 

support hospitals in Afghanistan and Iraq: learning from 

the first 2,000 admissions. J Trauma. 2009;67:762–768. 

10. Burnett M, Spinella, P, Azarow K, Callahan C. Pediatric care 

as a part of the U.S. Army medical mission in the Global 

War on Terrorism: Afghanistan and Iraq, December 2001 to 

December 2004. Pediatrics. 2008;121:261–265.

11. Matos R, Spinella P, Holcomb J, Callahan C. Increased mortality of young children with traumatic injuries at a U.S. 

Army hospital. Pediatrics. 2008;122:e959–e966.

12. Callahan C. Editorial. Honolulu Advertiser. October 20, 2004.

13. Reagan R. Address to the House of Commons, June 8, 1982. 

Constitutional Concepts Foundation Web site. http://www.

constitutionalconcepts.org/reaganspeech.htm. Accessed October 10, 2009.
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Pediatric Surgery and Medicine for Hostile Environments