MILITARY MEDICINE, 169, 10:810, 2004
Lessons Learned: Operation Anaconda
Guarantor: CPT George S. Midla, SP
Contributor: CPT George S. Midla, SP
With the recent long deployments of our military, a review of
lessons learned becomes a vital part of mission success and
helps to shape our forces for future conflicts. This article
examines some medical issues that were experienced by the
Raider Rakkasans of the 101st Airborne (Air Assault) Division
during Operation Anaconda in Afghanistan. Topics include
nutrition, altitude sickness, medical evacuation requests, and
the evacuation of wounded on resupply platforms (back-haul-
ing). When nutritional aspects of war fighting were discussed,
an emphasis was placed on making a greater variety of field
rations accessible to the force with the addition of a multivi-
tamin to each ration. Also, a meal high in caloric content
before infiltration and an education/inspection program to en-
sure the maximum benefit of each ration was reviewed. The
use of acetazolamide to combat altitude sickness was also
discussed. Dosing of 250 mg BID 24 hours before a rapid
assent, then 125 mg BID for 4 days was suggested. Line three
of the medical evacuation request was also reviewed for report-
ing inaccuracies. Complete physical examinations and direct
dialogue between medical personnel and commanders was
stressed. Last, a standard medical package to accompany any
resupply during hostilities was advised, instead of releasing
ground medical personnel to attend the wounded when using
this for an evacuation platform.
Introduction
he U.S. military’s most recent involvement in Afghanistan
T began in the latter part of 2001. By 2002, U.S. and coalition
forces were well established in the country and many military
operations had been conducted, with additional missions being
planned. One of these operations was code-named Anaconda.
Its mission was to destroy or capture al Qaeda and Taliban
forces in mountain positions located in the Shahi-Kot Valley and
Arma Mountains southeast of the city of Zurmat.
Operation Anaconda began on March 2, 2002. At the comple-
tion of this mission, U.S. and coalition forces had been involved
with the longest battle in U.S. history since the Vietnam War.
Anaconda was also the highest elevation engagement ever re-
corded by the United States.
Before I begin, let me state that I am the battalion physician
assistant for 2/187 Infantry Regiment (Raider Rakkasans) of the
101st Airborne (Air Assault) Division. I infiltrated the Shahi-Kot
Valley on March 2 in a CH-47 (Chinook) helicopter as part of the
first force on the ground. On this aircraft, I accompanied a
platoon of our C Company, a command element, a small number
of Special Forces Soldiers, and an Air Force Enlisted Terminal
Attack Controller team. I spent the next 12 days in multiple
locations throughout the battlefield. My comments concerning
lessons learned will be restricted to medical issues that were
Walter Reed Army Medical Center, Cardiothoracic Surgery, Perfusion Service, 6900
Georgia Avenue NW, Washington, DC 20307-5000.
This manuscript was received for review in July 2003. The revised manuscript was
accepted for publication in November 2003.
Reprint & Copyright © by Association of Military Surgeons of U.S., 2004.
Military Medicine, Vol. 169, October 2004 810
experienced by our battalion or myself directly. There were
many other units and supporting elements that took part in this
engagement, but I am not at liberty to discuss possible lessons
learned on their behalf. Topics of discussion will include nutri-
tion, altitude sickness, medical evacuation (MEDEVAC) re-
quests, and the transport of patients on resupply platforms
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(back-haul).
Nutrition
Nutritional aspects of premission planning are often over-
looked. Units are usually busy with rehearsals, equipment
maintenance, and thorough inspections, as we were, when pre-
paring for an operation. Sleep is often given a higher priority
than diet, but as troops are readied for bed, they are often
anxious and thus have difficulty falling asleep. This could cause
the force to be both fatigued and ill-prepared nutritionally at the
onset of the mission. Once on the ground, the first 24 hours are
the most demanding. Operational awareness has to be gained,
movement to a base or position must be accomplished, devel-
opment of gun emplacements, and much more must be ad-
dressed before a chow/rest program can be implemented.
During Operation Anaconda, the first 2 days were very de-
manding. Our unit was challenged with the enemy’s direct fire
weapons, shoulder-fired rockets, and mortar rounds while hav-
ing to maneuver over some very rugged terrain. No one had the
opportunity for a leisurely brunch and after 2 days of little rest
and food, our operational sharpness began to dull. I will also add
that we were not thinking of our meals. That is, some ate be-
cause they knew they needed to for performance, but being shot
at really does curb one’s appetite.
As time progressed, the initial rations that we carried in were
finally consumed. Resupply then became a problem. Most of our
unit was not able to acquire additional meals and thus went
without food, in some cases, for days. Historic records from
World War II support this finding. The Marines at Guadalcanal
went through extended time periods of not being able to eat
because of logistical problems. The acquiring of the enemy’s
food became a major part of some of the men’s diet during this
campaign.1
The newest version of the combat ration is the meal ready to
eat (MRE). It has been designed to be a high-caloric meal to help
support the soldier on the battlefield.2 A single ration contains a
variety of foods. These foods are dispersed in multiple pouches
throughout the MRE. For the soldier to benefit the most nutri-
tionally, he/she needs to consume all or at least some part of
each individual pouch. This brings up another nutritional issue:
our troops often do not sample each portion, thus defeating the
maximum benefit of the field ration. Instead, many individuals
get bored with the finite selection of meal choices. They then
attempt to function on a diet heavy in the desert items, which
are more palatable and located in every meal. Examples of these
foods include pound cake and the candy “Skittles.” These sol-
Lessons Learned: Operation Anaconda
diers may feel comfortable in their diet choice of eating just the
sweets from the meals. This reassurance is gained over a 1- or
2-week field exercise at their previous duty station where they
were able to complete a given mission on such a diet. During
overseas deployments, I have often had a nutritional regiment
strictly made up of MREs for 2 to 3 months before ever seeing
the next step up in the Army cuisine, which is the tray ration
(T-rat).2–4 The T-rat is delivered in a flat rectangular pan and
does not require refrigeration. This ration is prepared by simply
submerging it in hot water, opening, and serving. Because of its
design, T-rats can offer a hot meal with a kitchen appeal to large
and small groups of soldiers. Even with the introduction of the
T-rat, on some of my deployments, the MRE was the major part
of my daily dietary intake. This scenario is not uncommon. Our
troops are often not eating properly secondary to a weary pal-
ate.5,6
We now must reexamine my previous comments on soldiers
being nutritionally depleted before a major operation and then
not being able to get resupplied during conflict. Compile these
two points with the possibility of 1 to 2 months of poor eating
habits (the pound cake and Skittles diet), and we may determine
that part of the fighting force may not be able to give a 100%
effort.
To help attack this nutritional challenge on the battlefield, a
multiple approach should be examined. First, a greater variety
of meals must be offered to the soldier. This should be our
biggest priority. If we are unable to deliver those rations in a
timely manner, the purchase and distribution of foreign Army
rations should be investigated. It was always a treat for our
troops to acquire a Canadian, Portuguese, or Australian ration
while in Afghanistan. Also, the foreign forces that make these
trades also appreciated the variety. As an additional note, I just
returned from Iraq and one of my most enjoyable lunches was a
yellow-bagged humanitarian aid meal that I was given to sam-
ple. The lentil stew was not of a better quality than our standard
rations, just different.
A multivitamin should also be added to the MRE. For the
soldier who does not eat properly or is unable to because of
mission constraints, this addition would be a great help. I sug-
gest a sweet chewable to satisfy those who have difficulty swal-
lowing pills and to increase compliance.
The next step in operational nutrition should be an education
program directed at our force. This can be done at all leadership
schools for the commissioned and noncommissioned officers.
The stressing of a banquet of rations before a mission in prep-
aration for an unavoidable fast is paramount. Also, inspections
during the consumption of daily meals should be reviewed with
the highlighting of nutritional benefits when all portions are
ingested. I have presented the previous dietary notes at our
battalion meetings. These suggestions were always welcomed
and, when applicable, were enforced.
Altitude Sickness
High altitude illness is experienced by approximately 20% of
all those ascending above 9,000 feet.7 The percent affected con-
tinues to rise with increased elevations. Conditions experienced
may vary between acute mountain sickness, high-altitude pul-
monary edema, high-altitude cerebral edema, retinal hemor-
rhaging, and peripheral or facial edema.8 These illnesses are a
811
huge concern, especially during air assault operations that are
conducted at increased elevations.
Reaching altitude by vehicle or foot allows a slower assent
with the ability to stop at various contour lines to acclimate, if
needed. At the very least, medical personnel can evaluate those
developing signs and symptoms related to elevation changes
and can act accordingly when using ground techniques. None of
these luxuries are offered during insertion by helicopter (air
assault).
During our air assault, we were and typically are shoulder to
shoulder and knee deep in equipment flying in a CH-47D.
Within minutes, we were at altitude and then disembarked the
aircraft and conducted combat operations with full packs in the
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snow. Because of these expected issues, we examined the pos-
sibility of combating altitude sickness by pharmacological
means.
After our preliminary map reconnaissance of the area of op-
eration (AO), an initial altitude of approximately 11,000 feet was
determined to be our step-off point. A decision was made at that
time to premedicate for altitude sickness. Medications and dos-
ages for this illness vary. We settled on a regiment of acetazol-
amide (Diamox), 250 mg BID, 24 hours before infiltration. That
dose was changed to 125 mg BID upon landing and was con-
tinued for an additional 4 days, and then terminated. Diamox is
usually started 48 hours before a planned rapid assent. Our
decision to begin this medication only 24 hours before infiltra-
tion was decided on because of our mission constraints.
Weather changes, current intelligence reports, and the political
climate can quickly halt a mission. Starting and then stopping
pharmaceuticals never goes over well with the troops, but a
“thumbs-up” 24 hours before usually means that the mission
will be conducted.
Acetazolamine is a carbonic anhydrase inhibitor, effective in
the control of fluid secretion.9 This effect of increased urination
was considered during our planning phase. We decided that at
such a low dosage, diuresis would not be a health issue. Dehy-
dration, as expected, was minimal at this scaled-down measure
and thus was not a factor. At the end of this operation, we had
zero individuals complaining of or needing MEDEVAC for alti-
tude-related illnesses.
The most common side effect of Diamox experienced by our
force was a tingling sensation of the extremities, lips, and
tongue. A premedication brief was conducted and these possible
side effects were reviewed. I strongly believe that if this had not
been done, those experiencing these symptoms would have cer-
tainly had an increase in anxiety at the start of this particular
mission.
MEDEVAC Requests
When requesting for MEDEVAC, a structured report is trans-
mitted. This MEDEVAC request or “9-line” has been standard-
ized to aid in the quick and complete relaying of information.
The report is as follows:10
Line 1: Location of pickup site.
Line 2: Radio frequency, call sign, and suffix.
Line 3: Number of patients by precedence: A—URGENT,
B—URGENT-SURGICAL, C—PRIORITY, D—ROUTINE,
E—CONVENIENCE
Military Medicine, Vol. 169, October 2004
812
Line 4: Special equipment required: A—None, B—Hoist,
C—Extraction Equipment, D—Ventilator
Line 5: Number of patients by type: Litter and/or Ambula-
tory.
Line 6: Security of pickup site (use this version of the line
during wartime): N—No enemy troops in area,
P—Possible enemy troops in area, T—Enemy troops
in area (approach with caution), X—Enemy troops in
area (armed escort required).
Line 6: Number and type of wound, injury, or illness (use this
version of the line during peacetime).
Line 7: Method of marking pickup site. A—Panels, B—Pyro-
technic Signal, C—Smoke, D—None, E—Other.
Line 8: Patient nationality and status. A—US military, B—US
civilian; C—Non-US military, D–Non-US civilian, E—
Enemy prisoner of war.
Line 9: NBC contamination (wartime). N—Nuclear; B—Bio-
logical, C—Chemical.
Line 9: Terrain description (use this version of the line during
peacetime).
My next point relates to the caregivers’ tendency to issue
patients a higher precedence (line 3 of the MEDEVAC request)
than is warranted. After speaking to others who have been
involved with operations for some time, I found out that this is
not an uncommon occurrence. I determined that the motivation
for increasing the severity category is related to multiple factors.
First, the individuals calling in the request may want the
wounded to get the best care possible and receive that care
quickly, therefore an upgrade in status of the injured is issued.
This upgrade also allows for the termination of the many obsta-
cles faced while having to conduct a mission, possibly on foot,
and simultaneously performing the duties of moving, securing,
and caring for a patient. Another possible cause related to the
increase of precedence of wounded has to do with the stress
experienced during an operation. The first impression of a bat-
tlefield injury usually is rather shocking. An accurate examina-
tion needs to be completed before a MEDEVAC is called. The
U.S. military uses a two-stage model in the examination of the
10
trauma patient. The first part is called the primary survey.
During this examination, the standard airway, breathing, circu-
lation approach is used to identify life-threatening wounds. The
second stage or secondary survey is a more thorough examina-
tion to identify nonlife-threatening injuries. A request may be
placed before the completion of a secondary survey in some
situations. Also, a commander may get word passed up that he
has wounded. This information gets twisted as it is relayed from
soldier to soldier. A call is then placed based on that false report,
which may have initially been founded on an incomplete exam-
ination. I know of two examples pertinent to these issues.
The first example was a problem that developed from a previ-
ous patient upgrade. I learned of this issue while monitoring a
radio. An individual made a call for the evacuation of a soldier
who was diagnosed with a form of altitude sickness. Higher
command questioned the need for that request before imple-
menting a plan. The hesitation was a result of an earlier incor-
rect prioritization of wounded from the same unit. I do not
chastise the command for their actions. Releasing a MEDEVAC
platform in a hostile situation means that they are putting
others in harms’ way. Having the time, if only a few additional
Military Medicine, Vol. 169, October 2004
Lessons Learned: Operation Anaconda
hours, to plan or wait until nightfall is often crucial when flying.
Many of the division’s AH-64 (Apache) attack helicopters were
damaged during this operation. Sending in an unarmed MEDE-
VAC aircraft, even with an escort, is never an easy decision.
The second event happened to me directly. A call came over
the radio stating that one of our soldiers was “unstable,” al-
though a field medic was administering some type of care. The
patient was 2.5 km away over some very tough terrain. I re-
quested that the medic be put on the radio or have someone
relay information for us. I was hoping to talk him through
treatment because I knew I could never get there in time. With
no response back after several minutes, I contacted the unit and
received the same report that he was still unstable and nothing
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else. I left my position, commandeered a gator (a gator is a
variety of garden tractor with a “go anywhere” attitude), and
drove with a small security element to the base of the mountain
where they were positioned. An uphill run followed, while I was
carrying a very large trauma rucksack. When I reached the
soldier, he was quite stable and resting easily. The field medic on
the scene was surprised to see me and stated that at no time was
the individual’s health uncertain.
I do not have the answer to correct this concern except to
make others aware of the problem. At a minimum, I must stress
the completion of a primary and secondary survey before a
MEDEVAC is requested. Also, leaders need to speak directly to
medical personnel before requisitioning this type of evacuation.
This dialogue would correct any confusion that may develop
from the multiple “word of mouth” transfer of information.
Back-Haul
The evacuation of wounded is normally carried out by a UH-
60A (MEDEVAC) helicopter. This occurs in a perfect world. Dur-
ing Operation Anaconda, things were not quite perfect. The
command had to make a decision that vacillated between letting
the MEDEVAC helicopters fly and possibly risk additional
equipment damage and personnel injury or to evacuate the
wounded on the Chinook aircraft that had to resupply the
ground forces with additional men and equipment anyway. This
technique of MEDEVAC is referred to as “back-haul.” The Chi-
nook helicopter is the workhorse of the 101st Airborne Division.
In some cases, the decision was made to back-haul the wounded
on the Chinooks instead of putting a greater number of helicop-
ters and their crews in harms’ way.
This brings up the point of medical assets, or the lack of them,
on resupply platforms. Doctrine would have us believe that
when back-hauling the wounded, they should be supported by
releasing ground medical personnel. The decision to attach this
support would depend on the severity of the injuries. In reality,
nothing could be worse. Having a platoon or company medic,
battalion physician assistant, or physician leaving his unit while
under hostilities is bad medicine. This action has great psycho-
logical repercussions on the ground force and the medical per-
sonnel identified to attend those injured. Additionally, a section
commander will lose all or part of his medical team.
Medical personnel and equipment should accompany addi-
tional troops and supplies that come in during conflict. Future
plans should include the standardization of this medical sup-
port. This would ensure that the wounded being extracted
would be cared for without removing ground assets.
Lessons Learned: Operation Anaconda
Conclusion
This article has been a review of nutritional issues, altitude
sickness, MEDEVAC requests, and the use of resupply plat-
forms to evacuate the wounded as experienced during a combat
engagement in Afghanistan. Nutritional aspects of premission
planning are often overlooked. To ensure that our troops are
eating properly, a greater variety of meals, a multivitamin, in-
creased caloric intake just before infiltration, education, and
inspection of the ingestion of all parts of the field ration were
suggested. To combat the physical threats of altitude sickness,
acetazolamide was prescribed. The dosing use during this op-
eration was 250 mg BID 24 hours before infiltration, and then
125 mg BID upon landing with continued dosing for an addi-
tional 4 days. Line 3 of the MEDEVAC request was examined for
reporting inaccuracies. This line determines the number of pa-
tients by precedence. The precedence is often inflated, which
causes time constraints and air management problems during
combat operations. Complete physical examinations and the
direct dialogue of medical personnel with commanders was
stressed. Last, the use of resupply platforms to evacuate the
wounded was discussed. A standard medical package to accom-
pany additional troops and equipment into battle was advised in
lieu of ground medical personnel leaving their units to treat
those wounded.
I hope that this review benefits those during the planning
813
phase of their missions. It is my deep belief that it is everyone’s
duty to present his/her lessons learned at the conclusion of all
major operations. In the future, I hope to see additional notes
from within the ranks, at all levels and in all disciplines, that
took part in this conflict. There is still much to learn.
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Military Medicine, Vol. 169, October 2004