Baghdad duty was derm’s ‘most rewarding’ experience

San Antonio

- Army Capt. Christopher Collins, M.D., a staff dermatologist at Wilford Hall Medical Center, says he saw what every dermatologist sees - only worse - during his recent seven-month deployment to Iraq.

Army Capt. Christopher Collins, M.D., poses with an Iraqi man and his daughter in an outpatient clinic at Ibn Sina Hospital, Baghdad, Iraq, in March 2009. Dr. Collins treated the girl, who was suffering from keratoderma. (Photo: U.S. Army)

While he treated predominantly dermatology cases, Dr. Collins says his 12- to 15-hour days also involved stepping in where needed - whether to help triage mass casualties, suture soldiers’ blast injuries, or simply talk to the walking wounded, when they needed an ear.

Dr. Collins returned to Texas in July, after a voluntary seven-month tour of duty. The sole Iraqi theater dermatologist during his deployment, he was posted to Ibn Sina hospital in Bagdad, a facility named for the renowned Islamic physician, philosopher and scientist.

Once Saddam Hussein’s private hospital, Ibn Sina was operated by the U.S. Army’s 10th Combat Support Hospital (CSH), and dubbed "Baghdad ER." It was returned to control by Iraq’s Ministry of Health on Oct. 1.

"I took care of the American troops, including Army, Air Force, Navy and Marines," Dr. Collins says. "'We also took care of coalition forces … the majority of those being Australian and British forces." In the seven months he was there, he says, he saw about 1,800 patients in clinic, and more than 1,500 teledermatology consults.

Conditions made worse

Dr. Collins saw many run-of-the-mill dermatologic conditions, including acne, psoriasis and eczema; however, he says, patients with these common skin diseases were generally in a lot worse condition than those who typically walk into any U.S. dermatologist’s office, due to the extreme environment.

"My job was to keep the troops battle-ready," he says. "If they had horrendous psoriasis, eczema or acne, I was able to treat the vast majority of those patients without having to send them home."

Limited armamentarium

Dr. Collins says he treated most of his psoriasis patients with oral acitretin, and on occasion used methotrexate. Biologics were not available to troops in theater. Isotretinoin worked to clear the severe acne patients when oral antibiotics failed, he says.

Dr. Collins says short courses of oral prednisone in combination with topical steroids worked well to treat severe cases of eczema. He says he only had to resort to cyclosporine in a few patients.

For the most part, the conditions were manageable.

"I probably only had 30 medicines - topical and oral - for dermatology, and I was easily able to manage the majority of all the conditions I saw," he says. "I did not need a lot of the fancy things that we always see advertised."

With temperatures in the 120s to 130s (Fahrenheit) in July, the troops are at risk for heat injuries, especially acute sunburns. But, according to Dr. Collins, troop commanders proactively have their troops use protective uniforms, sunblock and wide-brimmed boonie caps.

Skin cancers

Treating and screening for malignancies was an important part of his work, Dr. Collins says.

He says he treated more than 100 malignancies - mostly basal cell carcinomas, followed by squamous cell carcinomas and melanomas. He had to send home some of the patients with aggressive malignancies, including several melanoma cases, so that they could have sentinel lymph node biopsies and surgical oncology evaluations and treatments.

Dr. Collins helped to spread the word about skin cancer by holding two screening clinics, at the U.S. Embassy and at the United States Agency for International Development (USAID) compounds in Baghdad.

"On one weekend, I would easily screen from 50 to 100 patients and promote skin cancer awareness and skin cancer checks. In those two screenings I did, I probably diagnosed over 40 malignancies," he says.

Unusual cases

Along with the usual, Dr. Collins treated the unusual. He says he saw about 12 cases worthy of publishing.

One was a leiomyosarcoma in a male in his early 40s. Doctors thought he had a ruptured cyst on his back, but Dr. Collins diagnosed it as a slow-growing malignancy. The patient was evacuated immediately from the theater and treated back in the United States, and is now doing well, he says.

Another interesting case: Dr. Collins treated a Peruvian guard with steatocystoma multiplex suppurativum.

"I do not think I’ve seen a case published with the severity that he had," Dr. Collins says. "Being a guard, he had to wear a protective Kevlar vest. He had close to 100 lesions, and many of those were two- to three-centimeter cystic lesions, covering his upper chest and upper back."

The guard was unable to wear his vest because the lesions had grown so large. Dr. Collins excised more than a dozen of the lesions, so that the patient could comfortably wear his vest and continue his duty.

He also saw a patient with Reed syndrome (hereditary leiomyomatosis and renal cell carcinoma, or HLRCC), which is a smooth-muscle tumor syndrome. The patient had a prior shrapnel injury and doctors had attributed his lesions to the injury. But Dr. Collins noted that the lesions had a segmental distribution and biopsied one.

"They were tender, especially with changes in temperature. He had about 30 of these lesions on his right shoulder. Because they were so tender, I had him follow up with me every three to four weeks, and I would remove five to 10 of these lesions at a time," he says.

"However, the reason the syndrome is important is those patients can develop renal cell carcinoma. So he is being closely followed for development of renal cell carcinoma down the road."

Rare keratoderma

Dr. Collins also treated an Iraqi child for a rare form of keratoderma on her hands and feet. It was painful for her to walk and to hold objects. Her parents drove about nine hours for each of the three treatments with Dr. Collins, since no prior Iraqi doctor had been able to help her with her treatment or diagnosis.

He says he treated the child, who had centimeter-thick skin buildup on her hands and feet, with three topical therapies, which cleared her about 80 percent. The therapies: urea 40 percent, twice a day; alternating clobetasol and calcipotriene daily for anti-inflammatory effects; and salt water soaks, all to help decrease the skin thickness and allow her to walk and play as a normal child.

Dr. Collins also treated teledermatology patients all around the Middle East, including consults from ships in the Persian Gulf, and troops in Afghanistan, Africa and Egypt.

"It is challenging, because you cannot talk to or see the patient in person, but I was able to save many medical evacuations by helicopter or ground transportation, in the majority of cases, with the telemedicine system," he says.

Military experience

At 31, Dr. Collins has six years of military experience. He did his dermatology residency at Brooke Army Medical Center in San Antonio. He says that he might be deployed yet again.

"The military rotates us every two to three years; so, if I do go back, I will probably go to Afghanistan. The next time I go, I might go as a GMO, or general medical officer, rather than a dermatologist, because the need for a general practitioner or GMO is higher in a deployed setting," he says.

"When you deploy, you are a doctor first. I could be anywhere, doing any kind of medicine. Before we go on these deployments, we get trained in trauma medicine and combat medicine," he says.

He has gone back to his roles as a staff dermatologist at Wilford Hall and teaching dermatology residents, which he loves. But, he says, the deployment was the most rewarding experience of his life.

"You have a lot of pride for your country and fellow soldiers, being in the military. Treating the patients and seeing personally what is going on over there - and how much good we are doing - is so rewarding," he says. "You really feel like you make a big difference."

Dr. Collins’ wife, Michelle Collins, is proud, too.

"I am most proud of my husband’s devotion and passion for helping others," she says. "While deployed, my husband worked extremely long hours and stayed up many nights to make sure he saw every patient and completed any consult he received.

"In addition, he volunteered and risked his life going on medical missions he arranged to evaluate soldiers in other areas of Iraq, including Balad," she says. "My husband loves his profession and is proud to have served his country in Iraq." DT