threads that link the Falklands to Iraq
Twenty-five years ago this weekend British territory was invaded by a foreign power. The Argentine invasion of the Falkland Islands followed six months in which the British government, for extraneous reasons, claimed that no such threat existed, corrupting the conduit of intelligence to that end. It blinded itself to the possibility of conflict. In the subsequent war, 255 British troops died and £3 billion was spent recapturing the islands. An inquiry, under Lord Franks, was staged to exonerate ministers of guilt.
Four years ago a British government was in an eerily inverse predicament. It spent six months claiming, again for an extraneous reason, that a foreign power posed an imminent threat to Britain, corrupting the conduit of intelligence to that end. It blinded itself to the possibility of no conflict. In the subsequent war 134 British troops, so far, have died and well over £3 billion has been spent. Two inquiries, under Lord Hutton and Lord Butler, have been staged to exonerate ministers of guilt.
After the Falklands war, stern efforts were made to ‘learn the lessons’ of what appeared to be a failure of intelligence and deterrence. Yet a dense fog still surrounds the run-up to that war. There are few accounts of the war seen from the Argentine side, as defeat is always an orphan. Last year’s official British history by Sir Lawrence Freedman broadly accepted the Franks thesis that the invasion came as a bolt from the blue. It was a spur-of-the-moment response by the Argentine junta to a threatened general strike, capitalising on a visit to South Georgia by some scrap-metal merchants in March 1982. Such an invasion, said Franks in 1982, ‘could not have been foreseen’ and therefore, ‘We would not be justified in attaching any criticism or blame to the present government.’ The truth is that the Argentine invasion was a complex operation that had been long in the preparation. Although plans for an invasion were standard exercises in Argentine navy circles, 1981 was different.
The British government was clearly signalling that it had lost interest in its South Atlantic possessions. At the United Nations in New York the Foreign Office had been negotiating to transfer sovereignty over the islands to Argentina and then ‘lease them back’ to enable the islanders to continue as self-governing. These negotiations deteriorated abruptly when Margaret Thatcher indicated to Foreign Office ministers that she was unwilling to pressure the islanders to agree terms. To the intelligence community the result was clear. It meant a seriously increased risk of Argentina staging an occupation, against which the islands had to be better defended, the so-called ‘fortress Falklands’ option.
Thatcher’s desire to appease islander opinion was equalled only by her desire to cut defence spending, best illustrated by the navy review boldly engineered by her defence secretary, John Nott. This embraced the end of ‘out of area’ seaborne operations, the withdrawal of HMS Endurance from its patrol duties in the South Atlantic and even an offer to sell the carrier, HMS Invincible, to Buenos Aires. To Argentina’s naval attaché in London, Gualtar Allara, Britain was pulling in its colonial horns. The Falklanders were not being offered full British citizenship, Rhodesia had gone and Hong Kong was going. The Diego Garcians had been sold down the river.
Earlier Argentine plans for seizing the Falklands had been codenamed Plan Goa, after the similar seizure by India of the Portuguese colony in 1961, a seizure that had been accepted by the United Nations (and by Britain). In December 1981, the navy commander, Admiral Jorge Anaya did exactly what a Joint Intelligence Committee assessment the previous July had warned.
That same December Anaya’s close associate, Leopoldo Galtieri, seized power in a coup. He was a bombastic soldier much favoured by the Reagan team in Washington. Anaya agreed to support him on condition that the navy were allowed not just to occupy South Georgia but to realise its fondest dream — a full invasion to ‘recover’ the Falklands before the 150th anniversary of their occupation by the British in 1833. Galtieri agreed and the invasion plan was authorised by the new junta on 15 December.
This was a wholly different scale of operation from that on South Georgia. Since glory was to be shared, it required a full tri-service planning team under Lombardo, with associated legal, diplomatic and public relations support. The invasion would take place in the depths of the southern winter, between 15 May and Argentine independence day on 9 July, when any British response would be near impossible. This was approved by the junta on 12 January. It was to be a bloodless exercise in ‘coercive diplomacy’ as a preliminary to resumed UN negotiations.
Demographics, Stone Characteristic, and Treatment of Urinary Calculi at the 47th Combat Support Hospital during the First 6 Months of Operation Iraqi Freedom
There are few publications describing urolithiasis in deployed military personnel. Renal colic was the most common urologic indication for air evacuation from the 47th Combat Support Hospital during the first 6 months of Operation Iraqi Freedom and we describe our observations and experience herein. Institutional review board approval was obtained to create a database of patients presenting to the 47th Combat Support Hospital with urolithiasis. Patient demographics, stone characteristic, imaging modality, urinalysis results, treatment course, and outcomes were evaluated for 182 patients. Sixty percent of patients qualified for conservative treatment and spontaneous stone passage was documented in 28%. We conclude that conservative therapy is safe and appropriate initial treatment for the majority of deployed personnel with urinary calculi, however, many patients were lost to follow-up. No patient treated conservatively required admission for sepsis, azotemia, or other serious stone-related complication.
Although the impact of urinary calculi on the military mission is difficult to quantify, renal colic was a frequent reason for referral to the 47th Combat Support Hospital (CSH), Camp Wolf, Kuwait, and the most common urologie indication for air evacuation out of theater. Yet, despite the apparent prevalence of stone disease in military personnel deployed to desert environments, there are few publications addressing basic information such as patient demographics, stone characteristics, necessity for air evacuation, and the success of treatment in the field.
The influx of military and civilian Department of Defense personnel into southwestern Asia in support of Operation Enduring Freedom and Operation Iraqi Freedom (OIF) provided a unique opportunity to observe stone disease in the deployed population. Southwestern Asia is a high risk area for urolithiasis with a reported incidence of urinary calculi up to five times higher than other regions of the world.1-4 During the 6-month period of this study, the 47th CSH was the largest tertiary referral hospital for the military theater and was the main evacuation route for southwestern Asia. As a result, the majority of renal colic requiring definitive diagnosis, subspecialty care, hospitalization, or evacuation was cared for at the 47th CSH. The objectives of this study were to evaluate patient and stone demographics, determine the time interval until formation of a symptomatic stone, and evaluate treatment outcomes and indications for air evacuation at a single, level III military treatment facility (MTF) deployed in support of OIF. Herein, we summarize our experience diagnosing and treating urolithiasis in the combat and early posthostilities operations during the first 6 months of 0IF. Our goals are to provide information to aid in the diagnosis and treatment of renal colic in the deployed environment, improve the planning of medical support operations, and provide insight into the timing of stone formation.
Methods
Database Construction and Demographics
Institutional review board approval was obtained to construct a database of all patients who presented to the 47th CSH from March through July 2003 for the diagnosis, treatment, or further air evacuation of symptomatic urinary calculi. The database included the patient demographics, stone characteristics, imaging modality, date of arrival into theater, date of the onset of renal colic, urinalysis results, treatment outcomes, and indication for air evacuation.
Imaging Modality, Stone Characteristics, Time Interval
All patients included in the database were evaluated by a urologist at the 47th CSH and had urinary calculi or evidence of a recently passed calculi documented by standard radiographie criteria. Imaging studies were not repeated if the patient arrived with images adequate to confirm the diagnosis or if the patient was referred from an outlying facility by a urologist who included in the medical summary a description of the radiographie findings adequate to confirm the diagnosis and characterize the stone. If more than one modality was performed, only the diagnostic imaging modality was recorded in the database.
Patient demographics and stone characteristics were entered into the database at the time of the evaluation. The patients were asked the date of the onset of renal colic and medical records, when available, were used for confirmation. The date of arrival into theater was supplied by the patient and was cross-referenced with the Joint Theater Personnel Roster. The stone location, laterally, number, and size and other pertinent radiographic findings were documented. A history of stone disease was not exclusionary, but patients who had undergone treatment for stone disease in the 30 days immediately before deployment, and patients presenting with a second or subsequent episode of stone disease since arriving in Southwestern Asia, were excluded from the analysis of the time interval.
Chemstrip (”dipstick”) urinalysis was performed when clinically indicated and results were recorded in the database. Urinalysis was not repeated if the results from a referring facility were adequately documented. The study patients were compared to 292 controls comprised of outpatients who underwent urinalysis at the 47th CSH during the study period for a diagnosis other than urinary tract infection or urolithiasis.
Treatment Outcomes
The treatment course and initiation of air evacuation was determined by the treating urologist and dictated by the clinical scenario. For the purposes of this analysis, patients were divided into two initial groups. The first group consisted of patients manifested for evacuation during their first evaluation at the 47th CSH. The indications for air evacuation included failure of inpatient management and/or stone characteristics, radiographie findings, or concomitant medical conditions not conducive to conservative therapy. Inpatient management consisted of intravenous and/or oral hydration, pain control, and treatment for constipation, admission did not equate to treatment failure. Patients were considered to have failed inpatient management if they had pain and/or nausea/emesis that required intravenous therapy for longer than 48 hours. Patients who failed inpatient management were not candidates for conservative management.
The second group consisted of patients given a trial of conservative outpatient management and returned to duty. Conservative therapy was initiated for patients with stones 4 mm or less in size, who could hydrate well, and whose pain was controlled with oral medications. The size criterion was selected based on published rates of spontaneous stone passage.5″7 Conservative therapy consisted of 2 to 3 weeks of duty restrictions, oral narcotic pain management, and hydration. All patients were instructed to return for repeat evaluation by a urologist at the 47th CSH even if their symptoms resolved, and they were issued appropriate documentation for their chain of command. Patients who received an initial trial of conservative management were further divided into patients with radiographie evidence of spontaneous stone passage, patients who failed to pass their stones, and patients who were lost to follow-up. Successful conservative management was defined as documentation of stone passage on follow-up radiography.
The U.S. Transportation Command Regulating and Command and Control Evacuation System fTRAC2ES) was searched by name and social security number for records that matched patients in the study database and the matching records were reviewed. TRAC2ES records for medical condition other than urinary calculi and TRAC2ES records documenting transfer for the purposes of demobilization were eliminated from analysis.
Statistical Methods
The arithmetic mean and range were calculated for the age. Stone size and number were compared using an unpaired Student’s t test with a two-tailed distribution. The locations of the stones were compared using a ?^sup 2^ test of distribution. The time interval until the development of symptomatic urinary calculi was calculated for each patient by subtracting the date of entry into Southwestern Asia from the date of onset of symptoms. Histograms were constructed for the time interval and the date of the onset of symptoms. SD, mean, median, skew, SE of skew, kurtosis, and SE of kurtosis were calculated for the time interval. The distribution of the time interval was evaluated with the Kolomogrorov-Smimov test, which compares the data set to a normal distribution. An insignificant p value from the Kolomogrorov-Smirnov test signifies the data set is not statistically different from the normal distribution. SPSS software was used to compute the results.