A cut above the average surgeon

From the battlefields of Cambodia and Afghanistan to cancer hospital wards in London and Adelaide, Dr Susan Neuhaus has more than earned her medical stripes. Lumen caught up with the Associate Professor of Surgery to discuss medicine and the military.

Q: As a former military surgeon who has performed tours of duty in hot spots around the world, what has changed in the last 100 years when it comes to treating those injured in war zones?

A: One of the big differences is that people are surviving injuries that in previous wars would have been fatal. Thanks to huge advances in medicine and also in battlefield resuscitation, soldiers are able to perform very simple, life-saving manoeuvres on the battlefield. This, combined with improvements in body armour mean that soldiers are surviving blast amputations, head and chest injuries that in earlier wars were fatal. We also have the surgical capability now to stabilise and evacuate the injured to highly sophisticated facilities within 48-72 hours.

Q: You have written a paper in the Medical Journal of Australia recently which addresses the complex issues of medical ethics in the battlefield. What are the different judgements that come into play for doctors in war zones?

A: Doctors in the military are in a unique position as they have dual obligations - to the defence force and also to the individual. Some of these are enshrined in law; some are enshrined in the Geneva Conventions and others in the Hippocratic Oath. The judgements a soldier makes are not the same judgements that a doctor makes. There's a whole grey zone that we have to address.

Doctors need to make a whole range of ethical decisions under tremendous pressure in a war zone. For example, how far do you pursue aggressive treatment with individuals when faced with limited resources and their post-war standard of care available in their own communities?

If you go back to WW1 or WW2, if you were injured on the battlefield the treatment pathways were equal for all - civilians and military, regardless of race or nationality. Arguably, it is no longer that simple. Unlike in previous conflicts, military health facilities now treat more civilians than combatants, and a large number of these are children. Military personnel have access to sophisticated evacuation and retrieval, to highly sophisticated health facilities, usually many thousands of kilometres from the battlefield. Clearly this option does not exist for locals and this does impact on their treatment options. I'm not saying it is right or wrong, but it's the world in which we live.

Q: Where do you draw the line with treating civilians then, given many of these people may not have access to sophisticated medical facilities after being discharged?

A: If you look at a reconstruction effort in a foreign country, it is vital to understand the health environment in which you work. It is no use providing incredibly sophisticated First-World services if this level of treatment cannot be continued when you pull out of that country. You are better off promoting medical resources that support the local community and the local doctors.

Also, you need to take into account the cultural sensitivities of each country you are deployed to. For example, amputations and colostomies have different implications in developing countries because after-care is not always available in these communities. You may be saving someone's life, but then again you may be creating a more difficult situation for them.

Q: How far have women come in the military in Australia in terms of equality and ability to perform similar jobs to men?

A: If you go back to the Crimean War (1853-1856), women's roles were clearly defined. Florence Nightingale argued passionately for nurses to be allowed to go to war and she won that argument, although that was the only capacity in which they could serve. Fast forward to WW1 (1914-1918) and there were very strict rules in the army: only women could be nurses (not men) and only men could be doctors. Despite this, a remarkable group of Australian female doctors formed their own quasi military hospital units during the war. Over half of these women were actually decorated for their service, including University of Adelaide medical graduate Dr Phoebe Chapple, who was awarded a medal for gallantry for her efforts in France.

By WW2, professional women were allowed to step into uniform but there were still caveats. They were allowed to have the same rank, promotional opportunities and pay but were often denied the chance to be awarded honours. A lot of men still thought it was scandalous that women were allowed to join the military.

By the Vietnam War, it became more acceptable for women to take on more diverse roles and today we don't blink at the roles that women are performing, from doctors to nurses, drivers, signallers, physiotherapists, engineers, helicopter pilots and even commanders.

Q: How has the nature of conflict changed?

A: The days where armies lined up in distinct uniforms against their enemy, facing each other on either side of the battlefield, are long gone. We now live in a world where conflict is among the people, where the threats are invisible and come in the form of suicide bombs and improvised explosive devices. There is no discrimination between men, women, children, civilians or soldiers.

The battlefield is far more complex now because it is no longer obvious who your enemy is. The need to be constantly vigilant, of having to be hyper alert and dealing with the reality of war is all contributing to the mental and emotional costs of war that people bring home with them. Also, for the first time in our history we are not just deploying women, we are deploying mothers, and I don't think we really understand the long-term consequence of this on them or their families. That in itself should make us hit the pause button in the whole discussion about women serving on the front line.

Q: How have these experiences changed the way you approach your own medical career?

A: My surgical practice deals with a lot of complex cancers, especially soft tissue tumours, which requires constant ethical judgements about when to operate or not and the impact on an individual's quality of life. Some of these things are incredibly hard and emotional to navigate. I suspect that my military experiences have been very helpful in providing decision making frameworks and focusing on what is important. You have to be resilient and develop your own coping strategies because the decisions you make always have consequences. ■

Story Candy Gibson

A road less travelled

Associate Professor Susan Neuhaus graduated with an MBBS from the University of Adelaide in 1989.

She joined the Australian Defence Force in her 5th year of Medical School. After completing her internship at the Royal Adelaide Hospital she worked in London for 18 months doing surgical rotations before returning to Australia as a full-time general duties army medical officer.

In 1993, Assoc Prof Neuhaus was Australia's first female doctor to be posted overseas as a regimental medical officer, serving in Cambodia for nine months with the United Nations Transitional Authority, working out of a 6-bed hospital ward with minimal telecommunications access.

Four years later, she spent several months in Bougainville as Officer Commanding - this time as a member of the Army Reserve - providing surgical support to members of the Peace Monitoring Group.

In between these tours of duty, Assoc Prof Neuhaus worked in Queensland for a couple of years, completing her aviation medicine training at the Oakey Army Aviation Centre and her PhD in Laparoscopic Tumour Surgery at the University of Adelaide.

After completing a Lumley Surgical Fellowship in London in 2004, she was appointed Commanding Officer of the Third Health Support Battalion in Adelaide, training and despatching staff to the Middle East.

In January 2009 - by now a mother and a Colonel in the Army Reserve - Assoc Prof Neuhaus went to Afghanistan as Clinical Director of the Dutch-led multinational NATO hospital in Uruzgan.

Later that year she was awarded the Conspicuous Service Cross in the Queen's Birthday Honours List.

Assoc Prof Neuhaus now practises both as a general surgeon and a surgical oncologist, specialising in melanoma and sarcoma surgery.