The Little Hospital That Could: A Personal Recollection of the 24th Medical Group At the Crossroads of History

© Terrence O’Neil, Gwen O’Neil Beaudet, Annette O’Neil 2018

Print ISBN: 978-1-54395-112-7

eBook ISBN: 978-1-54395-113-4

All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review.

Contents

Dedication

Foreword

The Scope of the Effort

First Contact

A Leadership Summary for the New Commander

Morning Bike Ride

Baggage Check

Mandatory Fun

TRICARE Region WHAT ?!

Side Effects

Critters

Trabajos Excelentes (Did I Say That Right?)

Eating Snakes and Breaking Bones

Yanqui Pirates Air Ambulance Service

Out of the Sky

Pictures Out of History

Seizure

Rescue at Fort San Lorenzo

In the Tall Grass

Encounter at Fort Kobbe

Little Plastic Boxes

Hurricane Mitch

Happy Hour

The Embolism

Shuttin’ Her Down

A Swing Outside of Time

The Little Hospital That Could

Servicios Emergencias

The Snake Eater

Change of Cat-Mand

Finale

A Personal Memento of Panama – By Gwen O’Neil Beaudet

Those Who Made It Happen

Dedication

I am indebted to Susan, my wife of forty years, whose tolerance of my perfectionism, irascibility, and long hours spent in medical and leadership activities over the years sustained me. She has been the brightest light in my life. Without her calm help I could not have accomplished any of this on my own.

My two daughters—who became strong independent women while bouncing around the planet with us—were always patient and supportive. When they could have made decisions that complicated our lives, they instead made decisions that made us proud. They have helped in editing and contributing to the reminiscences that made up this volume. I am deeply indebted to them.

I gratefully salute Brigadier General (Ret) Greg Trebon, the 24th-Wing Commander during my tenure at Howard. He also was understanding of my idiosyncrasies and served as both mentor and guide during the time I commanded the 24th MDG, showing me by example how to lead, not by dicta and demands, but by helping a team of talented professionals do their jobs without getting in their way. His support and faith in his fighting medics gave us all the inspiration and strength we needed to do what we honestly feared at time was probably impossible.

Thanks are also directed to Brigadier General Klaus O Shafer (Ret) who was the Air Combat Command Surgeon during our time in Panama. He personally traveled to Panama to give direct personal engagement and support during a period of turbulent relations with the USARSO Army Community and gave us every conceivable measure of support to assure that we were able to accomplish our mission.

Major General (Ret) Randy Randolph was the Commander of the 60th Medical Wing, David Grant USAF Medical Center, at Travis AFB while I was the Chief of Medicine and subsequently the Chief of the Medical Staff. He mentored me constantly, helping me succeed as the Commander of the 60th Medical Operations Squadron, and then supported my candidacy for a Medical Group Command. No more steadfast supporter can be imagined. I owe him immensely for his faith in my ability to perform those roles.

And finally, to the women and men of The Little Hospital That Could, military and civilian, Panamanian and American, whose names are recorded to the best of my ability at the back of this book, I dedicate this volume with respect and humility. Wherever you have gone in the last twenty years since we served together, know that you made a difference for the better.

Foreword

Imagine being called out of a routine meeting at your hospital and being told that you had been selected to command a health-care organization in a country 3,000 miles away—one spread over multiple facilities spanning forty miles, and also tasked with overseeing the operation of an air- ambulance service with a 6,000-mile radius. An organization that additionally served in the turbulence and politics of a huge and complex American military community nearly one hundred years old that was trying to do its day-to-day job while simultaneously looking at a hard date in two years to have packed up every man, woman, child, and pet and left the area.

Imagine further that this organization was scheduled to grow in size by a factor of three and then abruptly downsize and close over that two-year span.

That was the situation that confronted me in April of 1997. To be honest, I knew that my time at the David Grant USAF Medical Center located on Travis Air Force Base in California was coming to an end. I had been there for a long time—thirteen years—starting as a junior major, staff kidney medicine physician, and culminating in being a squadron commander for the 1,200- person 60th Medical Operations Squadron.

There comes a point in the military where you either take on new responsibilities or depart for civilian life. That was the point I had reached.

And I loved military life far too much to say good-bye.

I had learned that I was being considered for a hospital commander billet at Minot, North Dakota; Incirlik, Turkey; or Howard Air Base, Panama. Having a wife, two daughters, two cats, and a deep involvement in our Base Chapel community at Travis. I knew that a move like the ones I was being considered for was going to be an adventure and a huge challenge, whichever one of these very different commands I got.

And, since military life was, and remains, a loss-of-control fantasy, I would have absolutely zero choice over which direction our lives went.

Ah, well.

So, it was a relief to finally be able to sit down at our supper table in Vacaville, California one evening and say Guys, we’re going to the Caribbean. To their everlasting credit, our girls both said, Neat. When do we leave?

Military brats. Gotta love ‘em.

In the last twenty years since that fateful supper conversation, much water has flowed under the bridge of life. The vignettes I will recount in this slim history will hopefully celebrate the wisdom, determination, and outstanding character of those I served with in Panama. It is to them that this is dedicated, with deepest appreciation, humility, and respect.

We truly were The Little Hospital That Could.

The Scope of the Effort

For over fifty years, Howard Air Force Base, located across the Panama Canal from Panama City, was the busy focus of American air power projection into Central and South America. Countless missions came and went as the political tides ebbed and flowed over the immense landmass to the south of the United States. Public and secret, banal and history-molding, local and far- ranging, these missions proceeded in concert with the Army headquarters at Fort Clayton, on Corazol, and a host of subsidiary bases scattered the length and breadth of the vital passageway between the seas.

Besides the headquarters of the U.S. Army South at Fort Clayton, the Army had a coastal defense station at Fort Randolph, Fort Amador, Fort Grant, and Fort De Lesseps; the Jungle Warfare Training Battalion; and a few old coastal defense batteries at Fort Sherman. There was a branch of the Jungle Warfare Training Center at Fort William D. Davis near Gatun. The sometimes-controversial School of the Americas—also known as the Western Hemisphere Institute for Security Cooperation—was situated at Fort Gulick on the Atlantic end of the Canal, between Margarita and Cristobal. France Field, an old Army Air Corps base, had been turned over to the Canal Zone as a civil airport in 1949. Fort Kobbe, born in 1932 as Fort Bruja, was an old artillery base transformed into a helicopter staging area and base housing facility.

The Navy was also heavily invested in the Canal. Galeta Island hosted an elephant cage, formally called a Circularly Disposed Antenna Array (CDAA), that allowed intercontinental low-frequency ionospheric bounces and radio navigation triangulation. So-called Wullenwever high-frequency direction-finding (HF/DF) sites, originally developed by the Germans as a secret long-range communication system, were vital to safe navigation in the days prior to satellite relays and GPS capability. A sister site was located at Clark Air Base in the Philippines. The Soviets also copied the technology for their own uses after World War II using captured German technical experts. Coco Solo, northeast of Colon, was a submarine base. The Gatun Tank Farm, located near the Atlantic-end locks of the same name, served as a high-capacity fuel reserve.

Semaphore Hill, with its iconic round white radar tower located near Gamboa midway along the northern border of the Canal and the Summit facility were long-range radar and communication links, contributing to the drug-aircraft-tracking mission. The Arraijan Tank Farm, with its oil terminal at Rodham Naval Station, served the fueling needs of the many naval vessels transiting the Canal. So too were the Naval Communications Station Balboa at Farfan and the eighty-one-mile-long Transisthmian Pipeline the Navy’s responsibility until the Pipeline’s closure in 1996 due to declining Alaskan oil transport demand.But for most of its fifty-plus years, the Air Force personnel and their families on Howard Air Base were almost totally dependent on the Army for medical support. Yes, there was a small outpatient clinic on Howard run by the 24th Medical Group, but all inpatient work was conducted at the towering Gorgas Army Community Hospital on Ancon Hill, across the swaying three-lane Bridge of the Americas.

From the opening of the Canal in 1914 to October 1979, the Canal was essentially the property of the U.S. Government—a U.S. territory operating within an approximately 10-mile-wide strip of land bisecting the country of Panama. Fences restricted access to that territory, and those residing or working within that strip of land were either U.S. citizens or Panamanians present with the permission of the U.S. Government. However, from the first of October 1979, the Carter-Torrijos Treaty of 1977 placed the responsibility for managing, operating, and maintaining the Canal under the aegis of the Panama Canal Commission. The Commission was an agency under the Executive Branch of the U.S. Government, with its own corps of workers whose employment was analogous to, but separate from, the U.S. Government Service (GS) system. The American Administrator and the Panamanian Deputy Administrator reported directly to a Board of Directors, which in turn reported to the Secretary of Defense through the Secretary of the Army. That treaty also created a timetable that called for abolition of the Panama Canal Commission and transfer of the Canal and all its fixed assets, including the U.S. military bases but not including the remaining 8,000 Panama Canal Commission personnel, to the government of the Republic of Panama on December 31, 1999. Efforts to soften the blow of the loss of U.S. postal and military shopping privileges were put into an Equity Package for Canal Commission employees, but the specter of being jobless in the year 2000 remained.

Stepwise transfer of important Canal maintenance functions to the Government of Panama was explicitly planned as part of that process, as exemplified by the assumption of the position of Administrator by a Panamanian citizen. So, too, was the inevitability of the stepwise shutdown of the U.S. military bases and transfer of their functions to locations outside Panama. A clock was ticking, softly at first, as denial made 2000 seem very far away, but the ticking was much louder by the mid-1990s, when the inevitability and complexity of the transfer were nerve- rackingly manifest.

Between 1980 and 1989, over a billion U.S. dollars were invested in completing major Canal improvement projects, implementing new programs intended to increase Canal transit capacity and improve navigational safety. However, world trade was changing, and requirements for economies of scale drove changes in the size and draft of the container ships plying the seas that progressively outran efforts to improve concrete and steel infrastructure set in 1917. For the decade of the 1980s, Canal operations resulted in between $278 million and $330 million in transit fees each year, but this was insufficient to plan major upgrades, and the inevitability of the Canal’s transition to another Government dampened Congressional interest in the multi-billion-dollar investments that would be required for fundamental quantum improvements.

Construction in 1982 of a trans-isthmian oil pipeline reduced the number of oil tankers transiting the Canal, and this reduced fee intake by about $50 million each year. From 1987 on, operating expenses exceeded income by $5 to $7 million annually.

Political upheaval that began in June of 1987 was endangering the stability of an increasingly contentious relationship between the U.S. and a nation many of whose citizens increasingly perceived the country occupied at its center by a foreign power and whose leader was exhibiting increasing bellicosity amid charges of criminality. In March of 1988, the Government of Panama closed all banks operating in the Republic. This cut off Commission access to all its funds on deposit at Chase Manhattan and Citibank, endangered the ability of Canal Commission employees to cash their paychecks, and precipitated emergency ship-clearance procedures to assure uninterrupted flow of vessels through what was a crucial international waterway. By April 1988, U.S. military personnel, their family members, and Canal employees were being increasingly harassed both administratively and physically. Through the summer and fall of 1988, the tempo of hostility and harassment rose in jagged surges. Finally, on the December 20, 1988 the situation reached a breaking point, and Operation Blue Spoon, later renamed Operation Just Cause, led over the next few days to a change of government and removal of the immediate threat to the Canal. It left, however, lingering resentments and physical scars that persisted up to 1997, when the last two momentous years of closure and turnover of the Canal began. The trans- Canal railroad never reopened, and those driving to the BX and Commissary at Corazol during the closure-and- turnover period drove alongside the wreckage of a train that had been attacked while carrying Noriega’s forces during the invasion a decade earlier. If you took the wrong turn coming off the Bridge of the Americas going south and dove into the El Chorrillo district, you saw that many walls still bore the pockmarks of 20-millimeter and 50-caliber firefights, years after the battles ended.

The delicate balance of simmering hostility and the hope of ultimate independence and ownership of the Canal were being managed by the officials of the two governments. Those of us on the ground had a much more immediate day-to-day concern: caring for those left in Panama, both U.S. and civilian, who defended and manned the Canal as the number of personnel and bases dwindled visibly week-by-week.

Then, in June 1997, Gorgas Army Community Hospital closed. In anticipation of that momentous change, the engineers had been furiously constructing a one-story, eighteen-bed inpatient facility in front of the old Howard AFB Clinic. The old Fort Clayton dormitories in Building 519 on the hill overlooking the base had their bottom two floors reworked as a large branch clinic. Other healthcare functions were scattered in sixteen buildings on six different bases or residual base enclaves. Even so, there was no way that the remaining Air Force personnel and infrastructure could handle the volume or sophistication of medical needs for the remaining 25,000 Active Duty personnel and their dependents. As a result, equally strenuous efforts had been underway to create an entirely new contracted-care region, TRICARE LATAM, to secure sufficient beds and specialties in downtown Panama City at three of the most reputable hospitals. However complete and technically adequate those arrangements were, the shock to the military community of the loss of the massive, trusted Gorgas facility was physical. There was resentment, anxiety, and a sense of a vital service being abandoned to an unknown new entity at a time of maximum stress.

People justifiably asked, Who ARE these people that our care has suddenly been given over to?

From the perspective of the Air Force healthcare personnel, if you know that your organization is going to close up forever and go away and you are going on with your family to another job at the same pay a continent away regardless how things work out in your current gig, you might not feel a great deal of pressure to be the best you can be. If you were a part of the U.S. Air Force Medical Service and you were stationed at Howard Air Force Base during closure, you found yourself being told that plans have changed; the Army MEDDAC has left town, and YOU are the ones who are going to take up the slack. And then you are told that by April 1999, next year, most of your patients are going to be making plans to leave for the States, but you can’t, because the others are depending on YOU for their medical care. Neither of these messages is going to exactly fill you with unbridled enthusiasm.

Similarly, if you were a Panamanian contractor or Canal Commission employee facing the termination of the organization you have worked for since 1977 with no concrete promise of a similar job at similar pay, you could be excused for being completely distracted and not really caring a great deal about your rapidly telescoping career.

But, being a healthcare professional meant that every day required intense concentration on the business of giving good, compassionate care.

By October 1998, when the redeployment of U.S. forces and their families was just picking up speed, the 24th MDG peaked its delivery of services. Outpatient appointments at virtually all of the clinics at least tripled. The members of the Medical Group, who were worried about their own Stateside moves, were working overtime to meet the needs of Active Duty members and their families. The numbers retrieved from the monthly record of encounters tell the tale. The average number of patient visits at all sixteen 24th MDG facilities in 1997 tripled, to 31,867 by October 1998 just prior to the peak downsizing and repatriation of families and redundant Service members. The Fort Clayton GYN Clinic, beloved of the wives living on Clayton, had gone from 278 to 835 visits per month, and the Howard GYN Clinic from 327 to 980 visits per month. Pediatrics was bulging with pre-relocation checks and immunizations, at over 1,700 visits monthly. Primary Care on the Howard side was seeing almost 5000 visits monthly. As a unit, all seven of the Fort Clayton/Building 519 clinics saw almost 10,700 visits in October 1998. Hidden in these numbers—which are startling in their own right—are some amazing insights into the culture of the military overseas. People were working extremely hard. Bases and facilities had been closed. Folks were lifting heavy boxes, carrying heavy packs, and doing frequent HUA runs. Yet, only 27 visits took place to Pain Management. Every one of us, the author included, turned in urine samples to the closely monitored Golden Flow drug-abuse-monitoring center on an average of once every three months. If you were doing any of the easy-to-find