Life on the Front Lines

Daniel Nicastri, MD, a former Navy doctor and current Mount Sinai thoracic surgeon, interviews Lou Guerra, former Green Beret and current student at the Icahn School of Medicine at Mount Sinai. Guerra shares his journey from running a successful pizza restaurant to the battlefield to the classroom, and how the lessons he learned in Afghanistan and Ukraine helped him meet the academic challenges on the Upper East Side of Manhattan.

This episode of Road to Resilience is published in observance and support of Veterans Day.

For more information on early assurance programs for veterans, including the institutional pathway for military vets and Flex Med to gain acceptance to Icahn School of Medicine at Mount Sinai, click here:
https://icahn.mssm.edu/education/medical/early-assurance

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Check out more episodes of Road to Resilience —as well as guest pictures, transcripts, and more— on the Mount Sinai website.

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Visit https://www.mountsinai.org/clinical-trials to see if you're eligible to enroll in a clinical trial with the Mount Sinai Health System. Check out more episodes of Road to Resilience—as well as guest pictures, transcripts, and more—on the Mount Sinai website.

Transcript

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Stephen Calabria: [00:00:00] This episode contains vivid descriptions of battlefield injuries and wartime medical care. Listener discretion is advised.

From the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about facing adversity. I'm your host, Stephen Calabria, Mount Sinai's, Director of Podcasting.

On this episode and in honor of Tuesday, November 11th, being Veterans Day, we're privileged to have two esteemed vets on the show.

Lou Guerra is a former financier turned owner operator of a successful coal-oven pizzeria, - turned US Army Special Forces Green Beret, where he served as a medic.

Lou has served in both Afghanistan and Ukraine and come face-to-face with some of the gravest trials a human being can endure.

He is guest interviewed on this episode by Daniel Nicastri, MD. Dr. Nicastri is a former staff surgeon at the Guantanamo Bay Detention Center, then later commander in the US Navy.

After completing his Navy active duty service, Dr. Nicastri joined Mount Sinai in [00:01:00] 2014 and currently serves as a thoracic and general surgeon. Together, the pair illustrate the lessons that veterans offer the rest of us through their grit, determination, and sacrifices.

We're honored to welcome Lou Guera and Dr. Daniel Nicastri to the show.

Daniel Nicastri: Hello and welcome to Road to Resilience, Mount Sinai Health System's groundbreaking podcast.

I'm your host, Daniel Nicastri. I've been a thoracic surgeon at Mount Sinai Hospital for 11 years, and prior to that I served in the US Navy. I was stationed in the DC area working at Fort Belvoir in Northern Virginia and at the National Military Medical Center at Bethesda, the Naval Hospital at Guantanamo Bay.

And I also served in afghanistan and the role three hospital in Kandahar in 2012. So that brings us to my introducing someone whose unique experiences have led him through many great challenges, which he'll likely see many more challenges in his career as well, with a focus on military veterans and the unique strengths they bring to medicine.[00:02:00] 

I have the pleasure of introducing Lou Guerra. I would like to start with a description of Lou from one of his closest Special Forces teammates- When my Special Forces team was tasked to clear a valley in eastern Afghanistan of Taliban and Haqqani fighters, we were planning to enter the valley with over 900 Afghan soldiers to support our mission.

As a sole Green Beret medic on my team and on my first deployment, to say I was worried is an understatement. Fortunately for my team and me, Lou Guerra was only a phone call in a helicopter right away.

He eagerly jumped into action, offered to help wherever possible, and seamlessly integrated my with my team for the next six days as we took on the massive responsibility of clearing a hostile valley. That is who Lou Guerra is.

Many people like to talk about being there for their family, friends, or community. However, Lou does not talk about it. He is about it. So let me just flesh that out a little, Lou. Did you basically volunteer to do an extra mission at, in [00:03:00] wartime? 

Lou Guerra: Dr. Nicastri, first, thanks for having me. I think to answer that question, it helps to understand a little bit about how Green Beret teams work. So at that time in Afghanistan since 2017 our company, so our company consists of approximately six Green Beret teams.

Those teams consist approximately of anywhere from six to 12 guys. We had very few Green Beret medics in country. This was fortunate for me as a new Green Beret in my first combat deployment because basically I had the opportunity of jumping on missions of other teams that needed medics.

Daniel Nicastri: So recapping that, Lou, you could get called in at any time, anywhere, and did you have a choice in the matter or, 

Lou Guerra: Yeah, absolutely. You had a choice at that point in Afghanistan, I had networked with as many medics as I possibly could. The individual who wrote that is one of my closest friends, as you mentioned.

So the second that there was an opportunity for me to go to combat, [00:04:00] I wanted to do so. And as I went on more of these missions, the more confident I became as a medic and as a result, the more missions I wanted to go on. 

Daniel Nicastri: That's fascinating. Lou's on this podcast because he is not only an Army veteran and a former Green Beret medic, and if you were here in person, you could see Lou is right outta central casting as representing a Special Forces operator.

He's got the beard and the physique, so it's no stretch to imagine him in the Special Forces, but he's also a first year medical student. And so, as a surgeon being able to interview him and having a background in the military as well, it's really fascinating to me.

And the reason Lou is at Mount Sinai is, Mount Sinai has some special programs. For those with different backgrounds to attend medical school. And originally there was a Flex Med program for non-traditional academic backgrounds for, students who studied more liberal arts than pre-med and they could forego the MCAT exam.

There was an offshoot of this, was a US Military Institutional [00:05:00] Partnership Program and up to date now there've been 11 students enrolled in this program who are veterans that came through to this medical school, and Lou is one of those.

That's one of the reasons I have the pleasure of speaking with Lou today. So, I want to get to the beginnings of your training and your experiences, Lou, and, you're a New Yorker from Long Island. I'm from Queens myself, we, not too far apart from our beginnings.

And tell me about what it was like with, your family growing up, all the way leading to your first career choice. 

Lou Guerra: Absolutely. As you mentioned, I'm from Long Island, New York originally. The most important thing about me is, I'm the oldest of four, so I have two brothers and one sister.

And really I grew up in a traditional working class household. My father still works night shifts, 78 hour, 80 hour weeks in Hunts Point Terminal Market and he would be the first guy to wake me up on a Saturday morning to practice baseball.

So that left an impression on me as a young kid, as I was growing up, my mom was at [00:06:00] home, she was definitely the disciplinarian and she put a primary focus on academics for the entire family.

Neither of my parents went to college and I think it was important for them to see one of their kids go off to college. I think, from my mom, I can remember and still tap into from this day, the feeling of pride you get from putting your name to a project that you've done, have done well.

Not going to sleep when you think the project is half done but actually going to sleep when that project is completely done. You can be proud of it and I could still tap into that. And that took me all the way to a full academic ride to NYU.

My parents definitely burned the candle on both ends so that their kids would have better opportunities. And I might not have been as appreciative as I should have been as a younger kid, but I certainly am appreciative of it now. 

Daniel Nicastri: So your dad would practice baseball after being up all night with you, on Saturday morning? 

Lou Guerra: Yeah. I would say that man averages maybe four hours of sleep. I can't remember a baseball game that he didn't attend. So keep that in mind. If he's working a night shift [00:07:00] driving from Long Island to the Bronx, that means he's probably leaving at about three o'clock.

He's getting home maybe three, 4:00 AM. What does that mean? He might wake up at, 1:00 PM to practice baseball with me or basketball with one of my younger brothers and then continue to drive on.

And that was, that was just accepted like, that's what I saw as a kid and it didn't necessarily, I didn't understand what he was doing. I just understood that that he cared about me. , 

Daniel Nicastri: That's some really valuable time. You mentioned that you went to NYU. What'd you study at NYU? 

Lou Guerra: I was an econ major, so first wanted my immediate family to go to college and I was following the traditional path. You do well in high school. For me, I was fortunate enough to get an academic scholarship.

You do well in college, something business-related. My dad was in business, it made sense and then you see where that takes you. So this, I graduated in 2007 from NYU and immediately went into finance because it just made sense. It just flowed with what I was doing.

Daniel Nicastri: In finance, how long did [00:08:00] you spend in finance before you went onto your next stop?

Lou Guerra: So 2007, 2010. Turns out not a great time to be in finance. But it actually worked out for me because I hated it. And the reason why I didn't like it is because, simply put, it wasn't enough. I didn't feel like the stakes were high enough.

Yes, I made money, I was applying my degree, but it really, it wasn't interesting enough to continue. So the fact that the recession hit was a great opportunity for me to pivot. And I'm sure we'll talk about that in a second.

So I was in finance for three years before made my next move. 

Daniel Nicastri: Yeah. So it's interesting, for those listening, it seems like the natural jump is, it wasn't enough for me and he's gonna go right to the military, but there's a catch. What happened next? 

Lou Guerra: Yeah. So at that time, so I mentioned I have two brothers. I have a brother who's a year and a half younger than me, Anthony. He was gonna UNC-Chapel Hill. My dad would visit my [00:09:00] brother at Chapel Hill and at the time North Carolina, and in some ways it still is, a food desert. 

There's absolutely no food there, but a lot of North Easterners were skipping Florida and instead settling in North Carolina because of the value. So there was a tremendous opportunity there and the opportunity was creating something in food.

And keep in mind, none of us have any restaurant experience. My dad sells produce, so tangentially food related. But we had, no one had cooked an omlette before we started the restaurant.

So I was ready to leave finance. My brother and my dad were eager to start this restaurant. So basically we all invested everything we had as a family. And we started a restaurant from scratch and carry North Carolina.

Daniel Nicastri: How'd your restaurant do?

Lou Guerra: Lemme tell you how it started because, the initial start was certainly not indicative of where we were headed. 

Daniel Nicastri: And your dad was down there with you? 

Lou Guerra: That's correct. Yeah. So literally I ran the front of the house. I ran the back of the [00:10:00] house. Me and my two brothers made every single pizza for three years.

So my youngest brother is 10 years younger than me. My sister, she occupied many different roles from hostess to server to salad maker. So it was definitely a family run operation through and through. Every single day, the lights were on.

I was there for three years and it gave me a real appreciation for what hard work means. So those first three months, now think about what we're trying to do. I'm doing coal oven pizza and the way we use those coal ovens would be closer to how wood ovens are used here in New York.

So really high temperature, a thousand degrees plus, pizzas cooking in, let's say 90 seconds to two minutes. And people think of pizza as a fast food, but it's a slow food if you do it right.

Fermenting the dough for days before, sourcing the best ingredients you possibly can and then ultimately cooking the pizza. So I was asking a local North Carolinian to pay twice as much as they would for [00:11:00] a CC'S or Domino's conveyor belt-style pizza because that's the standard that we held as a family.

Not surprisingly, that was a big ask. So for those first three months, we literally just fed ourselves. 

Daniel Nicastri: Wow. And you didn't have encountered the same types of laws with the ovens there that pe that restaurateurs see in New York is having.

Lou Guerra: Yeah, that, that's correct. Because coal ovens were really unheard of in North Carolina anyway, we could pretty much do as we pleased. That was one benefit.

 And also too, we weren't really competing with anyone because the traditional, the best pizza there at the time was something that was more conveyor belt style.

But there was definitely an educational piece that we had to overcome with the customer because, at that three month mark, we were basically looking at ourselves like, we're gonna have to make a decision here.

Are we going to cheapen the product so that we can stay in business and keep the lights on? And again, keep in mind, all chips were on red from every single member in the family.

So this is everything that we've ever owned [00:12:00] on this restaurant. Or, do we stick to our original mission, not let the standards slip one bit, and basically wait for the right person to find us?

And we chose the latter. And within, I'd say about a month from that three month point, we had a review from the biggest food writer in the area that basically said, your pizza dream is here. And the dream he was talking about was our pizza dream.

Now as a family, we had always gone to great restaurants where you see the lines out the door and you're doing your research on Zagat surveys, like where, where do I go? We became that restaurant, where people were calling until we had to take the phone off the hook and people were lining up.

So that initial review was an inflection point for us as a restaurant, and within that first year, we won restaurant of the year as a coal oven pizzeria, competing with other fine dining restaurants in the area. 

Daniel Nicastri: So you were able to catch up to the [00:13:00] business though? Did you have to hire a lot of new people? 

Lou Guerra: Honestly, it's similar to the Green Beret teams. I need to find people who are worth 10, 10 men, so I had rather have a very small team where each person is a force multiplier versus they're hiring.

I mean, In some ways, and I think my family could attest this, I felt like I fired and hired every single person in North Carolina just to fill a small family business and carry. But the reason for that is because our standards were so high, and this was not a restaurant to us.

Like I'm a celebrity chef that occasionally visits. This was us living and breathing every single day. This is a true 100 to 120 hour work week for that first year. So if I was bringing you on as an employee, I was bringing you into our family, in a way, 

Daniel Nicastri: I don't know if it's been said before, but it's the Greek diner model. It's the family run business. Everyone's working there all the time. Family invested in it. 

Lou Guerra: Yeah, if any listener has ever seen The Bear, it was The Bear times 10. 

Daniel Nicastri: Serious Eats [00:14:00] included your pizzeria eventually and top 25 in the country, right? 

Lou Guerra: Yeah. An interesting closure of the loop there. So a lot of the research we did prior to opening a restaurant. And was through this book by Ed Levine, who is, at least at the time, was a founder of Serious Eats.

And he went through the entire continental United States searching for the best pizza. We as a family basically followed Ed Levine and that second year, so this is after we won best Restaurant in the Triangle, we won 24th Best Pizzeria in the United States.

So that was another surreal moment for us, where the book we were reading, years prior, now included our restaurant as part of the top places in the United States. 

Daniel Nicastri: So take us from being a pizza restaurateur to joining the military. What happens?

Lou Guerra: Okay, so after the second year, we had an offer on the restaurant that third year. Keep in mind, we are absolutely hammering as a family and [00:15:00] we felt that if we entered as a unit, we were gonna leave as a unit as well.

I was 27, about to turn 28, and I knew that I was aging myself out of a Special Operations career. That was something that was planted, a seed was planted early on in my life. Watching Discovery Channel Special Operation documentaries, like Class 234.

Reading books like The Warrior Elite by Dick Couch. When you watch. People suffer on that level. You have two reactions. Either you're aghast, like, why would anyone do that? Or you ask yourself, why would anyone not want to do that?

And for me, it was a hundred percent the latter. So at that point, at 27, 28, now the rubber was starting to meet the road. It was either time to do it or not. And I think everyone in my family was ready to transition. The best way to put it, it was time, and we had an offer.

So then we sold the restaurant, and then I joined the military six months thereafter. 

Daniel Nicastri: I like that question. You said, why would anyone not do that? I think some choices in life you make, and some you are almost compelled to do, and it was a compulsion [00:16:00] for you, almost.

Lou Guerra: A hundred percent. I knew at the time that it was gonna be regret if I didn't do it. No, I have a personal mantra, and that is, if there's any doubt, there is no doubt. Meaning it was just a hint of doubt, right? Should I do this? Should I not do it?

That is enough of a confirmation that I should have done it. And so ultimately I made the leap. I've been talking a lot about Navy Seal documentaries. The first recruiter I went to was a Navy recruiter. But I didn't get a great feel from the interview.

So what do I do? I walk across the hallway and there's an Army recruiter who, who sits down with me for an hour talking about the mission of Green Berets and I signed on the dotted line then. 

Daniel Nicastri: You mentioned there was a special program for Green Berets.

Lou Guerra: That's correct.

Daniel Nicastri: Just like there's a special program for military at Mount Sinai Medical School, there was a special program, explain that and the washout and 

Lou Guerra: Yeah, absolutely. So, the beauty of the Mount Sinai program for veterans is, it's a fast track to medical school. If I was gonna go to medical school a different way, I would've taken, had to have taken at least an [00:17:00] additional year to prepare for the MCAT after exfilling from the military.

So it saves me time. Similarly, the 18 x-Ray program, this is a civilian to Green Beret program, allows you to fast track to become a member of the Green Berets. However, and this is with a large asterisk, you have to meet every single requirement over the course of potentially a three year journey.

So from the military's perspective, it's a great recruiting tool to bring people into the regular infantry, like not into Special Operations because they're looking, they're staring down, a 70% attrition rate, overall.

So of all those people, you know, who have bright eyes and big dreams, likely, only 30% are actually gonna make it through that entire pipeline. And what was attractive to me at the time was, again, I was a little bit older, so I just wanted to get to it.

It was 2013 at this point. I was late to the war and I wanted to get overseas as soon as I possibly could.

Daniel Nicastri: Off the top of [00:18:00] your head, what percentage of Green Berets do you think had a college degree? When they start as a Green Beret, at least. I know that some will get degrees afterwards.

Lou Guerra: I would say it's higher than you'd think. Ballpark? I'd say 50%, honestly, based on my experience, 

Daniel Nicastri: I don't doubt it. My minimal experience supporting the SEALs as a medical student the first thing I recognized was what a smart group they all were. It's, what an intelligent group.

Lou Guerra: Yeah, no, 100%. And we're talking about my story today. My story is not that abnormal for a lot of 18 x-rays. Why is that? They're people who have life experience who wanna get to war as soon as possible.

So naturally they're gonna follow this expedited path. I encountered plenty of interesting stories on my route to become a Green Beret. 

Daniel Nicastri: So what brought you to being a medic?

Lou Guerra: The ar, the short answer is the Army told me. So, within a Green Beret team, again, we're [00:19:00] talking anywhere from six to 12 guys and like, what is our mission? Our mission is essentially, to be behind enemy lines and work with and through a local indigenous force, a resistance force to overthrow a potential oppressor.

Like, that was the origin of Green Berets. This goes back to early 1950s when the United States thought the Soviet Union was gonna continue to expand westward. And we were gonna have to essentially have a solution in these countries that were overtaken by the Soviet Union to form a resistance force and then, in turn, overtake the oppressor.

So that's kinda the origin story of the Green Berets. In real time contemporary examples, I'd say , the book Horse Soldiers is another great example of what Green Berets could potentially do.

And I think it's worthwhile to understand that for a second before I, I dig into the medic piece. If you go to Liberty Park now outside the World Trade Center Museum, there's the America's Response Monument, which is a Green Beret on a [00:20:00] horse.

And the reason for that is, the Green Berets from fifth group immediately following 9/11, worked with the Northern Alliance to essentially topple the Taliban regime with a very small group of people.

So you can imagine like what kind of jobs you would want those people to have if they're put in very dangerous places, pretty much disconnected from a larger military force. You'd want to have a medic, you'd want to have a communications expert.

You'd want to have a person who knew every weapon system out there. You'd want to have a guy who is an expert in demolition. And then an officer and team sergeant.

So you have these array of occupations that you could choose from after you pass the initial selection point, but ultimately it's the illusion of choice. So you pass that initial part of selection, you write down your wishlist, what do you wanna do?

For me, again, I'm late to the war. I knew becoming a medic would add on at least another year to my time. So I buried medic in my wishlist choices. [00:21:00] But, when they called my name, they said, Gary, you're going to medic school next.

So it wasn't my choice at all, and I couldn't be more grateful for it.

Daniel Nicastri: And was that placement tests or that 

Lou Guerra: Yeah. So during that initial selection, and there are plenty of YouTube videos on this, Two Weeks in Hell is a humorous example of what, quote unquote, selection could be for Green Berets.

And you're in a generally sleep deprived state. You're doing land navigation, individual events, team events and sprinkled within there you're taking IQ test, you're taking math and science tests, and

Daniel Nicastri: There's spatial tests as well? 

Lou Guerra: Spatial tests are built in, like language capability because that's a big portion where, whereas you can imagine if you're gonna go behind enemy lines, man, it's helpful if you can speak a different language.

So you're doing all those sprinkled in and there's an extensive backside operation that is counting every single widget about you so that they can place you where they feel like you'll be the most productive and most successful.

Daniel Nicastri: Can you tell me about some of the [00:22:00] tours you went on that you're at least authorized to discuss?

Lou Guerra: Sure. So I showed up to 10th Group outta Colorado in 2017, and I knew I was going to Afghanistan that summer. So within three months of me showing up to a team, I went to Afghanistan.

And it was a fantastic experience for me because at the time my senior medic was moving on to other things. So as a new medic, I became a senior medic instantly and got to assume a lot of those responsibilities and have exposure to other missions that, that you brought up initially where, I could essentially jump on these other missions and be the main medic for my team. Because that's all we had.

Daniel Nicastri: Where else? You went to Ukraine as well, right? 

Lou Guerra: So after combat trip to Afghanistan, I went to Ukraine in 2019. So typically, my company was the war company. We only went to [00:23:00] Afghanistan, but there was a reshuffling. Likely because leadership wanted to give guys a little bit of a break.

As you can imagine, training for deployment, going on a combat deployment can be very exhausting over time.

Daniel Nicastri: And tough on the families at home.

Lou Guerra: Yeah, a hundred percent. Yeah. And certainly I'm not the guy to talk about that. It's, It's just me and it's been just me for a while, for a reason.

Daniel Nicastri: For sure your mom was worried.

Lou Guerra: Yeah, for sure. She was, but she knows what Lou needed to do. So there was a rearrangement and that rearrangement was shifting towards Eastern Europe, Ukraine in 2019.

And you know, like you say, like timing's everything. So there were people who graduated in my Green Beret class who never got to go to combat. And that's a real tricky beast, right?

Because the reason why, that's certainly the reason why I signed up, and I would say a lot of folks that I know closely is, you want to prove yourself in a very difficult situation. And there's no situation quite like war.

So when [00:24:00] you do all the things, you pass Special Forces selection, you become a Green Beret and then you don't get to do the thing that you're trained to do, there's a certain amount of regret with that.

The flip side of that is as a Special Forces medic, somebody has to get hurt for me to do my job. So it's almost a requirement for someone to get hurt, which who could potentially be someone that's very close to me in order for me to cross that Rubicon and feel like I proved myself.

So it's a balance between the two.

Daniel Nicastri: In your combat experience, what percent of injuries that you cared for were for fellow Americans versus civilians or Taliban fighters. How would you divide that?

Lou Guerra: So it's actually quite rare for you to treat a teammate. The reason for that kind of goes back to that Green Beret mission. We're working with and [00:25:00] through indigenous forces to help them overcome the oppression.

So, it's one thing if we were to do a mission unilaterally, at some point we're gonna leave. And we can look back and see what happened there. If these people don't have the skillset to do these missions by themselves once we leave, all that's gone.

So it's actually quite rare for you to treat a teammate. By and large, you're gonna treat indigenous forces.

Daniel Nicastri: How about enemy forces? Did you treat any?

Lou Guerra: For me, no. It honestly didn't come to play. I'd say in, perhaps you have experience in this in a role three, i'd say that it's a better chance if you're in a more remote area, but again, I personally don't have any experience with that.

Daniel Nicastri: Yeah. We, at the role three, we treated enemy forces, civilians and NATO forces as well. And we had to have room at the hospital for the civilians, but the enemy forces were treated to the exact same standard as NATO forces.

Lou Guerra: Were you made aware of [00:26:00] that before they came in?

Daniel Nicastri: Where they were from?

Lou Guerra: Yeah.

Daniel Nicastri: Like it was always obvious. Obvious forms. I don't think it was ever not obvious. I guess if it was enemy forces though, yeah, we were made aware, versus distinguishing between civilian and not.

There were also, there were different dispositions after surgeries, depending on where they're coming from and what our availability was.

Lou Guerra: I could dig into Ukraine a little bit more.

Daniel Nicastri: I mean, it's obviously relevant now and you were there before it was probably pretty relevant to the rest of America.

Lou Guerra: Yeah. And it goes to that timing piece. So for me, I caught Afghanistan at a great time where I got to be extremely active on the deployment as a medic. And then I caught Eastern Ukraine right before major Russian invasion in 2022.

So I was there in 19, and our mission was primarily a training mission. So it was our job to train Ukraine Special Forces. At this point, there's a proxy war ongoing on the eastern fringe of Ukraine between [00:27:00] Russian-led forces and Ukraine Special Forces.

So the folks that we were training a month later were immediately going to a combat zone. So for me, I had mixed feelings on it because there were still Green Berets in Afghanistan conducting combat operations, people that were very close to me, and here I am in a non-combat area training Ukrainian Special Forces.

So you you have that feeling that you're missing out. For me, also, based on the experiences of my first deployment, I felt like I could make a difference. Whether or not that was true, who knows?

But as you start to get more experience with anything, you start to feel like you make more difference. And in fact, you want to take more risks and get out to missions even more because you have experiences that other people don't have.

So I was kind of dealing with that. The way I reconciled it was that I knew these Ukrainian folks were gonna see war a month after our training and I got to take lessons [00:28:00] that I learned in Afghanistan and immediately employ them to Ukrainian folks.

And honestly, they couldn't have made it easier for me. The most motivated group of individuals I've probably ever trained. And these folks had absolutely nothing. We were eating a bowl of oatmeal day in far eastern Ukraine, where I was at.

It didn't make a difference. They came and showed up, and in fact, they met you exactly where you were at. For me, I really I've got two switches. It's on or it's off. And I'll give you one training example.

I was like, again, my whole thing is I wanna make this as realistic as possible because combat medicine is so much worse when you have to do it for real. It's easy to do simulations back at home and feel good, yeah man, I crushed that scenario and then all of a sudden you go overseas you're getting shot at.

And something as simple as putting a tourniquet on becomes very difficult. So my whole thing was how do I make this as [00:29:00] realistic as possible and how can I lean on even my restaurant experience? So what do I do? Well, you know, I talked to some local guys.

I say, go to the Butcher shop, find some awful organ meats. And we're gonna make this next training scenario as real as it gets. And so what did I do? I had pig intestines, I cellophaned pig intestines on a patient as moulage evisceration.

I'd use different organ meats to simulate torn up arms. We used actual pig's blood.

Daniel Nicastri: I just want to point out the dichotomy of how hungry I was getting when he was talking about pizza earlier and now I'm not as hungry. 

Lou Guerra: That's, maybe we'll finish on Pizza Wreckx in New York City, or I'll bring you back that back Dr. Nicastri, I promise. 

Daniel Nicastri: Okay. So go on.

Lou Guerra: Yeah, so, pig tracheas for caral autotomies. I took it that far and I'll never forget the first time a student ran up and saw that evisceration and smelled that evisceration and threw up. But he threw up and then continued to train.

Daniel Nicastri: We've been through your life [00:30:00] from starting a restaurant business to your joining Army Special Forces. And I know you've competed in 100 mile races. Now you're a medical student. What's the common thread in your approach to all of these challenges?

Lou Guerra: I see two threads. The first is a lesson I learned while I was in the restaurant business, and that lesson is in order to understand who I am, I have to push myself to extremes. That means that, I'm not catching farm raised salmon.

It means that I'm chasing Moby Dick, and if I find Moby Dick. I have to find his brother and his sister next like that. That pursuit of something mythical and bigger than yourself is integral for me to understand who I am. That's one part of it.

The second part, and this is the deeper layer, goes back to the introduction. [00:31:00] The most important part of my identity is being an older brother of four, and I feel it incumbent upon myself to set that example and lead from the front.

I can't do that as a mid-level management associate, especially because I have a lot of extremely talented siblings. In some ways, I have to go to med school at my current age, which I'm not gonna reveal, just to keep up.

And that when you distill everything down, that's why I'm doing it. But it's a pretty amazing thing when you accomplish something that you never thought you could accomplish. And a hundred mile race is another microcosm of that.

Like in your brain when you think there's absolutely no way I can do this, and then all of a sudden you can, you are forced to look at the world entirely differently.

Daniel Nicastri: How long does that take?

Lou Guerra: If you're a 6, 1, 220? A long time, if you're, if you're 160 pounds, a lot less.

For [00:32:00] me, my goal is the same every time. It's to get the buckle. So there's a cutoff to get this buckle, right for each race. The hardest race that I've ever been a part of is Uua 100 and Uua North Carolina. And the cutoff there was in the ballpark of 36 hours.

I think I ran it in 35 30. So it doesn't get easier as time goes on, I'll say that. But certainly it can take a very long time.

Daniel Nicastri: So if you go into surgery as a resident, you can do it on your weekend off. Okay. I actually post calls Saturday morning. You go do it. You have enough time. Get some sleep Sunday night.

Okay, here's another one. The military and medicine are service oriented professions. These questions are coming in from all the callers that are calling the show right now. So some would say these service oriented professions are callings.

I've even said it's sometimes a blessing to be a surgeon. They both require lengthy commitments, meaning that you not only bring different life [00:33:00] experiences from being in the military, but also you have some different experiences from being more mature than your fellow students. Do you think that changes your perspective on medical training?

Lou Guerra: Dr. Nicastri, you calling me old?

Daniel Nicastri: I've seen how young some of your fellow classmates look, so compared to them, Yes. Not compared to me, that's for sure.

Lou Guerra: I think I, I'm I'm forced to tap into all of those experiences in a difficult environment like medical school. To me it's actually almost identical to the a hundred mile race that I mentioned because it required, at least as of right now, it requires a great deal of physical and mental stamina.

You can't let off the gas. So I think having those experiences and knowing that I actually, I have tapped into this before is very helpful. I think in terms of overall habits i've made [00:34:00] enough mistakes that I know what works for me at this point.

Having a strong foundation that has worked for me in the past, it, I think can be predictive of what will work for me here as well. In terms of medical training, the last portion of my military career was as an educator. I taught at the special operations medical center.

We're basically training special forces medics. I have a very specific view on, I think, how training should proceed. And a big portion of that is, basically allowing people to fail in high stress environment sooner rather than later.

How that applies to medical, I think we'll see more so in clerkships than right now in, in the didactic center. But, maybe you can speak to that too in, in terms of your surgical training.

Daniel Nicastri: I think it's better to fail in models and in real life. It depends on the training exercise. But yeah, listen, [00:35:00] medicine. Medicine is if you're comparative a sport, you we all lose. But we hope to have a good game, play a good game, but eventually we lose. 

So it's trying to, make someone's quality of life better, give them better quality of time. You have a great attitude to get through training, that's for sure. You'll have no trouble with the training.

And when we were talking before, I think you've done a lot of things for other people, and your medical training is ultimately for other people. But when you're in medical school, it's one opportunity you're actually doing it for yourself too.

So you can enjoy it and you're making, you know yourself better and it's for now it's for you, and you earned it.

Lou Guerra: Yeah. And to be honest with you, Dr. Nicastri, it's great to be around so many other talented people. There's a palpable energy. That keeps you moving forward, whether you want or not, because of how great the people are around you.

So that's one thing that, that I think I personally have benefited from is the folks around me versus my old age. 

Daniel Nicastri: Lou, [00:36:00] between all your various experiences from starting up a successful pizza restaurant or working in Special Forces as a medic to being a medical student, there are definitely some common themes, some unifying themes, and you talk about the people around you. Can you expand on that at all? 

Lou Guerra: Sure. I mean, the people who have been most consistent in my life are my family, and we are an impenetrable unit. My mom gets the brunt of it. She gets to live every victory and defeat from every single kid, every single day.

And I probably, owe her a tremendous therapy bill. But the truth is, knowing that I have a family that's always willing to support me, and quite frankly, each member of my family serves a different role, and I hope they feel the same way about me.

Knowing that that foundation is always there, allows you to endure those defeats. [00:37:00] Maybe you take 24 hours, lick your wounds, but guess what? It's time to go out there and do it again.

And I think, when it comes to support structure, med school, restaurant or otherwise, it always, it ties back to my family.

Daniel Nicastri: that's a hard one to follow. I'd agree. It's your, the family is your backbone and then you also have peripheral social support networks.

So in, in medical school, it's the fellow students. Are there any similarities you're seeing between maybe the professors in medical school and some of your trainers in the military? The doctors are way softer than the military.

Lou Guerra: Yeah. It's funny. In the military, they tell you the interrogator, you have to worry the most about. It's not the most intimidating looking guy, it's the friendly interrogator. So it's been It's been a little off putting for me by how nice everybody is.

Not only students, but professors as well. I'm waiting for the shoe to drop at all times. And [00:38:00] man, are they extremely tolerant of punctuality issues within medical school, but overall I think a connecting theme is, they actually both want you to do well.

They just have different ways of showing it.

Daniel Nicastri: I was always intimidated by people who are quiet 'cause I have no idea what they're thinking.

Lou Guerra: It's just great.

Daniel Nicastri: Having served as a medic, you're bringing a lot of different medical experiences over most the average medical student, let's say. How do you think that's gonna help benefit yourself and other students?

Lou Guerra: Look, a, as the older guy and as the older combat vet, I think it would be very easy for me to be isolated in this environment. I felt like I was lied to a couple times by some mentors before I went to medical school.

Everyone said, yeah, there's always at least that 55-year-old guy. You won't be the oldest. I'm the oldest, but that being said especially with how great my fellow students are, [00:39:00] you can tie in as much as you want to.

And I think, one route for me is when we start doing more hands-on skills, because I've trained in those skills, I've made those mistakes, and sometimes it helps as a student to learn from another student more so than a teacher.

So I think as we start moving into more of those skills, I'd be happy to share that with them. And then, when it comes to patient interactions, I've had both positive and negative. I'm happy and open to sharing those as well, as more and more students get experiences in the ER and elsewhere.

Daniel Nicastri: Do any of the younger medical students run a hundred mile race?

Lou Guerra: I'm sure there's one or two. Nowadays, Dr. Cashier, you kinda have to write your first book by 10 to get in medical school. I wouldn't be surprised would be my short answer to that. And I and knowing other medical students, they probably did 101, if I say a hundred.

Daniel Nicastri: What advice would you give to a younger you?

Lou Guerra: So this is to my 14-year-old self. And that's an [00:40:00] important time because generally the time when people start high school. I'll start with the worst piece of advice I've ever got. The worst piece of advice I ever got was from a guidance counselor.

And that advice was, you've got time. And that couldn't be further from the truth. I would tell myself that you have no time. In fact, what I'd say is, everyone around you knows exactly what they wanna do and you don't. What are you gonna do about it?

And I think that would've lit a fire under my ass to start exposing myself to more things and ultimately find what I'd like to do way sooner. What's interesting about, my name is, for such a long time, I search for what am I gonna be good at?

And it was staring at me in the face my entire life. My last name means war in, it means war in Italian and Spanish. So I think for me, I needed to expose myself to way more things.

I felt like I was doing the right thing. I was following the traditional path, doing good in school, getting a white collar job. But really I couldn't have wanted anything [00:41:00] less when I actually got it.

So that's the advice I'd give my 14-year-old self, but maybe I wouldn't be here on this podcast with you.

Daniel Nicastri: And you definitely had a trial by fire of jobs. But if you're happy where you're today, I think your route was good.So that's another way to think about it. So in defense of the the advice you got.

So gimme the best example of resilience you've seen in your multiple experiences. Careers. Or one, one good example, doesn't have to be the best.

Lou Guerra: Sure. I have one phenomenal example, I'm not gonna say good. Phenomenal example was from one of my teammates who I treated in Afghanistan in 2017. So as I mentioned before, it's very rare for a Special Forces medic to treat one of their own.

In my case, I had both the misfortune and privilege to do that. So a little bit of background on the situation. We're basically hunting down a bad guy, [00:42:00] and we come across this compound. It's a two story compound that's open air, so there's no roof.

A wide open courtyard in the middle with a very large door in front. To get a better position, myself and my communications guy, who's another incredible human being, we essentially went to flank on the side to see if we could look in.

And my other buddy, the demolitions expert started working on the door to breach it, to blow it up. As soon as he blows the door open, an eruption of gunfire occurs. It sounded like the entire night sky was lit up.

As soon as that happened, myself and the communications guy, now keep in mind we have local Afghans with us. We take our small contingent of Afghans back to the breach to see what's going on.

Within, maybe 30 seconds of us initiating moving back to the [00:43:00] breach, we get a call over the net, Medic, Medic. Now, in my mind, it wasn't necessarily clear that it was a US PAC personnel that was injured.

I just know they were calling for medic and I was headed there anyway, so I'm headed back to the main breach. And that's when I see my teammate walking towards me. We're pretty much linking up at the same time.

And even though it's pitch black, it looks, honestly, looks like his arm was hanging from his shoulder by a thread. We have two, at least two second story barricaded shooters within that courtyard.

And you can imagine this from their perspective, it's like shooting fish in a barrel. From our perspective, as a fighting force on the ground, it's extremely difficult to deconflict that because they're barricaded on a second story and we're down below.

So we're in an extremely disadvantageous position. I take my buddy to a [00:44:00] safer place still against the wall because honestly, that was the best cover we had. Gunfire is still erupting and I get to work and do my job, while other folks worked to deconflict the issue inside.

At the same time, we knew it was bad enough that my teammate was gonna have to get evacuated out. It turned out that a 7 6 2 round, so a very large bullet, pierced behind his elbow on the upper arm, and essentially blew out his humerus, transect his radial nerve.

And what I saw was just profuse amounts of bleeding from the upper arm and the lower. At the time, I didn't know honestly if it was a lower arm injury or upper arm, but he was bleeding a lot.

So I did my job, my other teammates did theirs, and ultimately we worked an evacuation plan. Fortunately at the time, I had a senior medic who really mentored me the entire deployment.

He was there, double checked my work, gave some medications to my buddy to help him basically evacuate himself out. I held onto him [00:45:00] throughout the maybe 400 meter movement back to the aircraft, and then he was on his way.

He goes to surgery and fortunately is alive. His radial nerve was transected. And it's it's interesting. We just,

Daniel Nicastri: Where'd he go? Germany. Did he go?

Lou Guerra: So initially he went to an FST, so a forward surgical team. Then he went to Landstuhl after that. So he got stabilized at that forward surgical team, then he goes to Landstuhl. 

Daniel Nicastri: Landstuhl American Base in Germany, where we were pretty much sending all of our soldiers and sailors back there for a more definitive treatment before sending them stateside. During the Afghan campaign. 

Lou Guerra: Exactly. And there was a short time where he actually, so FST, then he went to Bagram and then he went to Landstuhl. That was the trajectory there. We linked up with him in Bagram, so our entire team was there when he woke up.

Daniel Nicastri: How's he doing now?

Lou Guerra: He's doing great and the [00:46:00] original question was, a great example of resilience. Guess what? He had complete wrist drop because that radial nerve was cut in half. But we had a deployment basically slotted a year after he got hurt. He wanted to get on deployment, you know that just like we did.

Daniel Nicastri: Still had wrist drop?

Lou Guerra: Oh yeah, a hundred percent. 

Daniel Nicastri: He was wearing a brace at that time?

Lou Guerra: This is wrist drop on his dominant hand. So you can imagine, you can't shoot a gun if you have wrist drop on your dominant hand. At least certainly not with that arm. So he worked physical therapy for that next eight months or so.

And fortunately now I spoke to him the other day to make sure he was okay with me sharing the story and he's, he said about 80 to 90% back.

Daniel Nicastri: That's fantastic.

Lou Guerra: Yeah. Which is incredible. And he made that deployment as well.

So to see a guy do that, and I think it's a great example of a Special Operations veteran, if there's anyone listening to this podcast and his Special Ops veteran comes to your [00:47:00] hospital and asks for help, he probably really needs help, because we typically suffer in silence and do everything we can not to ask for help.

And I think my buddy's a great example of how resilient we can be.

Daniel Nicastri: I'm gonna bookend that story with, when we were in Afghanistan, we saw a lot of limb loss due to IEDs. And so that's what we were primarily treating at the role three in Kandahar.

Then when I was separating from the Navy, I was back at Walter Reed area and I would see a lot of the veterans who had lost limbs and they were all young and I'd see them working hard, doing PT and sometimes two limbs lost.

In our jaded way, we said someone was lucky if they only lost one limb. At the time we were there in summer of 2012, but sometimes three limbs and major injuries to the perineum or groin.

And when you separate from the military, you go through classes so you can get a job and [00:48:00] adjust to regular civilian life. And in the classes I was there with a young lieutenant who had lost two and a half limbs, so both lower legs.

There may have been one above knee amputation, one below knee amputation, if I remember right. And then one of his forearms as well. And he was telling us about his desire to go to medical school and how he didn't want to be defined by his injuries and was looking forward to his next steps. And I just found that so inspiring.

Lou Guerra: Yeah, it's incredible. And honestly, one, one of the worst parts is, you see a guy who shows up to the team room who's hurt, who's working through this injury. At that time we didn't know if he'd ever get any wrist extension back.

And I know for him, it's one thing to wear a Green Beret, but everyone, like the best guys wanna feel like they're contributing, that they're still part of the team, not in name only. So the fact that he was able to deal with that, which I'm sure was its own mental hurdle throughout that recovery process, is pretty [00:49:00] incredible.

Because, a lot of us are sled dogs and we're gonna mush. You take off two of our paws, we're gonna use our back too. If you take us all four, we're gonna use our chin to move forward.

To see that actually occur in real time was incredible and I'm fortunate that he was the best patient I ever had. He was literally talking to me when he got hurt with the same level of composure you and I are talking to each other right now, and this is while gunfire's going on. 

Patient, tolerant. Listened to everything I said. Maybe until we gave him ketamine, but r eally the ideal patient, especially at that time in my career where I was a new medic. So I'm incredibly grateful to him.

Daniel Nicastri: A lot of themes we talked about in today's discussion and I think one of them's the perspective you've gotten from your military experiences. I think there's a certain adaptability that's been read into all these situations.

Especially the Green Beret [00:50:00] experiences, adaptability to going to a foreign area and working with a group with a different culture and trying to mesh different ideals for a common goal. Teamwork.

You mentioned force multiplier before, and having the whole being greater than the sum of parts, that's always what you wanna do in these team environments. And I think that's why Mount Sinai embraces bringing in military veterans and people with different backgrounds.

This is one of the most diverse areas of the world. And one of our satellite hospitals, Elmhurst Hospital, in the most diverse neighborhood in the actual world. So Jackson Heights and Elmhurst are like the most diverse neighborhoods in the world, and if you ever call their main number, they'll tell you on the phone while you're on hold.

So it's been great working with you and speaking with you, Lou. It's been real pleasure for me and thanks for your service to our country. It's your commitment to all the ideals that we honor in Veterans Day.

Lou Guerra: Thank you very much, Dr. Nicastri. I appreciate it.

Daniel Nicastri: Thank you.

Stephen Calabria: Thanks again to Lou [00:51:00] Guerra and Dr. Daniel Nicastri for their time. That's all for this episode of Road to Resilience. If you enjoyed it, please rate review and subscribe to our podcast on your favorite podcast platform.

Want to get in touch with the show or suggest an idea for a future episode? Email us at podcasts@mountsinai.org.

Road Resilience is a production of the Mount Sinai Health System. It's produced by me, Stephen Calabria, and our executive producer, Lucia Lee. From all of us here at Mount Sinai. Thanks for listening, and we'll catch you next time.