Providing Care on Middle East Battlefields
from Clinician News Posted 08/14/2003 Melissa Knopper Public opinion regarding the war with Iraq was divided in the United States, but there was one thing on which everyone could agree: whole-hearted support for the troops doing the fighting. Taking care of those soldiers — and civilians — was no less important, requiring a high level of skill and the ability to think quickly in pressured situations. Now, with the major combat over according to President Bush, Clinician News has tracked down and conducted e-mail interviews with three physician assistants and a nurse anesthetist who provided medical support during the conflict. Army PA Gives Iraqis Equal Care As director of Emergency Medicine Services for the Army Health Clinic at Camp Doha, Kuwait, CPT Winfield Winegar, PA-C, has taken care of American soldiers, enemy prisoners of war, and Iraqi civilians. Most of the US soldiers visit the clinic for routine primary care or emergency services. "We take care of everything from the common cold to fractures," Winegar says. When he treated Iraqi patients during the war, however, it was usually while working from the back of a "Dustoff" helicopter. The aircraft carries people with critical injuries from the battlefield to military hospitals, located either on a coalition hospital ship or on land. One of the Iraqi patients Winegar treated in the field was a 12-year-old boy with leg burns. "Can you imagine being 12 years old and having a foreign soldier with gear and weapons load you into a helicopter?" Winegar says. He could tell the boy was scared, so he tried to reassure him despite the language barrier. "I rubbed his head and smiled and then gave him his 5 mg MSO4 [morphine]," Winegar recalls. "He smiled and gave me the thumbs-up." The boy's parents also were hurt. His mother, who had more severe burns, was unconscious and had been intubated. (She died two weeks later.) To protect the boy from the trauma of seeing his mother this way, Winegar and his colleagues decided to transport her separately, even though it would take longer. Instead of a routine two-and-a-half-hour mission, it turned into a six-and-a-half-hour journey, with the last leg of the trip ending in an unassisted night flight over the Persian Gulf. "The US military does try very hard to be kind," Winegar says. "People are people, and are treated with respect and dignity by US and coalition forces." Air Force PA Practices in Combat Zone Capt Tim Howerton, PA-C, the officer in charge of medical plans and operations for the Joint Special Operations Air Detachment-South, keeps his clinic in a bag. Howerton, who was responsible for evacuating casualties during combat and who also served in Afghanistan and during the Persian Gulf war, is constantly on the go. "On deployments, we always work from the field, away from the mainstream," he says. "We never stay in hotels and usually do our clinics out of tents." Despite the rustic facilities, Howerton and his Special Operations colleagues rely on a collection of extremely compact, high-tech tools to help them save soldiers' lives in the middle of the combat zone. "For CASEVAC [casualty evacuation] missions, we set up a bare-bones ED in the air, in the back of a C-130," he says. The equipment on board the airplane includes portable ventilators, suction, Lifepac 10/12 portable defibrillators, thermal angels (to heat blood or fluid), ranger wraps (to heat people), and a roll pack — a 3 x 4-ft storage container, whose top rolls down. Inside, it holds medication, dressings, caths, needles, sutures, airway kits, and other supplies. Howerton's team also carries a 10-L portable oxygen machine and several units of blood. A special generator ensures that the equipment will work when it's needed. On the ground, Howerton carries a bag with such items as an oxygen bottle, bandages, meds, an airway bag, chest tubes, splints, and IVs. Howerton, who is a career military PA, has a wife and children at home in Florida. He has been deployed for more than a year, and is able to exchange e-mail with his family daily. Hearing from loved ones helps Howerton and the other Special Operations soldiers cope with life in a desert war zone. "It's dirty, dusty, and windy, and there's a lot of sand," he says. They live in tents and sleep in sleeping bags. They get three meals a day, but Howerton doesn't have much to say about the MREs (meals ready to eat). "It's a great weight-loss program," he jokes. While he is always armed and surrounded by highly trained troops, Howerton doesn't let down his guard. "Any time you are in the Middle East region and you aren't Arabic, it's a safety threat," he says. "You just fall back on your training, you don't do stupid things, and you think everything through." Special Operations forces keep a lower profile than the conventional military, which also helps with safety, he explains. "We are more secretive and usually do not let anyone know where we are," Howerton says. "Of course, we are well armed and operate almost exclusively at night." To become an aeromedical PA with the Air Force Special Forces, Howerton needed a solid background in primary care and at least 100 hours in the emergency department (ED). He also took courses in combat casualty care, combat survival, and medical management of chemical and biological casualties. Medically, it's exciting and challenging work, but for Howerton, it's also meaningful on a personal and philosophical level. "If you could see the faces of the Iraqis and the Afghanistan people who have been abused and tortured and don't have the everyday freedoms we have.... Well, I hope my children never have to see that," he says. "And I hope none of our next generations have to do this ever again." Nurse Anesthetist Prepares for War Before the bombing started in Iraq, MAJ Brian Benham, CRNA, was there, preparing for war. Benham, an instructor for the US Army Graduate Program in Anesthesia Nursing at Fort Sam Houston, Texas, was deployed in November 2002 to gather medical supplies and check equipment in preparation for the impending conflict. "I was part of an advance party support team with orders to pre-position medical equipment in the Gulf, to check its readiness and availability," Benham says. That meant spending two months at an army base in Kuwait, Camp Doha. Most of the time, Benham was taking inventory and inspecting MASH-style tent hospital units — complete with portable operating rooms, x-ray rooms, and anesthesia machines — which can be dismantled and assembled as needed along the front lines. They are typically located 10 to 40 km from the combat zone. Inside the tents, CRNAs and surgeons who are part of a forward surgical team stabilize wounded soldiers for transport to a combat support hospital. While in Kuwait, Benham and his colleagues carefully dismantled each anesthesia machine and checked the electrical components and circuit boards. "We were going through the equipment to make sure it was in good working order," he says. "That way, when the conflict did begin we could be sure there wouldn't be any issues with the equipment." Medical equipment has improved since the last conflict in the Persian Gulf, says Benham, who was also deployed during Desert Storm. "The anesthesia machine used in the Combat Support Hospitals in Desert Storm was replaced in the late 1990s with a machine that is very similar to an anesthesia machine you might see in any civilian hospital," he says. The hospital tents, shelters, and monitors also have improved, he adds. Living conditions at Camp Doha were austere but comfortable, Benham says. He shared a room in a trailer with two other officers. "While it's in a strategic location, Camp Doha is a little bit bleak," he says. "There is very little green — it's just sand, concrete, and asphalt." The constant sandstorms during certain times of the year can be tough to deal with, he says. "You wear goggles and pull a bandanna over your face and continue on," he adds. Benham was able to return home before the fighting began, but many of his former CRNA students were deployed into the heart of combat. He estimates a total of 364 CRNAs from all branches of the military were deployed during the Iraq war. In Army Forward Surgical Teams, CRNAs are the sole anesthesia providers, says Benham. In the Forward Surgical Teams, CRNAs have to be able to function effectively in a field environment. In addition to saving lives, their duties might include running electrical cables, bringing in water, hanging camouflage netting, and filling sandbags. Army CRNAs also must be independent thinkers. "They are people who like to be able to make decisions without having to confer with a lot of other people," Benham says. "As CRNAs, we are given a great deal of responsibility for our own actions." The Army nurses who are part of the Forward Surgical Teams ride in Humvees with a team of medics and surgeons. In Iraq, some of the nurses riding in convoys came under enemy fire, Benham said. Since they work so close to the front lines, the CRNAs must put aside their fear and do their jobs. "Usually, the urge to care for people takes over," Benham says. "It's part of our medical culture — you take care of people. That's why we're here." Mentoring PAs Going to Iraq As Army PAs from the hospital at Fort Bragg, North Carolina, prepared to ship out to Iraq, CPT Sherry Womack, SP, PA-C, a veteran of Operation Enduring Freedom in Afghanistan, offered her most useful piece of advice: "Just stay low and don't let the bullets hit you," she recalls telling them. Womack was the only female PA to accompany Special Forces soldiers (who typically are deployed to combat areas) during Operation Enduring Freedom. With 20 years of experience as an Army medic and a PA, Womack was a natural mentor. But she also had just returned from Afghanistan, full of practical knowledge and expertise to share with her colleagues. For one thing, she told them to leave their handheld electronic PDAs at home. Womack's preferred method is to carry low-tech paper versions of all her favorite reference guides in her pocket. "I told them with all the sand here, it may or may not work, so don't even bring it with you," Womack says. She showed them pictures of unusual medical conditions they might see in the civilian population, like the flesh-eating disease leishmaniasis. Womack taught them how to take antimalaria pills and to watch out for deadly creatures like scorpions and poisonous vipers. Womack, who normally works as a PA in the ED at Fort Bragg, was called to serve with the Special Forces in Kandahar, Afghanistan, because they needed a medical person who could treat civilian women and children. "The local women and children were not to be treated by men," Womack explains. "In their culture, if another man looked at their women it was considered a curse." While it meant leaving behind her five children, ages 4 to 18, Womack did not hesitate to say yes to her assignment. She updated her will and sewed special quilts for each of her kids in case they would need comfort if she didn't come back. "It was tough, but when I went over there, I knew what I was getting into," she says. "You've got to prepare for the worst." In Kandahar, Womack worked in a tent-based medical clinic similar to those used by medical personnel in Iraq. Her duties included treating the soldiers in her unit, along with detained enemy soldiers and local civilians. Other times, Womack — who is barely 5 feet tall and weighs 110 lb — donned grenades, carried a 9-mm assault rifle, and rode with the Special Forces in armored vehicles to take care of wounded soldiers and civilians. Womack, who returned last fall, says the transition to coming home wasn't easy, and the PAs returning from Iraq will face the same kind of heartbreak and healing. When bad memories haunt her, Womack says she tries to replace them with happy moments in the present day. "I talk to my coworkers in the ED or I spend time with my kids," she says. "I have a strong faith, which also helps." Serving during wartime changes a person, she says. "When you go without electricity, water, and even toilet paper — things people here take for granted every day — it makes you see things differently when you get back," she says. "It makes you see what's important." The military life isn't for every PA, but Womack says it fits her skills and personality. She stays because of the camaraderie she feels with her fellow soldiers and her loyalty to the Army. When you're an Army PA, she says, the word Army always comes before PA. "You're a soldier first, so you've got to be prepared to carry a gun, accept orders, and go where they call you," Womack says. "It's a different kind of medicine." Melissa Knopper, Contributing Writer Clinician News 7(5):1, 16-17, 21, 2003. © 2003 Clinicians Group, LLC __________________________________ Do you Yahoo!? Yahoo! SiteBuilder - Free, easy-to-use web site design software http://sitebuilder.yahoo.com --- SMU-L Aimeriez-vous obtenir une adresse de courriel @paramedicine.ca ou @urgences.ca? 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