LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

Advanced Emergency Nursing Journal Vol. 29, No. 3, pp. 265–283 Copyright c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

Personal Stories and Lessons Learned in a Combat Support in Baghdad LTC John Groves, RN, BSN, MSN, CEN

Editor’s Note: The selections that follow are a col- constant concern about what we would face lection of impressions and memories from Army in terms of traumatic injuries. The Ibn Sina nurses, physicians, and medics deployed to Iraq in hospital, formerly the Bathist hospital, was 2005–2006. Many were written while the contrib- well known not only through the Army Med- utors were still deployed in Baghdad and, as such, ical Department, but throughout the world, represent very personal and real-time reflections as one of the busiest trauma centers in the on war-time trauma care, the intensity of which most of us will never experience. These are touch- world. A veteran of Baghdad told me, “It will ing and, in some cases, difficult stories to read; all be the best and worst time of your life.” She the more reason we need to read them. was right. The following is a compilation of —J.A.P. reflections on the professional challenges and personal stories of our experience and the im- The following manuscripts are a compila- pressions it left on each of us. The views con- tion of several of the 10th Combat Support tained herein are those of the authors and do Hospital (CSH) staff’s experiences in the com- not represent the opinions of the U.S. Army. bat zone for a year-long tour from October 2005 until our return in October of 2006. We —LTC John Groves had the youngest group of nurses and medics deployed in the 4 years since the start of Oper- REFERENCE ation Iraqi Freedom. We learned many lessons during the development of this team while in Bowe, M. (2007). The evolution of trauma resuscitation in a combat support hospital. Journal of Emergency treating some of the worst injuries any of us Nursing, 33, 83–86. had ever seen. Our 94% survival rate for the care of over 7,000 casualties has been well documented in several publications (Bowe, Taking Young People to War 2007). It is our hope that the insight shared LTC John T. Groves, Jr., RN, BSN, MSN, CEN by these personal first-hand accounts will be Formerly Emergency Medical Treatment (EMT) Head of help to our colleagues. Nurse, 10th CSH, Baghdad, Iraq When I received orders for deployment with the 10th Combat Support Hospital in Emergency departments are usually re- support of Operation Iraqi Freedom, I had served for the eyes of crusty old veterans in high expectations for the young nurses and the nursing and medical profession. Not so in medics. They exceeded my expectations. the Army. While maintaining a level of care During our 6-week training period and up to unprecedented in any previous conflict (less our nighttime entry into Baghdad, there was than 10% casualty rate) what may have gone

265 LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

266 Advanced Emergency Nursing Journal

Figure 1. Members of the 10th CSH EMT in Baghdad, Iraq, holding a flag sent from a civilian ED stateside.

unnoticed is not only how we train but who years of experience, it has become the pin- we train to go to war. Surgeon General Kevin nacle of my career to serve with such special Kiley stated, “other armies have brave peo- young people (Figure 1). ple, they have smart people but the differ- It is often said of our “greatest generation” ence between how we fight and how other that they were unique young people who an- countries fight is how we train.” Even hav- swered the call during World War II. Hearing ing had some unique teaching assignments those veterans speak, they have no doubt that ranging from Special Forces medicine to the our current generation will rise to the same Army Trauma Training Center in Miami, I am level if needed. I can certainly attest to that still surprised. We are currently deployed in without hesitation. Our Generation-Xer’s and Iraq with a staff so inexperienced that most younger men and women are more than up to would not consider hiring them for the task. their least challenging areas without special In just 4 months here in Iraq, examples training, let alone their emergency and critical of their heroics in saving lives are countless. care units. We train and take medical special- Three days after arrival in country, this young ists of all ages, but most are very young. Just team received four U.S. fatalities simultane- like the 18-year-old rifleman, the Army Medi- ously, a larger group of fatalities than the pre- cal Department takes 18-year-old medics and viously deployed Combat Support Hospital 22-year-old nurses fresh out of school and puts received during their entire tour. It was un- them in some of the bloodiest emergency de- nerving, shocking, sad, and heartbreaking. partments in Iraq. As a senior officer with 19 And, it all happened within a matter of LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

r July–September 2007 Vol. 29, No. 3 Personal Stories and Lessons Learned in a Combat Support Hospital 267

minutes. Watching inexperienced nurses and I now understand why we are here. It is medics challenged with the horror of death of for the combat soldier. But also it is for these young Americans their own age is something young heroes. They will carry the torch and that touches even the most seasoned profes- caduceus for all of those who have come be- sionals. One of the most memorable moments fore and all of those who will come after. of this tragedy came after lifesaving efforts were ceased on one young soldier. A colonel from the 2nd Brigade, 502nd Infantry Reg- “Oh by the Way, Flight Nursing iment, stepped up to the desk to offer his Is Part of Your Job.” comfort to one of our youngest nurses. His words were extremely touching, “Thank you LTC John T. Groves, Jr., RN, BSN, MSN, CEN for what you do and all your efforts; he was a Formerly EMT Head Nurse, 10th CSH, Baghdad, Iraq good man and is deserving of your tears.”Wit- nessing a colonel personally thanking a young Flight nursing is a specialty all to itself in lieutenant was something very special. the civilian community. For a nurse assigned Now fast-forward to 4 months later and you to the of the 10th CSH couldn’t pick out the two seasoned nurses in Baghdad, it’s considered an additional duty and three seasoned medics who were de- akin to courtesy patrol or pulling guard duty. ployed among the 31 rookies. Events oc- When we arrived in Iraq, the average ED curred daily that hardened the young soldiers. experience of our team was only 4 months. More important, skills have been forged at This remarkably young team quickly learned breakneck pace. Not only do these young to manage some of the most traumatic injures heroes resuscitate , but they also risk seen in the world from high-energy explo- their lives by jumping into helicopters with sions. However, our greatest clinical challenge patients who have severe brain injuries and was still ahead of us. We were informed in must be flown to another hospital. Treating early December 2005 that the neurosurgery an unstable, severely injured in-flight team would be leaving us on the 15th of De- is a task reserved for the most seasoned of cember. We had 2 weeks to train, equip, and nurses and medics in the civilian community. identify nurses and medics from our current Out of necessity, this is not always possible in staff to configure a flight program to trans- Iraq. port multiple trauma patients whose injuries Even with events from home overwhelm- included devastating trauma to the brain and ing them, they hunker down and drive on, the nervous system. not wanting to let their teammates down. One Make no mistake; our young medics who nurse and medic had to be evacuated due serve aboard MEDEVAC flights are some of to personal injuries, yet both pleaded to be the bravest soldiers in our Army. They pro- brought back. This is the value of selfless ser- vide one of the most essential missions and vice. It reflects one of our main Army val- contribute to the historically high survival ues: placing the needs of others ahead of your rate we have achieved in this conflict. How- own. ever, they do not have the critical care train- Here are some special moments from our ing needed to fly intubated, brain-injured pa- time here: friendly competition to get the tients who may be fresh off the operating most helicopter flights in, a successful thora- room (OR) table and commonly are receiving cotomy by a young physician who had only paralytic and sedative medications. With the trained on animals prior to deploying, and, high incidence of neurologic trauma we re- after saving a pulseless soldier, a young lieu- ceived at the 10th CSH, we immediately re- tenant remarked, “I learned today that when alized this would create a challenge. As the you do CPR that doesn’t always mean they Head Nurse of the ED, I immediately began to die.” brainstorm how we would be able to urgently LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

268 Advanced Emergency Nursing Journal

Figure 2. Neurologic transfer checklist.

evacuate these patients requiring lifesaving through the many difficulties involved in start- brain surgery to our sister facility in Balad, ap- ing a flight program from scratch. We devel- proximately a 20–25-min flight by helicopter. oped a neurologic checklist (Figure 2) with Multiple challenges are inherent in flight the help of Captain B., a flight nurse, and Cap- nursing. Experience is critical to success. We tain S., a critical care nurse, which we uti- were lucky enough to have one Certified lized to ensure that our patients were prop- Flight Registered Nurse (CFRN) to help sort erly prepared for flight. Classes were held on LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

r July–September 2007 Vol. 29, No. 3 Personal Stories and Lessons Learned in a Combat Support Hospital 269

Figure 3. LTC Groves precepting 1LT Skates in one of her early flights.

the critical care drugs necessary to maintain person job. Owing to the serious blast effect a patient with a traumatic brain injury dur- of IEDs on the pulmonary system and the ten- ing flight through the combat zone. Addition- dency for midflight failures of our portable ally, with input from our departing neurosur- ventilators, we frequently had to manually gical intensivist, Dr L., and neurosurgeon, Dr ventilate the patient for a significant portion E., we coordinated a few practice runs a week of the flight. These types of difficulties oc- prior to their departure so they could help curred in approximately 25% of all flights. We us troubleshoot any problems. With such a carried a supply of lifesaving medications and short notice, we decided to concentrate on adjuncts to manually ventilate in the event preparing the four most experienced nurses of complete ventilator and monitor failure. in the unit to fly first, with the intent of ex- When all else failed, our portable pulse oxime- panding the program to the rest of the team ter provided some rudimentary monitoring (Figure 3). Utilizing the neurologic checklist, capability. we developed and drilled the team on how We had all discussed at length, and planned to efficiently prepare the litter to transfer a on doing, “expectant” but no one men- patient. Standardizing patient packaging was tioned deciding on who was to risk their lives one of the early lessons learned. This con- flying over a hostile war zone to transfer a pa- tributed to successful transport regardless of tient who may not survive a surgery. Some the type of Army MEDEVAC helicopter that of the most challenging patients were taken picked us up. We have two distinctly different directly off the OR table after damage con- helicopter platform configurations and each trol surgery to a waiting aircraft. This sce- presents unique challenges to the delivery of nario confronted us with the challenges of patient care on board. A commercially de- both continuing resuscitation efforts as well veloped device called the “SMEED” (Special as monitoring a fresh postoperative patient. Medical Emergency Evacuation Device) was At moments like this the surgical staff would instrumental in standardizing the way we hand the patient over to us with the simple packaged our patients for flight (see Figure 4). statement “good luck.” This was not a phrase A second lesson learned in starting up a that I was accustomed to hearing spoken to MEDEVAC program is that it was not a one- an ED nurse from the surgical staff. LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

270 Advanced Emergency Nursing Journal

Figure 4. The Special Medical Emergency Evacuation Device (SMEED) prepackaged and prepared for use 24 hr a day. The components included a ventilator, portable suction, IV infusion pump, and cardiac monitor.

At first we flew everyone. We rushed out fer. And, to the credit of our medical col- the door to transfer unstable brain-injured pa- leagues, most of them seriously consider the tients to Balad with no consideration for the safety of launching a helicopter during day- safety of the four-person aircrew or ourselves. light hours in a war zone. We have treated Of special note, over 80% of these patients MEDEVAC crews for injuries here in Iraq and were Iraqi, not U.S. or Coalition Forces. We some have been lost to hostile action. I am do not differentiate in the level of care ren- relieved to say that we have had no MEDE- dered at the 10th CSH. Everyone gets what- VAC crew injuries during these 10 months of ever they need, to include $3,000-dollar med- duty. ication or the benefits of a whole blood drive, Operational security is a variable with with our staff as the donors. The criteria for which civilian flight programs do not nor- transport are based upon the Glasgow Coma mally have to contend. Threats from both di- Scale (GCS). We also have the technology rect and indirect fire are common. On one to electronically transmit computed tomog- particular transport we had to set the aircraft raphy (CT) scans to our neurosurgical col- down in an unsecured area to await gunship leagues for advice. Any patient with a GCS of support. On another run, the receiving facility 7–12 is generally considered for transport. Pa- was actively taking incoming mortar rounds tients with a GCS of 6 or lower and those with while we were trying to land, thus requiring particularly devastating injuries are placed us to take evasive actions that doubled our in our expectant category and receive sup- flight time to 40 min. The decision to launch portive end-of-life care. Those patients with had been initially delayed because the secu- a GCS above 12 are monitored and do not rity status was “red,” meaning unable to fly. receive neurosurgical intervention. The next Later I asked our doctor why we had ulti- step in the decision to transport is to con- mately been approved to fly and he told me sult the on-call surgeon, ED physician, and that the base was being mortared but that the flight nurse. A group meeting takes place status had been downgraded to “amber,”so it to discuss the pros and cons of each trans- was safe. All these decisions were made right LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

r July–September 2007 Vol. 29, No. 3 Personal Stories and Lessons Learned in a Combat Support Hospital 271

in the middle of our own 30-patient mass ca- We have limited neurosurgery capabilities at sualty event. the 10th Combat Support Hospital in Bagh- From both a clinical and wartime perspec- dad, and the only neurosurgeons in our war tive, the startup of a new flight program in the zone theater are in Balad, Iraq. Therefore, the middle of a tour in Iraq was nothing short of most common type of patient requiring trans- phenomenal. Remarkably we accomplished a fer is a patient with a head injury. The pro- 100% success rate in the transfer of 95 casu- cess starts with confirmation of neurological alties over 10 months with a staff of 12 regis- injury with a head or spinal CT scan. The neu- tered nurses and 18 medics who had little or rosurgeons are then contacted and we have no flight, emergency, or neurosurgical critical the radiology department transfer the images care experience. It is phenomenal that they electronically to the physicians in Balad. The became proficient emergency care providers ED physician, the surgeon on call, and the in the unexpected but necessary role of flight neurosurgeon in Balad collaborate before the nurse in less than 30 days. They made split- decision is made to transfer the patient. Once second, independent decisions and imple- the decision is made to transfer the patient, mented interventions that saved many lives. coordination starts between the patient ad- They often performed while unbuckled and ministration, the nursing supervisor, and radi- out of their seats, totally without radio con- ology. We call the nursing supervisor to gather tact, and in 125-degree heat. The fact that a any equipment needed for the transfer, radiol- high level of patient care was maintained on ogy starts to copy all CT scans to a CD, and the these transports and that young nurses could ED team starts “packaging”the patient. There step up to the challenges of wartime nursing are many ways to package patients for rotor are testaments to the true spirit of nursing. wing transport, the following steps are our ED standard at the 10th CSH. The steps are implemented to ensure consistency in pack- Transfer and Packaging aging for all patients (see Figures 5 and 6). Challenges in a War Zone 1. Place a litter and rickshaw in the pa- tient’s room. 1LT Natalie Skates, RN, BSN Formerly ED Nurse, 10th CSH, Baghdad, Iraq 2. Place a pad on the litter followed by an open blanket. War zone transfers present difficulties in 3. Remove all air from IV bags and drip preparing patients for medical air evacuation. chambers.

Figure 5. SMEED mounted on stretcher of a patient with a head injury packaged and prepared for urgent transfer by helicopter. LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

272 Advanced Emergency Nursing Journal

Figure 6. Preparing to load a brain-injured patient onto a Blackhawk helicopter.

4. Apply pressure bags to all IV bags. body bag with an opening at the face for 5. If the patient has severe head trauma, en- added warmth; however, this makes the sure that an arterial line is in place for unstable patient less accessible. transport. 15. Make sure all paperwork is copied (send 6. If the patient requires mechanical venti- originals with the patient), copy any CTs lation, apply a CO2 detector to the endo- onto disk, and gather all x-rays. tracheal tube. 16. Gather all needed medications for trans- 7. Place the patient onto the litter. port (standard list is epinephrine, lido- 8. Tape the tubing of at least one of the IVs caine, neosynephrine, 23% saline, at- to the shoulder, next to patient’shead for ropine, vecuronium, propofol, midazo- easy in-flight access. lam, and an analgesic). 9. Place bag-valve-mask (BVM) next to pa- 17. Call report to Balad ED. tient’s head. 18. Put on all protective gear (Kevlar vests, 10. Place Kevlar O2 tank between patient’s helmet, weapon). legs, attach to the ventilator and BVM. 11. Transfer the Special Medical Emergency Evacuation Device (SMEED) onto the “No Shit There I Was in foot end of the litter. Baghdad...” 12. Transfer cables over to the fully charged equipment on the SMEED. Captain David Boyd, RN, BSN, CEN 13. Last, switch the oxygen to the tank on Formerly ED Nurse 772nd Forward Surgical Team the litter. (FST), Baghdad, Iraq 14. Wrap the patient with the blanket, mak- ing sure all remaining cables are tucked “No shit there I was in Baghdad.” That’s in, and leaving the selected IV port avail- how all the stories start out in the Ibn able for access on the shoulder. Another Sina/10th Combat Support Hospital EMT option is to place the patient into a (Emergency Medical Treatment) section. This LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

r July–September 2007 Vol. 29, No. 3 Personal Stories and Lessons Learned in a Combat Support Hospital 273

was one of our standing jokes early in the year, vehicle but were either outside the hatch or because sometimes little dark medical humor the explosive device penetrated the vehicle. alleviates some of the stress and grim realities Dr S.M. and the medic team depart for the of yet another war story. helipad to complete a rapid triage and per- Little did I know when arriving in haps facilitate getting the patients to Balad Germany in February 2005 that in few more quickly. When the Blackhawk lands, months I would be working in one the they find two patients. Patient 1 has a Glas- busiest trauma centers in the world. I was gow Coma Scale (GCS) of 13–14 and a possi- temporarily reassigned from the hospital bly compromised airway. Patient 2 has a GCS in Heidelberg to the 772nd FST. We were of 15, stable airway, and vital signs. Both are colocated with the 86th CSH, which later transported to EMT for further assessment transferred the mission to the 10th CSH. and resuscitation. In December, LTC Groves, the EMT Sec- On arrival to the trauma room, Patient 2 is tion Officer-In-Charge (OIC), informed the placed in Bed 1 and the initial evaluation in staff that the neurosurgery team was leaving unchanged. LT Skates is the primary nurse. our hospital and would not be replaced. All She and her medic team go to work doing the neurosurgery cases would now require trans- algorithm we have all learned so well. ABC’s, portation/transfer to Balad, where the neuro- O2, bilateral large-bore IVs, draw the blood surgery team would now be operating. Un- specimens, and get the radiologic exams com- til this time most of the medical transports pleted. Later, a CT of the head would reveal an had been handled by the ICU staff, but now intracranial foreign body and small subarach- the EMT section would be responsible for noid hemorrhage. the bulk of the transfers. This would be a Patient 1 arrives to the trauma room only tough job for both the new and experienced 5–6 min after arrival on the helipad but his staff. Patients with traumatic brain injuries GCS is rapidly decreasing before our eyes. He would arrive from the field with multiple is now estimated to be around a 7 and his evolving injuries and undergo resuscitation left pupil is sluggish and dilated. Other in- and stabilization. Transfer for definitive neu- juries include penetrating wounds to the left rosurgical care in Balad would be the next forehead, “peppered” fragmentation wounds priority. to face, anterior and posterior left shoulder, The following is a good example of our chest, and back area. There is active bleed- process, how we worked through issues, and ing from the head wound without any visi- how the transport system evolved. On Jan- ble brain matter. Within 10 minutes, Dr S.M., uary 29, 2006, zero hour begins, with ra- LT R., and SPC S. have inserted two periph- dio traffic indicating two urgent litters are in- eral lines, administered rapid-sequence intu- bound with a 5-min or less estimated time of bation drugs, and successfully secured the air- arrival (ETA). The patients were involved in way with a 7.5 endotracheal tube. At zero a roadside improvised explosive device (IED) plus 13 min, a FAST exam is completed and explosion. Both patients have head injuries noted as negative. At zero plus 15 min the and at least one patient has an unstable air- portable chest X-ray is completed and the pa- way. The EMT physician, Dr S.M., and the staff tient is transported to the CT scanner. Thirty discuss the situation and consider diverting minutes after the patient’s arrival, the CT the aircraft to Balad. The flight medic and scan is completed with the results as de- crew also considered that option but owing to scribed in Table 1. In later discussions, Dr hemodynamic instability and an unstable air- M., our chief of service, simplified the ex- way, they diverted the flight to Baghdad. planation as “badness, cracked open bleeding The flight medic reports that the IED ex- skull fracture.” We now know that both pa- plosion occurred in the Taji area. The patients tients will need to be transferred as soon as were injured while riding in an Iraqi armored possible LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

274 Advanced Emergency Nursing Journal

Table 1. CT Report for Patient 1 Next we try to decide which personnel mix is right for the flight. It’s always the same question, who is going with the patients? Can • Open fracture left parietal bone; bone/ debris extending inferomedially from the we get the required seats on the aircraft? defect to deep within temporoparietal Which team combination is the best? Can the white matter; focal parenchymal MEDEVAC crews transport the patients with- hematoma and air surround these foreign out medical attendants? We finally decide on bodies. a nurse and medic team and to transport both • Subarachnoid blood in the frontoparietal patients on the next available aircraft. I am the sulci. Ventricles and cisterns are intact charge nurse today and have no patient assign- with no midline shift. ment, so lucky me, I get to go! We have been • Extensive debris and hematoma in the rotating the assignments and it’s my turn. I try frontoparietal and temporal scalp and soft to maintain my composure but I always get a tissues. 2.3-cm fragment penetrates the little adrenalin pumping when preparing for left temporal bone and lobe. • Blood in the left external auditory canal a transport. I had worked as a flight nurse in and behind the tympanic membrane Atlanta earlier in my career but it was nothing • At least one small fragment in the left like this experience. In fact, I really thought globe, multiple fragments anterior to the this part of my career was behind me. orbit. Packaging the patient involves placing the • Subcutaneous air tracks in the fascial SMEED (see Figure 4) on the litter over the tissue of the head and neck. 1.2- by 1.1-cm lower extremities. The litter is padded with fragment in the right parapharyngeal extra blankets and the head is elevated as space. 1.8- by 1.3-cm fragment in the left much as possible. Hypothermia can become lateral mouth area. an issue for trauma patients even in a desert • Fractures of the left maxillary sinus walls, environment, so we wrap the patients in mul- with multiple fragments. • Fracture of the left mandible comminuted tiple layers of blankets. Ventilator tubing, IV fracture of the left scapula, with multiple lines, arterial lines, and monitoring cables are large fragments. carefully secured and taped in place. It is now • Comminuted fracture of the 7th left rib. 60 min postarrival and the Patient Adminis- Abdomen and pelvis are unremarkable. tration office has notified the 30th of the MEDEVAC request. The local dust-off unit is now en route to our helipad. Ninety minutes postarrival, the patients are Dr S.M. is on the phone with Dr B., the neu- transported to the helipad and loaded on the rosurgeon in Balad, giving report and arrang- aircraft. The medical team consists of SPC C. ing acceptance. Simultaneously, the CT re- and me. A colleague of Patient 2 is talking with sults are being pushed electronically to Balad SPC C. as we approach the aircraft. She’s wor- by the radiology staff so Dr B. can review ried and asking us to take good care of her them while we are en route. We also carry a friend. It’s a tense moment, you would like to CD of the CTs with the other paperwork on take the time to reassure the friends but the transport just in case there are problems with bird is ready and we are in hurry. Time is brain the electronic transfer. One hour postarrival, in these cases and we want to get off the pad neurosurgery accepts both patients and we’re as soon as possible. I check out the aircraft as off and running! We begin to package the pa- we are loading. It is an “H”configuration with tients and start the ordered treatment modal- right stretcher load area. Patient 2’s litter is se- ities prior to transport. The medications are cured on top and Patient 1 is on the bottom familiar at this point: mannitol 70 g, fospheny- of the aircraft. The crew chief shuts the door toin 1 g, morphine, midazolam, cefazolin 1 g, and we are belted in and ready to go. We lift and gentamycin 240 mg. off the pad en route to Balad. LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

r July–September 2007 Vol. 29, No. 3 Personal Stories and Lessons Learned in a Combat Support Hospital 275

Five minutes into the flight, Patient 2 by the time March rolled around we had it crumps. His O2 saturation is steadily drop- down to a science. Dr B. had assisted us with ping. I hope it will rebound and that it is a false the acceptance issues, we had standing med- reading due to vibration or the oximeter being ication protocols, CTs were received and re- dislodged from the finger. SPC C. and I signal viewed prior to the transport. And, based the crew chief we are coming out of belts and on data that showed no improvement in out- need to get to work. I fear airway complica- comes with immediate transport, our goal for tion or obstruction. The flight medic and SPC transporting patients changed from as soon as C. take the head and start running the ventila- possible to a goal of having them on the OR tor tubing and checking tube placement. I’m table in Balad within 4 hours. at the foot and check the ventilator, O2 tank, The system issues outside the medical pro- ventilator tubing, and oximeter placement. tocols, treatment modalities, and local train- The O2 saturation drops to 88% and ventilator ing were more difficult change. We real- failure is confirmed. The cause is unknown ized the MEDEVAC system and flight medics and irrelevant at this point, the ventilator is needed our help. The system and training was discontinued and replaced by the bag-valve- great for field trauma and stabilization. But in mask. The chest rise is good and there is inter- cases like those above, something more was mittent vapor in the endotracheal tube. The needed. An organized transport team and all O2 saturation starts to rise. The patient is now the equipment and support that come with it also hypotensive. The mean arterial pressure were needed to successfully transport this pa- has dropped below 70 and the heart rate is tient population. Predeployment training and 124 and climbing. A 500-ml bolus of normal planning issues were also identified and com- saline is infused. The vital signs finally begin municated through the command and train- to stabilize and the flight medic signals that ing chains. These messages were not always we are 2 min from Balad. I have been inter- well communicated or received, but change mittently tapping Patient 1 to assure him (and in any system is usually painful and slower myself) that everything is okay. He nods and than clinicians would like. All in all, this was mouths that he is okay. It’s a good thing, two a clinically challenging, and rewarding expe- patients in distress would have been a serious rience. “No shit there I was in Baghdad...” problem and difficult to manage in this envi- ronment. We land on the pad and the patients are unloaded by the Balad staff. We make our Got It...Get “R” Done: A Note way into the EMT section, where at least 15– to My Colleagues Still in Iraq 20 people are waiting. The physicians identify themselves and I begin to give report, rotating LTC Terrence E. Flynn, RN, MSN between the beds. We collect our equipment Formerly Nursing Supervisor, 10th CSH, Baghdad, Iraq and make our way back to the aircraft. It is approximately zero plus 120 min. Two hours Editor’s Note: LTC Flynn was injured and re- from initially receiving the patients in Bagh- turned to the States before the rest of the unit. He dad until drop-off in Balad, including 20 of the sent this letter to his colleagues still in Iraq. longest minutes of my life on my knees, work- —J.A.P. ing in the back of the aircraft. We are on our way back now and I reflect over today and the Although I have learned many “new” per- past few months. It’s nice too know the old spectives in my transition from healthcare man can still do the work and now, for a little provider to casualty this past 2 months, the nap! thing that will stick out the most is this: “I got Lessons were learned from this flight and it.” many others. Collaborate with your friendly No, I’m not talking about the new Gatorade neighborhood neurosurgeon early and often, advertising campaign, yet I will admit I miss LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

276 Advanced Emergency Nursing Journal

Figure 7. LTC Flynn in Baghdad.

the unlimited access to free Gatorade we had that each individual had moved past the self- at the mess hall. Instead, I refer to our own centered, egotistical, selfishness of garrison recognition of what and how we expect our- life and job, life style, position, and titles to selves, and the other service members around forming that team-oriented, others-first, and us, to respect and appreciate each other and selfless attitude that earned respect and re- the importance of the mission we are engaged liability from your colleagues, subordinates, in. and leadership under very austere and diffi- When we first started out in Colorado cult circumstances. Did it happen to all who and then on to Kuwait and finally Baghdad deployed with us? Unfortunately it did not. (Figure 7), there was a slow but steady growth Now I can see what a tremendous loss of op- and acceptance of our situation and the mis- portunity for those who never “got it.” But sion we had been asked to undertake. As then, from that day to this and beyond ...they time moved on, people would comment as will never understand. Some people just don’t to whether or not someone “got it.” It meant “get it”! LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

r July–September 2007 Vol. 29, No. 3 Personal Stories and Lessons Learned in a Combat Support Hospital 277

At Walter Reed Army Medical Center, as I those who have never worn your shoes for had my surgery and started my recovery, I where you have been and what you have done saw many others who had it so much worse these past months. Find a veteran, another sol- than I did, yet I was treated as a “brother” dier, especially one of the severely wounded veteran...injured, hurt, in pain, and worried ones, and look into their eyes when you tell about the future. No one laughed at how I them you were in Iraq as a medic, nurse, or was injured (although the Chaplain in Ger- a doctor, and a soldier. In an instant, you will many told me to think up a better story than get that nod of appreciation that says “you got falling down and breaking my elbow...as did it.” a few others at Walter Reed. “Hey Chaplain, How do I know? On the first Friday I re- isn’t that lying?”) I was a casualty of war. turned to the United States, I was invited Granted, not a Purple Heart casualty, but a to a dinner at a nice restaurant in Washing- casualty nonetheless. So many people came ton, DC. It was my last weekend (finally) to my hospital room and asked what they before going into the hospital for surgery. I could do for me and my family: the American felt awkward and out of place as most all Red Cross; the Veterans Administration; the the other patients had been there for weeks, Disabled American Veterans; Wounded War- even months, recovering from severe injuries. rior Project; the Veterans of Foreign Wars; Many patients had family members along as the American Legion; and countless other well. I was alone, as my family had not yet military and civilian organizations and per- arrived. Onto the bus, in a wheelchair, came sonnel. I met sports figures, TV and movie a soldier that looked vaguely familiar. When celebrities, and many senior general officers the leader announced his name, I recognized from every service branch. All wanted to of- it immediately. He had been a casualty at fer support and a helping hand to a soldier. the 10th CSH a couple days before I was in- These people all “get it.” They visited the jured. He was already healing and progress- soldiers because they wanted to be there ing, thanks to the work done by all of you to and because they care about something be- save his life in the EMT, OR, and ICU. The bus yond themselves. Cher spent hours talking was informed that I was the “new” guy and and visiting with family and soldiers individ- was from the 10th CSH. Before the evening ually, she didn’t just sign autographs and rush was through, I had many soldiers and their on. Not quick photo opportunities, but hon- loved ones tell me their stories and thank est and heartfelt generosity of time. Maybe me for saving lives and express how grate- she isn’t a healthcare provider, but she helped ful they were that the 10th CSH was there make a lot of people feel better. She “gets for them. You see they “get it” too. Before I it”! left Washington, I met many more patients You are all coming down to the wire. Soon whose lives were saved at the 10th CSH by you’ll return to garrison life, family, and your your sacrifice and dedication to duty and the former place in the world ...and it will not casualties. be Iraq! Trust me, I know this well. What you So my brothers (and sisters )...you get it ... will see and find are people who don’t “get and real soon you’ll have achieved an even it.” That small percentage that never “got it” greater success. As Larry the Cable Guy would in Iraq, are here in volume and will be think- say on the Blue Collar Comedy Tour, you’ve ing more about themselves than about you. got to “get “r” done” when something tough However, the bonds you have forged in Iraq, comes along. as that special group of people that you have In the eyes, hearts, and minds of the grown into, will endure well past your time thousands of soldiers and civilians you have there. Remember this when you’re frustrated treated, and all those who understand it back by little things and a lack of appreciation from here: you “got it”and...you “got “r”done.” LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

278 Advanced Emergency Nursing Journal

Memorial Day 2006 ing. Reaching a crossroads in my career, I made the choice to join the Army. I decided MAJ Sumeru Mehta, MD, FACEP that I didn’t want to be one of those nurses with 20 years in the ED that were stuck with There were no barbeques. There was no no further advancement than being a head baseball. But there was heat and American nurse or a hospital educator. Be careful what ... flags everywhere. It was Memorial Day 2006 you wish for . in Baghdad. It will be one I will never for- My first assignment in the Army was Brooke get. I was working the day shift in the ER. Army Medical Center (BAMC) in San Antonio, At noon we got a call of multiple US casu- Texas, also a Level I . Again, alties secondary to a VBIED (vehicle borne I had an ED nurse staff job. This military improvised explosive devise ...basically a car hospital was the closest thing I could imag- ... bomb). Within 5 minutes we had reports of ine to a civilian job back up north busy multiple dead at the scene. nights, a growing elderly population, lots of VBIED always translates into death or hor- medical stuff and some trauma thrown in be- rific injuries. The first three casualties were tween. Motor vehicle crashes, stabbings, gun- sent directly into the main trauma bay. Two shot wounds, near-drownings, and the occa- went directly to the OR after they were in- sional snakebite would come our way. It’s a tubated and stabilized. The “lucky one” with teaching institution so you have medical stu- face and hand burns was admitted to the sur- dents, interns, and residents as well. Overall, gical ward. Five more were taken to the back not a bad gig as far as nursing goes, lots of rooms. All five required surgical interventions sick people and very little downtime. I’ll say to stop hemorrhage. Everyone lived. at this point that I thought I might have seen ... On this day when we celebrate memories it all not so fast. of those who died serving our country, I cele- My deployment orders did not come as a brate those who lived ...serving our country. surprise. I’d spent over a year at BAMC living Memorial Day will never be the same for me. the good life and watching over my shoulder It will forever be embedded with the memo- constantly, waiting for word that I’d be sent ries of those who lived. Maybe next year I will to the “sandbox.” Now that’s a crazy child’s celebrate with some barbeque and baseball. way to refer to a place of war in the cradle of God bless our troops. God bless America. civilization. I never enjoyed that reference, it minimized to me what I thought would be the most difficult time in my nursing career. Diffi- Charge Nurse Lessons Learned cult doesn’t even begin to describe what this past year has been for me. Someone described in Baghdad the situation to me as the best and worst expe- ... CPT Gwen Debias, RN, BSN, CEN riences of your life that couldn’t be more Formerly Assistant Head Nurse ER, 10th CSH, true. The highs coupled with the extreme Baghdad, Iraq lows were challenging to deal with, to say the least. The sadness of being away from every- As a nurse with 12 years of civilian ED ex- thing I knew gradually evolved to a feeling of perience prior to joining the Army, I thought extreme pride for what I’ve been involved in I’d seen it all. I’ve worked at Level I, II, & here. III trauma centers in Illinois and Wisconsin, My view of patient care has also evolved in city and suburban. I’ve had staff ED nurse the past year. In my wildest dreams, I never jobs, was the clinical coordinator in a Level II imagined what deploying to Iraq would be trauma center, acted as charge nurse, worked like. After finally arriving at our destination agency, and did a couple years of travel nurs- in Baghdad in October 2005, I was scared to LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

r July–September 2007 Vol. 29, No. 3 Personal Stories and Lessons Learned in a Combat Support Hospital 279

death. Seeing the place that I would call home tourniquets placed or reinforced, blood was for the next year was a humbling experience. being transfused, labs were sent, and that pa- If I closed my eyes and looked around, the tients were sent to the OR or ICU as indicated. lights, the moon, and the stars appeared just The fact that four more patients were com- as they would at home. The difference here ing in the next 30 min increased my level of was that I was carrying a weapon and acutely anxiety to get the first group out. One patient aware of the fact that I was now in a war zone. was pronounced dead and quickly moved out I was certainly not prepared for Decem- of the trauma room. The staff worked effec- ber 7, 2005. As the assistant head nurse in tively and efficiently to ensure that the bed the Emergency Medical Treatment Section of was ready for the next injured Marine to come the 10th Combat Support Hospital, I was in through the door. charge on night shift and received a phone I don’t quite know how to put into words call from another location in Iraq that we’d be what was going through my head throughout receiving eight Marines with extremity ampu- this hour of my life. To look down at a Marine tations from an IED blast. My heart dropped with no lower extremities was one of the sad- and I went into charge nurse mini mass ca- dest moments in my life. These tough guys, sualty mode. The staff and I raced to get ev- when asked how they were doing, replied, erything ready ...rapid-sequence intubation “It’s just another day at the office, Ma’am.” I drugs, checking O2 and intubation supplies, was truly humbled by the fact that they were notifying on-call ED staff, the nursing supervi- so strong in the face of such horrific injuries. sor, surgery, radiology, lab, and pharmacy. Oh, That night I realized very quickly that this mil- and did I mention that my boss was stranded itary that I had joined is a family and when at another location waiting for a ride back? one person goes down, we all suffer. Never in The challenges of caring for all of these pa- my life would I experience trauma like this, tients with a still relatively junior staff (most nothing and everything in my experience as with less than 6 months’ total nursing experi- an emergency nurse had prepared me for this ence, let alone ED nursing experience) were one moment. magnifying themselves in my mind through- I breathed for the first time that night out the preparations. I had a feeling of im- and continued on with what was required pending doom like never before in my 12 of me, making sure that things would run as years of emergency nursing. I’m sure that I smoothly with the second round of casualties. overcompensated by being especially bossy As the second group came in, I breathed a with the hospital staff, it was fight or flight for sigh of relief that only two were missing a leg. me and I sure wasn’t walking away. With ev- How sad is that? They were not as critically eryone in place, the Marines began arriving. injured as the first set of guys. All but one One by one, they were carried into the ED still needed to be intubated and resuscitated on litters from the helipad. Each man seemed with blood and intravenous fluid, but they to be a lot sicker than the last guy. Most of weren’t dying in front of us. The three most these Marines were awake with gray ghostly seriously wounded were fixed up and later ad- faces looking up at us and begging us not to mitted either to the ICU or the OR for further let them die. They were horribly volume de- treatment. pleted, hypoxic, and had vital signs that are My communication with the nursing su- nearly incompatible with life. The staff went pervisor and his subsequent dispersal of all to work to fix them so that they could be af- the information was critical. Utilizing anes- forded the blessing of another day. thesia staff to get airways and lines in these As a charge nurse, my job was to make sure guys was also important. The ancillary de- that the ED staff had what they needed to partments all stepped up and were literally save their patients’ lives. I went from bed to running back and forth to their departments bed, making sure that airways were secured, from the EMT to make things happen quickly. LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

280 Advanced Emergency Nursing Journal

Surgery worked tirelessly to address the needs I wonder what Tara and Charlie had planned for of all of these patients and get them definitive Valentine’s Day? care as rapidly as possible. We meshed to- They met about 2 years ago, on the job. gether that night, in a way that I’ve never ex- perienced before and I realized that I was part They were learning the intricacies of how to of something big. police. As charge nurse in the EMT, I facilitated They were learning how to be good soldiers. the staff getting what they needed in order to do their jobs well. The uniqueness of be- They were learning about each other. ing in a war zone and having people avail- And the most important lesson they learned... able literally at a moment’s notice allowed us to have the staff to handle these critical pa- They learned they were in love. tients. The multiple limb amputations were truly horrific. The fact that a fairly junior staff I wonder what Tara and Charlie had planned for of nurses, doctors, and medics were able to Valentine’s Day? dig in and do what was necessary to save Their love blossomed into a marriage. the lives of fallen comrades is nothing short of remarkable. One man died of his injuries, Their marriage blossomed into a deployment... but seven more would have died if not for Into war. the quick thinking of the staff on duty. My role in all of this is small. I consider myself Tara was riding in the front passenger seat of her to be a facilitator, a communicator, and most Humvee. importantly, a trouble shooter. If casualties Charlie was back at the base, waiting her arrival come into the 10th CSH EMT section, things and planning. should flow relatively seamlessly. My job is to ... eliminate roadblocks for the staff and to en- An explosion, some gunfire, a roll-over Tara is hurt. sure that they have the proper tools to save lives. Fortunately, on this particular night, the Charlie was wondering what was keeping her con- chain of survival remained intact. But we will voy, he had plans. never forget the life lost that night, he was a “Dustoff, we have multiple critical casualties...” hero. I wonder what Tara and Charlie had planned for The Day After Valentine’s Valentine’s Day? The Blackhawk roared outside ...we would have MAJ Sumeru Mehta, MD, FACEP work to do. I wonder what Tara and Charlie had planned for “We have 5 urgent litters ...CPR in progress on one Valentine’s Day? of them”

It was their first as a married couple. The medics rush her in ...a female soldier ...her color white as chalk. Tara was a young girl from Alaska. She had no pulse, no right leg and no life ...patient Charlie was a young man from the East Coast. 7654 was dead. They met on the job...but their job was not the “Continue CPR, push the epinephrine and hang 9–5 toil we are all used to. the blood ...” They were active duty soldiers in the US Army, mil- Still no pulse ...on Valentine’s Day itary police to be precise. Everyone working on 7654 was simultaneously And these were not safe times to be in the military. working and praying ... LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

r July–September 2007 Vol. 29, No. 3 Personal Stories and Lessons Learned in a Combat Support Hospital 281

We did not want to lose 7654 ...we could not. He held her hand. Someone shouted her name ...and she was no He caressed her hair. longer a number. But they were not alone ... She was someone’s daughter. A wife? A mother maybe? They were surrounded by machines, tubes, and the faint smell of illness. A soldier she was most definitely. They would not be spending this Valentine’s alone. We did not want to lose Tara ...we could not. Who did I pray to I do not remember, but I did pray ... I wonder what Tara and Charlie had planned for ... Valentine’s Day? For Tara, for Charlie for my own peace of mind. “I have a pulse, I have a pulse...I have a strong For our own selfish reasons, our team needed her pulse” to live. ... Simultaneously I felt my own pulse ...it was fast, And she did Tara had a pulse on Valentine’s Day like Tara’s. But I still wondered ... She had a pulse ...on Valentine’s Day. I wondered what Tara and Charlie had planned for Her heartbeat was back but her right leg was miss- Valentine’s Day? ing. ... The answer to that question at the end of the day “To the operating room now.” was obvious. ... She still had a pulse on Valentine’s Day. His plans changed today but Charlie still ... “Her husband is here ...can you talk to him?” planned What? That is a question I expect back home. To spend, with Tara, the day after Valentine’s. We are in the middle of war. A husband and wife in the middle of war? Combat Commander’s Observations He was young, like Tara and he shook ... Soldiers hated our facility. LTC John T. Groves, Jr., RN, BSN, MSN, CEN Formerly Emergency Medical Treatment (EMT) Head It represented injury and illness. Nurse, 10th CSH, Baghdad, Iraq It represented death. On Oct 31st, 2006, our third day in coun- try, we received four soldiers from the 2nd I wonder what Tara and Charlie had planned for Brigade, 502nd Infantry Regiment with full Valentine’s Day? CPR in progress. I wrote an article on young nurse and medics coming to age. I wit- Charlie expected to hear “I love you” tonight, nessed a full Colonel come across the floor not ...“She is alive but ...” to console one of my 2LTs saying, “it’s “She may not make it through the night ...” OK to shed your tears, he was worth your emotions.” “She is out of the OR ...” Today, the 5th of September 2006, Col. E., “She is still critical ...” an Infantry Brigade Commander comes back to give us a token of his thanks and shares No, no, no ...Charlie had plans. with us that he had been in command for 2 He whispered in her ear. hours and 8 minutes when he was here at LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

282 Advanced Emergency Nursing Journal

the hospital on Halloween visiting a burned when you get home.” He ended with choked soldier and heard that more of his troops emotions, “Yours is a noble profession, and I’ll were coming in. Four arrived, dead on arrival. leave it at that.” So in the first 2 hours of his command, he It’s the first time I have heard the whole lost four soldiers. What are the odds that he story from him. I always felt bad for our guys would have been here, at the hospital, for that and the 86th CSH that it was their last day moment? His words were so reverent that is in country. He further described having lost doesn’t do justice to repeat them in writing, over 50 soldiers, had 60 with permanent dis- but I’ll try. He started by saying, “I am pro- abilities, and over 100 that were seriously foundly grateful for your emotional connec- wounded. tion to your job and my soldiers, but I hope it What a story. will not be too great a burden for you to carry Thought I needed to share it. LWW/AENJ LWWJ351-10 August 8, 2007 0:50 Char Count= 0

r July–September 2007 Vol. 29, No. 3 Personal Stories and Lessons Learned in a Combat Support Hospital 283