Yet, since the early days of Operation Iraqi Freedom, many of the patients transported to U.S. military medical units in Iraq have been Iraqi civilians, enemy prisoners of war (EPWs), and insurgents. Almost three years into the war, Iraqi patients, including children, still frequently lie on the thin, hard mattresses found in military medical units . The number of Iraqi civilians admitted to U.S. military facilities in Iraq dating from February 2005 to January 2006 was 1,935, according to Sgt. Doug Anderson with the Combined Press Information Center in Baghdad.
On Sept. 29, 2005, when a terrorist bomb went off in the Iraqi village of Balad killing 10 people and severely injuring about 40 civilians, more than 29 of the injured were taken to the Air Force Theater Hospital on the nearby U.S. air base. Physicians, nurses, and medics went into mass-casualty mode, at one point running six ORs simultaneously and calling in every staff member available.
Traumatic injuries from the blast included severe abdominal wounds requiring temporary or permanent colostomies, fractured limbs, head wounds, and first-, second-, and third-degree burns. Most of the patients, who included men, women, and children, required more than one complicated, often life-saving surgery, according to the hospital’s military nurses and physicians.
And once the initial surgeries were completed, many patients returned for follow-up procedures, wound washouts, dressing changes, cast and external fixator adjustments, and self-care education, says Col. Donna Smith, chief nurse of the OR at the time. If an Iraqi patient could not perform self-care, then a close relative accompanied him or her to the American hospital to be taught by the nurses.
“Our goal was to teach them to do their own medical care and then to get them back into their health care system,” says Smith, an active duty Air Force nurse who in the U.S. is assigned to the Air Force’s Wilford Hall Medical Center in Texas.
She learned much of the country’s nursing care takes place in the home and not in war-damaged hospitals. “The care families give to patients is remarkable,” Smith says.
Smith also discovered that home nursing care is not relegated only to women. In fact, Iraqi women usually are not allowed to visit family members in the U.S. hospital. It is the husbands, sons, brothers, and fathers who arrive at the gates of Balad Air Base to be picked up and transported to one of the two largest U.S. hospitals in Iraq.
Iraqi men have been taught to change colostomy bags, dressings, and even diapers, Smith says. “The men come to the hospital and then teach their wives,” she says.
When Nursing Spectrum visited the Air Force Theater Hospital in June 2005, a 50-year-old Iraqi man was feeding lunch to his sister, 52. She had been sent to the Air Force hospital because she had a brain tumor the Iraqi hospital couldn’t treat.
Through a translator, the brother said his sister was receiving good medical care and was being fed well. Before this experience, he did not have a positive opinion of Americans because of the soldiers he saw carrying weapons and riding in heavily armored vehicles in the Iraqi streets. But his sister’s hospital experience was changing his view of Americans, he said.
Maithim, another Iraqi patient at Balad, would at times help staff calm some of his fellow patients and serve as interpreter during his hospital stay this past spring. A medic at the Iraqi hospital in Balad, Maithim had been shopping for CDs in Baghdad for his brother’s birthday when a car bomb exploded. The blast fractured his left leg and tore off an arm at the shoulder.
Iraqi physicians kept Maithim alive, but they could not properly close the amputation wound because it was so high on his arm. He was eventually taken to the Air Force hospital. His left humerus was still exposed, says Capt. Warner Tse, RN, who frequently worked in the Iraqi units when he was deployed to Balad last spring and summer. Air Force physicians were able to better close the wound.
Iraqis also fill Army, Navy beds
Army Col. Olga Rodriguez, RN, chief nurse of the 228th Combat Support Hospital (CSH) that was stationed in Mosul, Iraq, for a year, says at any given time 80% of the patients in the hospital were non-U.S. service members. The majority of the 80% were Iraqi civilians, says Rodriguez, a Reserve nurse who returned from Iraq in November.
“We were told from high up to provide one standard of care,” she says.
The mandate from the Army Medical Department and the Department of Defense is that all Iraqi patients receive the same level and quality of care as any U.S. service member, says Rodriguez, who as a civilian is director of the orthopedic line at The Methodist Hospital in Houston.
At the start of the war, Iraqi EPWs were some of the very first patients to be flown to the Navy’s hospital ship, the USNS Comfort, stationed in the Persian Gulf. That trend would continue during the several months the ship was in the Gulf. Iraqi EPWs were held and guarded on one level of the ship while Iraqi civilians, including mothers and children, were housed on a different level, says Navy Lt. Cmdr. Angela Nimmo, RN, who served on the Comfort for two months.
Although nurses, physicians, and corpsmen had talked about what they would do if Iraqi patients and EPWs were brought to the ship, it was more of a what-if discussion, says Nimmo. “I don’t think we expected to take on the role that we did. We certainly didn’t anticipate the volume [of patients].”
Providing care to Iraqi civilians, some of whom might be insurgents, sometimes causes ethical conflicts for military nurses. The instinct of a military nurse might be to provide care for a U.S. soldier first, but that response is inappropriate if a civilian patient’s condition is more urgent. Also, supplies and equipment in a war zone are often limited, so military medical personnel must use resources to their best advantage, always keeping in mind a mass casualty could occur at any time.
Navy Cmdr. Cheryl R. Ruff, RN, a nurse in Iraq during the first months of the war, says patients who medical personnel first thought were Iraqi civilians sometimes turned out to be EPWs.
“We treated a lot of EPWs,” Ruff says. She often worked in the tent that received patients with abdominal and head and neck injuries. EPWs had more of these types of injuries than U.S. service members because the combatants lacked the advanced body armor worn my U.S. military members.
In her recently published book, Ruff’s War: A Navy Nurse on the Frontline in Iraq, she writes, “We also tried to come to grips with our obligations under the Geneva Convention ... I prayed every day I would find the strength to make the best decision and to do what was right.”
To help resolve ethical quandaries, the 228th CSH held a medical ethics conference for some 200 military medical personnel. “We looked at the ethics of combat from different angles,” says Rodriguez. “We talked about how our mission was to provide care not only to the U.S. military and coalition forces but also to innocent bystanders and sometimes to the enemy. We talked about how people needed to verbalize their feelings and how to deal with the challenge of having to care for Iraqi patients.”
Cultural puzzles
The lack of a common language is the most difficult barrier to overcome when providing nursing and medical care to Iraqi patients. But Col. Laurie Hall, RN, who served as the chief nurse of the Balad Air Force Theater Hospital this past spring and summer, says sometimes all it takes is a gesture as simple as holding a hand to let patients know they will not be harmed no matter what opinion they have of Americans.
Because of other cultural differences between Americans and Iraqis, a sign hangs in the Iraqi units in the Air Force hospital spelling out a few basic rules of conduct in both Arabic and English. The rules include the statements “Order and discipline will be maintained at all times. No violent or rude behavior. No touching the medical staff.”
It is not unusual for military medical units to treat injured or ill insurgents, whether they are Iraqi or other nationalities. But these patients are usually separated from Iraqi civilian patients and U.S. service members who are patients. EPWs also are shackled and guarded around the clock by military police.
Nurses as ambassadors
Rodriguez says that during her year in Iraq, she helped remind and support the hospital’s nurses about providing one standard of care for all patients. Her nurses, she says, “were absolutely great. A number of them learned some basic Arabic and worked through the cultural biases.”
Military nurses say they hope the care they give to Iraqi patients will help bring understanding between the two cultures.
“I do believe we make a difference,” says the Air Force’s Smith. “The care we provide is state of the art, and I believe [the patients] will go back and tell their families. Ours is a soft mission, not delivered by bullets and bombs.” |
