In her 17 years as an Army nurse, Lt. Col. Elizabeth Vane, R.N., has learned valuable lessons about providing health care. She's certified to work in an OR and to coordinate central medical services. And her experience has made her an expert in keeping hospital supplies flowing while making sure every department from the ER to the ICU runs like clockwork.
But it took just a few days in Iraq for Vane to learn another valuable lesson. One that seems simple, but is as vitally important as anything she learned from her hospital training:
Never drive over a watermelon
From February 2003 to February 2004, Vane served in Baghdad as a section supervisor of OR/CMS for three Army field hospitals--or combat support hospitals (CSH), in military terms.
In the midst of a war zone, Vane's units conducted as much as 21 hours of surgery a day. It was her first time in combat.
But before she came home, she'd learned how to create a hospital from scratch and how to care for patients in 130-degree heat. But the watermelon lesson sticks with her the most. While driving through Baghdad, a soldier told Vane to steer slowly down what seemed like a peaceful back street. Avoid potholes, he said, and never squash a watermelon under your tires. Insurgents have been known to hollow out the fruits and fill them with homemade bombs.
One bump and suddenly your Jeep might explode under a hail of flying nails and glass. "That's not something they teach you in medical training," Vane says. "But you need to know things like that to stay alive."
Half a world away from their homes, more than 8,000 military medical workers are stationed in Iraq, serving their country by treating patients in combat zones.
And while they've been well trained in battlefield medicine, each day brought a new ordeals that were both trying and terrifying.
Universal issues
For these men and women, the challenges of running a hospital--even when it's just a tent in the middle of a desert--are strikingly similar to the daily grind civilian health care workers face. In places like Iraq, medical military personnel are asking familiar questions: How do I keep my supply chain moving? How do I keep my instruments clean? How do I attend to my pharmacy, X-ray or lab?
But they face a few extra complications. While caring for patients, they're wondering whether the hospital windows will be shattered by a bomb. Or whether the supply truck with much-needed medical packages will arrive in one piece. Or whether the next person through their door--or tent flap--will be a soldier missing a limb or an Iraqi woman in labor.
"I raised my hand and volunteered to pay the ultimate price for my country," says Maj. Greta L. Bennett, a medical logistics officer who spent a year in Iraq with the 5th Army Corp. "We're not the combat forces. We're not the people who really see the enemy. But I was still stunned when I got the call to go over. I said goodbye to my family. I updated my will. Then I hit the ground and thought, 'OK, let's go to work.'"
Part of the puzzle
For medical military personnel, the first task is finding, or making, a place to work. In Iraq, medical teams often must create their own hospitals. Sometimes they take over an existing facility; and sometimes they piece tents together like giant Lego sets.
Starting with an emergency center, they add tents to create an intensive care unit and another tent for an OR. Days later, another tent might be added to house an X-ray unit or a lab.
"We built hospitals from the ground up," says Jonathan Kissane, a retired Army colonel who served in Iraq for a year as director of logistics with the Office of the Surgeon General. "A CSH with well trained personnel can begin receiving patients within 24 hours of arrival."
Vane's team made three separate, full-service CSHs in Baghdad and Tikrit. Some were pieced-together tents. But Vane also moved her group into Saddam Hussein's personal hospital after it had been abandoned.
When she first entered the three-story building in Baghdad, the rooms were "calf deep" in debris, she says. Fleeing Iraqi soldiers had broken all the windows and pulled wiring from the walls. They littered the floors with food, clothing and shredded medical records.
Vane led a biomedical team into the building to clean up. "You learn not to sweep by yourself," she says. "You never know what kind of viruses and spores are lurking in there."
Once the facilities are in place, the medical teams must keep them well stocked. That job falls on the combat materials manager, who has to keep supplies flowing for battlefield medics, battalion aid stations and full-scale hospitals.
In Iraq, materials managers don't just supervise supply chains, they create them.
"Most people go to work at a hospital and are dealing with a supply chain that's been in place for years," Kissane says. "Our supply chain starts with the stuff you carry on your back."
Materials managers stock medic aid bags with the basics--bandages, I.V. solutions, ibuprofen, morphine. Battalion aid stations must have enough supplies to provide first-level trauma care. Above them are the brigade medical companies, which can perform battlefield surgery when absolutely necessary to preserve, as Army vernacular puts it, "life, limb and eye sight." But hospital supplies are more complicated. A CSH can quickly grow from 44 to 80 to as many as 200 beds. And each CSH requires the equivalent supplies for a full-service hospital. "A CSH has everything you would think of for a 200-bed acute care hospital that does trauma surgery," Kissane says.
Beans and bullets
The supply chain can be 5,000 miles long, starting with vendors in the United States who ship products to a 45,000-square-foot distribution center in Qatar. From there, the supplies reach medical forces by helicopters or trucks. Medic bags are refilled every few days and sent to prearranged drop-off points. But communication in a war zone is imperfect and there's no way to tell if the medics are getting the supplies they need most.
"You don't know if they've run out of chest tubes or trachea devices. So you send it all, even though you could look at that as wasteful," Bennett says. "We have to make sure they have enough to hold them."
Those stock CSHs are more worried about getting too few supplies than too many because the distribution chain isn't always reliable. Materials managers can't depend on supplies being frequently replenished. They compete for space on the same trucks with ammunition and food. "Are you going to resupply the beans and the bullets or the health care materials?" Vane says. "At different parts of the conflict, getting packages to you may not be the highest priority. You have to live with that and make due."
Medical personnel learn to anticipate what supplies they'll need. If they run out, they may not see another shipment for seven to 10 days, if not longer, Kissane says.
Even when new supplies arrive as expected, CSH's needs change every day. Medical teams often have unexpected patients. While tending to soldiers with bullet wounds, they may also deliver babies or treat chronic health problems.
Bennett's team encountered a reservist who needed a cholesterol prescription that they simply didn't stock.
"We used DHL to ship it all the way from the states," she says. "Sometimes you have to be creative."
Kissane's wards treated civilian Iraqis as well. "Iraqis brought their children to us because they couldn't get medical care anywhere else," he says. "We don't typically have pediatric needles and air wave and catheters in a combat assemblage. We have to respond quickly and try to fill those orders fast."
Heat and hazards
Sometimes the greatest challenges came from the environment. Iraq's punishing heat (Bennett called a 113 degree day a cool one) wore on both workers and supplies. Generators worked overtime to cool pharmaceutical items and blood. Water was also at a premium, whether for surgery or sterilization. If water arrived containing even a hint of sand, it could corrode the autoclaves and make sterilization a nightmare.
Teams worked to conserve every last bit of clean water, to the point where staff allowed themselves just one eight-minute shower a week, Vane says. "You might clean your clogged autoclave instead of wash your clothes," she says. "There's only enough water for one of those activities, and we know which is more important."
While dealing with harsh medical conditions, the teams also adjusted to impossible living conditions. They often slept in cramped tents with more than a dozen cots. Vane remembers waking up covered in sand with tiny animal tracks across her stomach.
They are taught never to leave their beds at night without their combat boots for fear that scorpions or rats will nip at their toes. Meanwhile, they're faced with the ever-present danger of snipers and bombs."You don't get numb to the fear, but you're too busy to panic," Vane says. "You don't think about anything but your work."
On the front line, the work becomes all consuming, Vane, Bennett and Kissane agreed. For the year they spent in Iraq, each says they coped with the dangers and frustrations by focusing on the job until they were lucky enough to be sent home. "I wasn't out there trying to be a warrior or a fighter," Vane says. "I was just trying to be a good nurse."
The views expressed in this article are those of the interviewees and do not reflect the official policy or position of the Department of the Army, Department of Defense or the U.S. Government.
John DiConsiglio is a freelance writer based in Arlington, Va.
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