Editors’ note: During 2006 we will publish coverage of hospital practices in other countries. This and the article on Africa (p. 26) are the third and fourth articles in that effort.
The sound of helicopters, the sight of concrete blast barriers and of sandbags, and the smell of smoke were the first impressions I had upon arriving at Balad Air Base, Iraq. I am a military physician used to working in a clean, safe, predictable hospital environment when I arrived in Iraq on my first deployment to a combat zone. Few military doctors arrive at Balad with extensive training in combat medicine even though that is our primary mission. Through teamwork and the varied talents of different backgrounds, we provide excellent care to American, coalition, and Iraqi patients. An internist by training and practice, I share my experiences as a member of that combat medicine team.
At one time the Iraqi Air Force Academy, Balad Air Base is approximately 40 miles north of Baghdad near the Tigris River in the heart of the “Sunni Triangle.” The Air Force Theater Hospital (AFTH)—one of several expeditionary hospitals in the Iraqi theater—is located at Balad Air Base. Although Air Force in name, the hospital is truly a joint mission, with medical staff from both the U.S Army and Air Force working side by side. The hospital is robust in capability, but is not permanent in nature.
The hospital functions out of a multitude of large tents joined in tandem. Although climate controlled, the tents provide only a minimal barrier to dust and noise, and keeping the area clean and speaking in normal tones is a constant struggle. Like hospitals in the United States, there are distinct units within the AFTH: an emergency department, operating rooms, an ICU, a general medicine and surgical ward unit, a pharmacy, a clinical laboratory, and a radiology section.
Patients arrive at AFTH either directly from the field or, after initial triage and stabilization, or from smaller treatment facilities. AFTH is primarily a trauma center, and the majority of patients arrive via helicopter given the need for rapid movement and the danger inherent in vehicular transport. The sound of helicopter rotors is omnipresent at AFTH. The proximity of the landing pad to the hospital results in one of the impressions of Balad that I will not soon forget: that of the conversation-deafening and air-reverberating arrival of new patients.
The majority of patients who arrive at AFTH have sustained some type of combat-related injury, usually gunshot or improvised-explosive device (IED) wounds. These patients are initially assessed by emergency medicine physicians and surgeons. Many of the patients go immediately to the operating room for wound management, and those who require a higher level of care (either pre- or post-operatively) are moved to the ICU.
As an internist, my role is as a member of the ICU team of physicians that cares for these critically ill patients. The physicians who comprise the ICU team have different backgrounds, including general surgery, internal medicine, anesthesiology, emergency medicine, and subspecialties (currently a general internist, a medicine intensivist, a cardiologist, and an infectious disease doctor).
The goal of the ICU team is to provide for continuity of care of these critically ill patients during their ICU stay and to ensure that other AFTH staff members—most notably surgeons—can concentrate on new patients as they arrive. In addition to caring for critically ill trauma patients, my fellow internists and I also function much as we do at home: evaluating and admitting patients from the emergency department whose conditions are traditionally managed by internal medicine, including acute coronary syndromes, diabetic ketoacidosis, syncope, and gastrointestinal bleeding, to name a recent few.