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.
How I Spend My Time
Apart from the caring for the occasional internal medicine patient, I spend the majority of my time working outside of the usual realm of the internist. In the noisy combat hospital, conventional internal medicine patient evaluations are impossible. The history is often limited by the patient’s physical condition and, for many of the Iraqi soldiers, a language barrier. Physical exams are done more with sight and touch than with a stethoscope. The past medical and surgical history is uncertain. The knowledge and skills required to care for these trauma patients are also a departure from routine internal medicine practice.
Fortunately, I discovered that, although little used since residency, my ability to manage ventilators and to perform invasive procedures was quick to return and was immediately put into practice. I have learned aspects of critical care as practiced in the theater hospital ICU that I was unfamiliar with initially—such as the intricacies of post-operative and trauma care—on the job. I have become familiar with dressings, drains, and the concepts of resuscitation and of “secondary survey.” I have acquired a working knowledge of the various types of surgical procedures performed, and the subsequent care required thereof, in trauma patients. I have become familiar with treating elevated intracranial pressure in patients who have had craniotomies for penetrating brain injuries, with monitoring airway pressures and oxygenation in patients with blast-related pulmonary contusions, with following bladder pressures and serial exams in patients with abdominal trauma, and with managing chest tubes in patients with penetrating thoracic injuries.
I have even overcome a reluctance shared by many in internal medicine and have learned to look under surgical bandages—a feat that may undermine the truth that gives rise to the joke about hiding something from internists. Perhaps the most important concept I have learned in caring for combat trauma patients in the ICU is vigilance.
The primary survey, completed by the emergency medicine and trauma surgeons, usually discovers and addresses the large or obvious wounds that bring patients to our facility. When the patients arrive in the ICU after having their initial resuscitation and “damage control” operative intervention, it falls to the intensive care physician to both continue resuscitation and to look for as yet undiagnosed or delayed injury presentations. This constitutes the secondary survey and is an ongoing process. Patients often arrive in the ICU still recovering from their injuries; they require close attention to physiologic parameters such as temperature, heart rate, arterial pressure, and urine output. Their laboratory measurements, including oxygenation and ventilation, acid-base status (e.g., a reliance on the base excess, a tool more familiar to those in surgery than in medicine), hemoglobin concentration, and indices of coagulation, require constant attention.
In addition, patients often come to the ICU with vascular lines that were placed in the field under less than sterile conditions and require replacement. While major wounds have usually been addressed, minor wounds (such as missed fragments of shrapnel and subtle vascular injuries) or delayed presentations (including blast injuries and compartment syndromes) must be identified in the ICU and mandate constant awareness.
There are challenges, both personally and professionally, to working in a combat zone. Like everyone here, I am away from family and home for an extended time. Although fairly secure, one’s personal safety from ongoing mortar attacks is also an emotional burden. The hours are long and the recreational opportunities are limited on base. Traveling off base is strictly limited for obvious security reasons and most hospital personnel spend their entire tour in Iraq within the confines of the base perimeter.
Professionally, the biggest challenge to working at the AFTH is our location and resultant long supply train. Almost every item needed to stock a modern hospital comes not from the local economy but from outside the country and must be either flown or trucked in. This logistic trail requires constant attention to efficiency and inventory and when supplies are out or equipment is down, sometimes we must resort to ingenuity. We try to do the best we can for every individual yet, akin to the concept of military triage, we must use our medical resources with the utilitarian philosophy of “the greatest good for the greatest number.”
Practicing medicine at AFTH has been, for me, the opportunity of a lifetime. I work with very talented people, learn an amazing amount, and—most importantly—help care for our men and women in uniform. Although we practice medicine much differently from the way we do at home, the adjustment to the combat hospital is facilitated by the close teamwork among physicians here. This is exemplified in the ICU, where twice daily ICU rounds are led by a surgical intensivist and are attended by general surgeons, surgical subspecialists, and the ICU team, including internists and medicine subspecialists. In how many medical facilities do surgeons and internists, caring for the same patients, perform bedside rounds together as a matter of routine?
I believe this sense of teamwork exists in the combat zone for several reasons, including necessity, in which efficient use of time and manpower is critical, and of fluidity, in which the constant mixing and turnover of hospital staff prevents departmental barriers from developing. Perhaps the most important reason teamwork flourishes at AFTH is the overarching sense of mission in an austere environment. We are at Balad Air Base primarily to care for wounded American and Iraqi military members, and that responsibility under these conditions requires a resourceful and collaborative approach to the practice of medicine. TH
The views expressed herein are those of the author and do not represent the opinions of the U.S. Government, the U.S. Department of Defense, or the U.S. Air Force.