Imagine being transferred to a hospital where the temperature is 20 below outside, and 40 inches of snow fill the parking lot. Few physicians would sign on for such an assignment. For a brave few, it’s all in a day’s work.
Maj. Ramey Wilson, MD, is a U.S. Army physician who encountered such conditions during his 15-month experience in Afghanistan. “A couple of times, when we couldn’t get helicopters [for evacuation], we had to turn my aid station into a mini-hospital. There were no nurses, labs, or X-ray,” he says. “With only basic supplies and my combat medics, we had to provide all the patient care until the weather broke.”
Not quite the circumstances most hospitalists encounter in their daily practice.
Hospitalists in the military face daunting odds, and at the same time are blessed with some unexpected advantages. On the plus side, military physicians cite the camaraderie, teamwork, honor of caring for soldiers, and the opportunity to train other providers, both in traditional, U.S.-based residencies and while deployed. Among the minuses, they mention a lack of equipment and supplies when they are assigned to forward-deployed soldiers on foreign soil, the heartache of being separated from family, and lower compensation. Most military physicians, however, say that the lower compensation can be offset by generous government benefits and the absence of medical school debt.
All in all, hospitalists in the military have a unique—and sometimes adventurous—story to tell.
Challenges Met, Success Exemplified
Dr. Wilson is a hospitalist and Army physician assigned to Fort Bragg, N.C. Until this past summer, he was the chief of internal medicine at Womack Army Medical Center, one of eight full-service hospitals in the U.S. Army Medical Command. Because the Army is still familiarizing itself with the HM model and the role hospitalists play in the delivery of healthcare, resident house staff meet many of the operational needs, including night and weekend coverage. “The Army doesn’t have a good system for 24-hour continuous care at busy hospitals without residents,” Dr. Wilson says, “and we’ve worked hard to get hospitalists into our system.”
While other Army medical centers have internal-medicine residencies, Womack has only a family medicine residency program. Residents once provided extensive coverage for the hospital, but decreasing numbers (only four interns this year) and work-hour restrictions have shifted the inpatient responsibilities to the internal-medicine staff. “All of the military general internists have functionally become hospitalists to support the inpatient medicine and ICU services,” Dr. Wilson says. “Our family medicine house staff coverage has evaporated.”
The conditions he sees at Womack are similar to what he sees at FirstHealth Moore Regional Hospital, the civilian community hospital in Pinehurst, N.C., where he practices part time. Womack serves two major military populations: those on active duty and their family members, and those no longer on active duty or retired (and not a part of the Veterans Administration program).
—Col. Walt Franz, MD, U.S. Army Medical Corps, Amarah/Al Kut, Iraq
Dr. Wilson, who served in the Ghazni province in eastern Afghanistan, was the only American physician in an area of 8,800 square miles. He and his physician-assistant staff were tasked with keeping U.S. soldiers healthy, serving acute resuscitative trauma care and “basic sick call.” In addition to caring for U.S. and coalition soldiers, he partnered with the Ghazni Ministry of Health to improve the delivery of healthcare to residents of the province.
“Afghanistan has a great plan for medical care through its ‘basic’ package of health services and ‘essential’ package hospital services, developed with assistance from the U.S. Agency for International Development [USAID], and which we used as our road map for the Afghan public health service,” Dr. Wilson says. He and a nurse practitioner from the nearby provincial reconstruction team worked out of a forward operating base outside Ghazni’s provincial capital—the city of Ghazni—and the nearby provincial hospital. He says his hospitalist background was helpful when it came to working with and teaching the Afghan physicians and nurses at the hospital, which served as the referral center for several surrounding provinces.
“There was no infection-control program; their hospital and clinics were heated by wood stoves; and they were using the one endotracheal tube that had been left by the International Red Cross years earlier,” he says, noting that during his tour, the U.S. military dropped basic medical equipment and supplies—which were shared with the local hospital—into his forward operating base. “They were doing anesthesia without monitors. We trained them with an initial focus of making surgery safer. … To say that it was challenging is an understatement, and for many different reasons.”
Almost every other week, Dr. Wilson hosted a medical conference at his base for 10 to 20 Afghan physicians. Due to local customs, female providers were not allowed to travel without a male relative, so Dr. Wilson’s team videotaped the classes, had them translated into the Pashto language, and arranged with the hospital directors to distribute them to female physicians.
The needs in both army and civilian circumstances are huge in Afghanistan. Most Afghan hospitals and clinics are without Internet access, so decision support and telemedicine consultative service is out of the question. Textbooks are in short supply, too. Because the Taliban decreed that no image of a human being is allowed in print, they confiscated and destroyed all of the country’s anatomy books.
In terms of training, the key to success with locals is demonstrating what success can look like.
“Most of these providers have practiced in a system that they think is as good as it can be given the lack of advanced machinery and equipment,” Dr. Wilson says.
Physicians who visit U.S. military or Western hospitals and witness the successes possible in infection control, nursing care, medication administration, and medical documentation return to Afghanistan excited about the skills introduced to them. “They see that the provision of really good medical care is more dependent on having a clean space, a well-organized system, good communication, and solid basic medical care,” Dr. Wilson says.
Contrast to Care Continuity
Col. Walt Franz, MD, of U.S. Army Medical Corps headquartered in Amarah/Al Kut, Iraq, has just begun the work of partnering with Iraqi physicians and nurses for the first time since 2003. In 2004, as a public health team leader, his primary task was helping Iraqi providers with hospital and clinic projects. The projects ranged in cost from $40,000 (for securing an X-ray machine) to $5,000 for such smaller repairs and fix-ups as securing parts to make an elevator run. In fact, patients were being carried up several flights of stairs in the local, six-story hospital.
For about five months in 2008, Dr. Franz was deputy commander for clinical services for hospital and outpatient medical care at a combat support hospital. Since the beginning of 2009, he has been the commander of the 945th Forward Surgical Team at a small forward base in Amarah, near the Iraq-Iran border. “Our mission here is to provide urgent surgical resuscitation for the critically wounded and evac[uation] by helo [helicopter],” Dr. Franz says.
When he’s at home and working at the Mayo Clinic in Rochester, Minn., he practices primarily as a family physician. With nearly 30 years of clinical practice under his belt, Dr. Franz also puts in plenty of hours as a hospitalist. He has practiced during four deployments: three to Iraq and one to Germany.
“Active duty in a war zone presents experiences ranging from the inspiring to the absolutely tragic,” Dr. Franz says. “There is nothing worse than a casualty coming in on a medevac. It’s someone’s son or daughter or husband or wife, and nothing approaches the joy of helping a soldier. In fact, as a civilian, we scrupulously follow the Geneva Convention requirements.” (The treaty affords wounded and sick soldiers to be cared for and protected even though they may become prisoners of war.)
After you eliminate the dangers of enemy fire, there are still big differences between combat versus civilian medicine, he says. One is that combat medicine is usually acute care with little or no followup in the theater of operation, Dr. Franz says. Combat medicine has a strong foundation in echelons of care and evacuations away from the initial point of care. It runs concurrent to the civilian premise of continuity, and the limited number of specialists in theater usually means the Army relies on evacuation or electronic consults.
Maysan Province, where Dr. Franz is stationed, is the poorest part of Iraq. Because of its large Shia population, its citizens were devastated during the Iran-Iraq war and brutalized by Saddam Hussein. “The docs here are very street-smart; their work ethic is great and they have done without for a long time,” Dr. Franz says. Providers at the 540-bed hospital in Al Amarah see 200 patients per day in the ED; several hundred outpatients are triaged, and senior staff physicians see 75 or more cases daily. “One young doc told me it was not unusual to have 500 patients present to a regional ED in a 24-hour period, making triage and care almost overwhelming,” he says.
The biggest problem Dr. Franz witnesses in Iraqi hospitals is the lack of specialty nurses. His teams are teaching classes and training trainers in ED triage, basic ICU care, and the ultrasound FAST (Focused Assessment with Sonography in Trauma) exam skills Iraqi providers can use anywhere in the hospital.
Other issues include a lack of continuing medical education; poor infrastructure, which chokes the supply of pharmaceuticals and other medical equipment; and paucity of specialty nursing. Dr. Franz also cites critical staffing issues, such as the large number of physicians who have fled the country and the rising prominence of the private, fee-for-service care system, which can attract physicians and nurses away from the public system.
Care for Female Soldiers
With three other OB hospitalists, also known as laborists, Brook Thomson, MD, spent the summer organizing an OB/GYN hospital medicine program at Saint Alphonsus Regional Medical Center in Boise, Idaho. A veteran of military medicine, Dr. Thomson trained at Uniformed Services University of Health Sciences (USUHS) and completed an OB/GYN residency in 1997, then was stationed in Germany for four years. From 2001 to 2004, he served as chief of obstetrics at Madigan Army Medical Center in Tacoma, Wash., during which time he was deployed to Iraq for 10 months.
The OB/GYN expertise combined with the HM practice model that Dr. Thomson offers is a growing need in the military. “The number of women in the military is increasing, and there just aren’t a lot of people who understand female soldiers’ special needs,” he says.
Supporting women’s health has become an important aspect of battlefield medicine, namely the rooting out of potential sexual abuse. Dr. Thomson has published on the subject.1
In 2003, he was deployed as a general medical officer in Kuwait and assigned to the Basra area of Iraq, treating the gamut of patient needs. Recent Army policy changes, he says, ensure that OB/GYN military physicians now practice within their specialty.
A Canadian Perspective
Brendan James Hughes, MD, CCFP, returned from his military tour of duty and became a family practitioner in Lakefield, Ontario, a small community about 100 miles north of Toronto, and medical director of first-aid services for the Ontario Zone of the Canadian Red Cross.
In 2001, when Dr. Hughes was deployed as a hospitalist to Bosnia-Herzegovina for six months, the unrest from the civil war that involved Bosnians, Croatians, and Serbs (more than 100,000 were killed, and millions were injured or displaced), had settled, and his unit returned home without any loss of life. Upon his return, he transitioned from military life to become a full-time civilian hospitalist for six years in Ontario and Alberta. He now works as a part-time hospitalist.
Dr. Hughes says Canadian military practice is more acute and trauma-based now, as compared to his 2001 deployment in Eastern Europe. He notices many more deaths and major trauma cases in reports from Afghanistan, mostly blast injuries, limb amputations, and acute brain injuries, than there would be in a traditional, nonmilitary HM practice. He also notes that a lot of time and effort was placed on rehabilitation-focused practice that the patients required in the recovery phase.
Military practice differs from civilian hospitalist practice in other ways, he says. “In the military, every patient is essentially a workplace patient where the military is the employer,” Dr. Hughes says. Although clinicians maintain patient confidentiality, they are obliged to the chain of command to provide information on patient abilities. “We are careful not to relay a specific diagnosis without patient consent, but we have to dictate any needed restrictions on duty that are important in a combat situation, for themselves and for others,” he adds.
Such privacy and disclosure concerns are particularly difficult to navigate when it comes to diagnosis and treatment of alcohol and drug abuse, depression, post-traumatic stress, and suicide risk—issues that can lead soldiers to develop such long-term problems as substance abuse, marital discord, and marital abuse. TH
Andrea Sattinger is a freelance writer based in North Carolina.
- Thomson B, Nielsen P. Women’s healthcare in Operation Iraqi Freedom: a survey of camps with echelon one or two facilities. Mil Med. 2006;171:216-219.
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PHOTOS COURTESY OF MAJ. RAMEY WILSON