Major Frank Strange, TD, MA, BSc (Hons), PGDE, RGN.
Nursing Officer, 34 Field Hospital, Iraq; Senior Lecturer, University of PlymouthRisk management has been described as 'an attempt to colonise the future' (Annandale, 1996). War is one of the riskiest businesses humans undertake. Each operation has different objectives and is planned on the success or failure of previous missions.
Risk management has been described as 'an attempt to colonise the future' (Annandale, 1996). War is one of the riskiest businesses humans undertake. Each operation has different objectives and is planned on the success or failure of previous missions.
The Army Medical Services (AMS) provide vital support in all operational areas. Their key function is to conserve fighting strength by sorting and treating casualties according to priority (Army Medical Services, 1993).
All British soldiers are trained in First Aid and are able to provide 'buddy buddy' care.
The AMS are strategically deployed in four roles:
- More advanced care is provided by Role 1 at a regimental aid post. This is situated near the front line and has resuscitation facilities
- Role 2 is the field ambulance. It evacuates the wounded and provides further care in dressing stations before further evacuation to Role 3 if needed
- Field hospitals at Role 3 provide care on a par with that in the NHS
- Finally Role 4 is the specialist care provided in Britain. The experience of previous wars demonstrates that prompt life-saving treatment and rapid evacuation for definitive care increases survival (Army Medical Services, 2002).
In this war the staff for three field hospitals were deployed and set up two field hospitals: one in Kuwait and one in Iraq. Both hospitals were told to expect British and Iraqi wounded. Around 10% of medical problems encountered in war require surgery (Army Medical Services, 2002).
Throughout history, disease and the elements have caused more casualties than bullets and shrapnel. This war was no different. Many casualties treated at 34 Field Hospital were the result of diarrhoea and vomiting.
Two casualties treated were the result of a storm - one had been hit by lightening and the other lifted by the wind.
The 34 Field Hospital crossed the Iraqi border on 22 March, 2003, and arrived at a severely damaged airport outside Basra at 3pm. Within nine hours a 25-bed tented hospital was set up and ready to receive casualties. The structure is pre-planned and practised on frequent exercises. On 23 March, sick and injured casualties began to arrive.
The logistics of setting up a hospital in nine hours are impressive. Staff and patients require food, toilets, water, defence and protection. In this war the threat of chemical and biological agents being used was high. These agents are cheap to produce in comparison with conventional munitions and the perceived threat to an enemy is extremely disruptive.
Defence is a gas mask, chemical-resistant suit and prophylactic medicines. Wearing these in a hot desert climate rapidly degrades the operational capability of even the fittest personnel. Protecting patients is an additional burden to care.
Environmental health issues are a key factor in a field hospital, with its potential to become a reservoir of infection. Siting of latrines, disposing of clinical waste and providing hand-washing facilities are vital to prevent cross-infection.
The casualties treated were Iraqi and British soldiers, plus a significant number of civilians. Many of the civilians had non-war-related problems. Our first casualty was a child scalded in a domestic incident, who was later evacuated to England. In the initial stage of the conflict 65% of casualties were combatants.
Up to 16 May 2003, the combined intensive care unit (ITU) and high dependency care unit (HDU) of 34 Field Hospital treated 218 casualties. About two-thirds were postoperative recovery patients, brought in for airway management and observation. This enabled the operating theatre to have a faster turnround between cases.
The ratio of ITU patients to HDU patients was 2:1. The major cause of ITU admission was bullet or shrapnel wounds, although 5% had burns.
Dealing with prisoner of war (POW) casualties presents problems of communication and expectancy. We had Kuwaiti interpreters, some medically qualified. This eased the problem of giving information and gaining informed consent.
Overcoming the expectation that as POWs our patients would be badly treated was partly achieved through non-verbal communication, mostly using smiles and gestures.
Word must have circulated fairly rapidly that we were not the barbaric invaders predicted in the propaganda, because from the start parents were bringing their children to us in increasing numbers. This put further strain on our ability to deliver care.
Field hospitals are not supplied with paediatric equipment, so the skills of innovation and adaptation were needed.
One patient was found abandoned outside the hospital gates. He appeared to have received a head injury about six weeks before and had a tracheostomy. He had a severe chest infection, a sacral pressure sore and constant seizures.
We stabilised his convulsions and treated his chest infection. He was eventually transferred to the local hospital, from where he had come in the first place. When resources are scarce, long-term rehabilitation care appears to suffer.
A 25-bed hospital would not be adequate for the casualty flow expected, so the building of a 200-bed facility started within two days of arriving in Iraq. This was built on the hard standing of the airfield and completed in six days. It was a triumph of planning, motivation and training.
Bullet and shrapnel wounds are always severely contaminated, and their treatment involves debridement of the wound, application of a sterile dressing and delayed primary closure (Army Medical Services, 1990).
This treatment is expensive. It requires at the least a second operation before a clean wound is finally closed. Some casualties treated at Iraqi facilities had not been given this care, and had severe problems with sepsis, and limbs requiring amputation.
Three themes emerge to form a gestalt, resulting in a whole that is greater than the sum of its parts. They are: a cohesive team, logistics and training.
Cohesive team In 34 Field Hospital and in particular the ITU, the teams were organised into shifts before going over the border into Iraq. Each shift had a leader, who got to know the abilities, skills and background of the team. This enabled the allocation of patients and roles within the team to be distributed according to ability.
The teams had the chance to become acquainted and establish a sense of trust during the period of uncertainty in the build-up to war. Before any testing experience there is a time of self-questioning, referred to by Lazarus (1966) as 'cognitive appraisal'. This has a primary and secondary component. The primary appraisal involves an assessment of the situation. Is it threatening? The answer for most of us was yes, war is an uncertain and risky business.
The secondary appraisal concerns the individual's ability to cope with the threat. When the result is positive, the situation is perceived as less stressful. Social support plays a role and the sense of not being alone and having others to turn to appears to act as a buffer (Pearn, 2000).
There was an atmosphere of openness, allowing disclosure without fear of judgement or criticism - not always present in a military context.
Logistics - In war the winner is often the side with personnel and equipment remaining at the end of the conflict. To fulfil its task a field hospital requires a mass of sophisticated equipment.
The harsh reality of war is that it is cheaper to kill than to keep alive. Munitions such as mines are designed to maim rather than kill, because this occupies more of the combat strength treating and evacuating the injured. Without equipment even the most cohesive team is ineffective.
Training - Well-equipped teams require training. Our team had years of training and practice. The protocol used was simple, while implementation was complex (Army Medical Services, 2002). This procedure is similar to that of the Advanced Trauma Life Support approach first described in America (American College of Surgeons, 1997).
The Battlefield Advanced Trauma Life Support (BATLS) system is modified to deal with the unique conditions of war. The set of rules uses a primary survey with treatment followed by a secondary survey (Army Medical Services, 2002).
The primary survey focuses on Airway, Breathing, Circulation, Deficit and Exposure (ABCDE). Resuscitation treatment is performed at each step of the ABC assessment if needed.
All casualties were triaged using this protocol and equipment at each ITU bedside was arranged in hanging containers with ABC compartments. Building a unit helps familiarise people with its layout and the algorithmic approach to treatment and the arrangement of equipment helped in systematic delivery of care.
In practice these three themes were integrated and refined, with the result that all casualties, whether British or Iraqi, received treatment on the basis of individual need and triage priority.
War is a risky business, but a cohesive team, good logistic support and training reduce the risk and ensure people come home alive. Even if the future is not colonised according to risk-management terms, the presence of a field hospital in Iraq ensured that many of those injured had a future.
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