Inside the busiest combat support hospital in Iraq

[big bad john]

There are a series of articles from the ArmyTimes that I thought were particularly thought provoking under the above title.  I thought that you would enjoy reading and discussing them.

Soldiers with the 10th Combat Support Hospital, a Fort Carson, Colo., based unit, learn on the job at Baghdad’s busy Ibn Sina hospital.


http://www.armytimes.com/story.php?f=1-292236-1687853.php

Critical care
10th CSH soldiers learn on the job in Baghdad’s busy Ibn Sina hospital

By Gina Cavallaro
Times staff writer



1st Lt. Leigh Tofte brings a wounded Iraqi policeman into the 10th Combat Support Hospital in Baghdad. About 75 percent of the patients treated at Ibn Sina by soldiers from Fort Carson, Colo., are Iraqis. — James J. Lee / Times staff

BAGHDAD — The chopping sound of an approaching Black Hawk helicopter could mean the arrival of one patient with heat exhaustion or the onslaught of more than a dozen patients with catastrophic injuries — what the Army calls a “mass cal.”

From the bird, patients take a short, rushed ride on a flatbed Gator vehicle to the emergency room at the Ibn Sina Hospital, the U.S.-run facility inside the fortified Green Zone where floor-to-ceiling marble sets an unusually elegant backdrop for a war zone trauma ward.

Inside is a team of experienced soldiers of the 10th Combat Support Hospital, seasoned in record time by the events that have unfolded before them.

“When we got here [in October], we were scared. I didn’t sleep for 45 days,” said Lt. Col. John Groves, head emergency room nurse for the 10th, which is the fourth unit to run this hospital.

“Out of 36 nurses and medics in the ER, only two nurses and three medics had any experience. The rest were rookies who had never been in a trauma ward,” he said. “In this hospital, the ER is the center of the universe. It’s because of how much action we see.”

The hospital here uses 75 percent of the blood in Iraq. The emergency room averages 500 cases a month; about 300 of those are classified as trauma cases. That’s more than the number of cases seen at the Army Trauma Training Center in Miami, where soldiers on forward surgical teams train with Army surgeons and nurses before deploying, The training center also has pediatric and burn units.

 
The Air Force’s 332nd Expeditionary Medical Deployment Group in Balad logs a higher admissions count, but the number includes patients from this hospital and elsewhere being evacuated.

“Balad does a lot of business because they’re a staging facility. Their primary mission, in addition to being a CSH, is to prep and stage all our medical evacuations out of theater,” said promotable Lt. Col. Mark Smith, deputy commander for clinical services.

None of these 10th CSH soldiers were trained to face the magnitude and seriousness of injuries they now see in Iraq. But they’ve learned fast.

“It’s the combination of blast and penetrating trauma. You rarely see both together in the states,” said Groves, 40, of Portage, Ind., who has been in the Army for 19 years and was a Special Forces medical instructor. “These are 22-year-old kids out of college and you put them into the bloodiest ER in the country and it’s amazing how they adapt.”

Saving lives, facing death

More than 20 procedures are performed each day in the operating rooms, from burn treatment and amputations to appendectomies and hernia operations.

“In a 24-hour period, we could do 41 hours of surgery,” said Sgt. 1st Class Nicole Colbert, NCO-in-charge of the operating room.

The 17 surgeons here have seen their share of happy days — they delivered two babies on the third floor, for example. But they say the toughest days are when they have to let go of a U.S. soldier whose life they just can’t save.

“On Christmas, we had a young soldier come in, and he had a horrible injury. No matter what we did, he just bled out. It was horrible,” said Colbert, 36, of Westminster, Colo., who recalled that the 19-year-old soldier had a new wife and baby at home. “The unit was outgoing. They only had 10 days left.”

Iraqis now dominate the hospital’s patient load. In the intensive care unit, Iraqi soldiers and policemen lie wounded alongside U.S. troops — some silently clinging to life, others fighting the stupor created by the morphine dripping into their arms.

“I rarely know how they’re injured. Back here, they’re only patients. We don’t know if he’s the bad guy or got shot by the bad guy,” said Lt. Col. Kathryn Moore, 48, of Nashville, Tenn., a reservist with the 801st Combat Support Hospital in Chicago and senior head nurse for the 10th CSH. She volunteered for the slot after two years of trying to get to the war zone.

She’s been a nurse for 20 years and also teaches at Vanderbilt University in Nashville. She worked with Groves at the Miami trauma center and conducts certification classes in Baghdad for the nurses at the 10th CSH.

“We’ve got a younger level of staff than you would expect to see in a trauma center, but I see the same kind of enthusiasm and excitement I see in my students,” Moore said. “They really have stepped up to the plate.”

On the same floor as the ICU, there is an intermediate care ward that treats U.S. soldiers and non-Iraqi civilians who are generally evacuated within 24 to 48 hours to Balad and then to Germany.

A similar ward on the other side of the same floor treats Iraqis, who account for the bulk of inpatients. Their stay can be as long as seven days or until they are stable enough to be released to an Iraqi hospital.

The 10th CSH soldiers use interpreters to communicate with their patients — including suspected insurgents, who are guarded by military police but not restrained.

“They’re hurt or sick just like every other patient,” said Spc. Elizabeth Sessions, 27, of Rye, N.Y., a medic who said the Iraqis, some of whom speak English, range in age from 17 to 65. “Now and then, the translator comes in and they’ll ask about their families.”

Sessions said she and her fellow soldiers have learned a lot about Iraqi culture. “They’re very family oriented. Patients and family members will help other patients. They’re a tight-knit community,” she said.

Few Iraqi doctors or nurses

That is part of the dilemma soldiers in the 10th CSH face each time they decide to send an Iraqi patient who has been stabilized out to a local hospital.

“It’s hard because it’s an evolving system out there. It’s harder on us because nursing here is virtually nonexistent,” said Lt. Col. Steve Drennan, chief nurse at the 10th CSH.

The Iraqi hospital system — about 200 hospitals, with 25 in the Baghdad area — includes general hospitals and some specialty facilities.

However, it suffers from a dearth of physicians who have had access to continuing education, the training and sharing of information that allows for professional development.

And there are only about 200 certified nurses in the entire country.

“There’s a lack of sophistication in the health care system,” said Smith.

“It’s a moral, ethical challenge. You send them out there and you wonder what’s going to happen to them,” Drennan said. “At the same time, if we keep them here, we’d be filled to the rafters. We try to make sure there is family there for them.”

Called up at war’s start

Ibn Sina is a 1960s-vintage three-story building that is not up to the standards one would expect in the U.S., but it’s a hard building and provides housing for the surgical staff.

The 10th CSH is based at Fort Carson, Colo., but only about half the 650 soldiers who came with the unit — 550 soldiers here and 100 working at Talill Air Base in southern Iraq — are stationed there. The others hail from 23 posts across the rest of the Army.

At home, the 10th CSH falls under 1st Medical Brigade, but here it is administratively under the 30th Medical Brigade out of Heidelberg, Germany.

The 10th CSH deployed at the beginning of Operation Iraqi Freedom in March 2003 but never got to Iraq. Instead, some soldiers and equipment were siphoned off and the rest of the CSH returned to Colorado.

Seeing trauma injuries in fellow soldiers is serious business for everyone, but there are different levels of emotional involvement. In the ER, seriously wounded people require fast action — there’s no room for an emotional response.

“It was kind of a shock at first, but they told us before we came to ignore it, to focus on the breathing and stuff,” said Spc. Reagan Stockman, 20, of Kemp, Texas, an ER medic who spent eight months at Darnell Army Community Hospital at Fort Hood, Texas, before coming to Baghdad. “Any time it’s ours it’s going to really affect you, but you just do the best you can and hope and pray.

“You don’t imagine that each patient is your family member. You’re going to treat them the same, but you don’t get attached to them — you distance yourself emotionally,” said Spc. Nick Guess, 21, of Galveston, Texas, an ER medic who turned 19 in Kirkuk two years ago when he was deployed with 4th Engineers, 4th Infantry Division.

Always seeking improvement

Every day, the clinical staff holds what they call a “morning report” meeting where they discuss each case in detail and review every patient in the hospital for disposition.

Those meetings include a weekly morbidity and mortality conference where each death is discussed.

But the best and most intimate after-action reviews occur among the staff.

“We might get a call that we’ve got a stable belly wound. There’s no such thing as a stable belly wound,” said chief anesthesiologist Lt. Col. Michael Gehrke, chief of anesthesiology at Brooke Army Medical Center, Fort Sam Houston, Texas.

“We talk about how we would have done better,” he said. “That soldier who waited an hour to take that patient to the OR is going to kick himself a lot harder than we ever could. We just don’t do that.

“You go forward with whatever you have to go forward with. It’s not like anybody has the all-seeing of what’s going to go on. We all talk about it later and what we could have done about it.”

 

[big bad john]

http://www.armytimes.com/story.php?f=1-292236-1687856.php

‘We just couldn’t do it’
Long surgery, tender treatment not enough to save soldier

By Gina Cavallaro
Times staff writer



The operating room staff performs surgery at the 10th Combat Support Hospital in Baghdad. — James J. Lee / Times staff

BAGHDAD — The patient, a 20-something female U.S soldier, died four days after arriving at the Ibn Sina Hospital with a fresh gunshot wound.

A bullet had pierced her chest a few inches below her right collarbone and exited through her back on the upper part of her right flank, gouging a hole the diameter of a soda can.

During the last days of her life at the hospital, her health dipped and spiked, but she never improved beyond critical condition despite the aggressive efforts and passionate ministering of the surgeons, nurses and medical technicians who treated her. The blast severely damaged her right lung, and her body struggled to deal with the trauma.

Her left lung, the smaller of the two, worked harder to take in oxygen to compensate, but she couldn’t get enough carbon dioxide out; a ventilator kept her alive.

She woke up at least once while in the intensive care unit and, in a groggy state, nodded “yes” to a nurse who asked her if she had pain.

“Occasionally, when we’d turn her or mess with her dressing, she’d rouse to the pain. She would wake up and look around, she’d lock eyes with you,” said Capt. Virginia Griffin, 42, of Tampa, Fla., an intensive care unit nurse on the day shift.

 
The first full day the patient was there, a nurse from night shift came to visit on her day off. Standing next to the gurney in her physical training uniform, 1st Lt. Kathleen Williams tenderly stroked the patient’s hair and looked at her, checked her vital signs and watched her for a few minutes, whispering a private word into her ear.

The staff knew little about the patient, but they acknowledged that, as far as they knew, the wound was self-inflicted and the incident was under investigation.

But the cause of her injury was secondary; there was a great deal of sympathy and concern that her life be saved and that she be able to return to her family.

In the ICU room where the female soldier was cared for, others came and went.

There was a male soldier, a medic, who had been banged around in the back of a Bradley fighting vehicle when a roadside bomb exploded. He was evacuated the next day.

There was a Marine from an explosive ordnance disposal unit with burns and lacerations from at least one explosion that he could remember. He said he suspected the bomb had been laced with petroleum. He was burned trying to save another Marine whose body had caught on fire. He, too, was evacuated the next day.

In surgery 12 hours after the woman’s first life-saving operation, the hospital’s chief cardiothoracic surgeon, Lt. Col. Joseph McClain, painstakingly and reluctantly removed her right lung. At first he thought he would remove only part of it, but when he got a look at it and saw the damage, he took it all.

At 3:40 p.m. March 8, with a Beastie Boys song blaring from an iPod docking station, McClain began what would become a 3½-hour operation with a team of surgeons, anesthesiologists, a perioperative nurse and operating room technicians.

There were more people on hand than usual in the green-and-blue environment of the operating room. Nurses from ICU were there to watch over their special patient, joined by the 10th Combat Support Hospital’s chaplain, Maj. Robert Leathers. He and the patient’s father, also a chaplain, know each other and had spoken on the phone.

Before surgery, a couple of nurses stood near the patient and delicately stroked her arms and hands as if to soothe and reassure.

“It’s the human touch. I always think that a lot of these could be my children, so that’s why the touch,” said Maj. Beth Pettit-Willis, who has been a perioperative nurse for 25 years and has a son serving in the 3rd Armored Cavalry Regiment.

With arms crossed and necks craned, the crowd watched most of the first hour of the surgery, some eventually slipping out to get back to their jobs.

Things were going reasonably well. The damaged lung was out and hope was rising when McClain’s voice pierced the optimism with a cautionary tone: “Wait a minute. Something’s happening here.”

The music was turned off and someone was sent for more blood. A whisper suggested the patient been lost and, in fact, her chances of surviving were dim. But McClain, with dozens of lung and heart transplants behind him, was not about to give up on his patient.

“A pulmonary artery tore. It’s very tough to repair. Normally a patient would die from that,” McClain said afterward. “She’s young. She’s going to make it through.”

And she did make it through the first pneumonectomy for the 10th CSH. Despite the odds, this patient looked as if she had weathered the worst.

Patients who are stabilized after surgery usually take a 20-minute helicopter ride north to Logistical Support Area Anaconda in Balad within 24 hours. But this patient’s condition was too fragile. With her right lung gone and her left lung debilitated, she was deteriorating one hour and rallying the next.

The left lung was slowly shifting into the cavity that once held the right, and the vessels connecting her remaining lung to her main arteries were being torqued, creating blood pressure problems. After air was pumped into the cavity, pushing the left lung back into place, her condition — and her outlook for survival — improved.

A team of respiratory specialists was flown to Baghdad from Landstuhl Regional Medical Center in Germany to accompany the patient. It was determined her chances of surviving would increase if the Balad transfer were eliminated.

But the team never accompanied her. On day four, her body, which had been in overdrive on several fronts, began suffering multiple system failures. She died during another surgery that would become the last attempt to save her life.

“We beat her up pretty bad trying to save her, but we just couldn’t do it,” said Lt. Col. Michael Gehrke, the hospital’s chief of anesthesiology.

The hospital continued to throb with activity the day the patient died, but heads hung a little lower when the news of her death got around.

As he does with all patients who arrive in critical condition at the CSH, Leathers looked for dog tags or a wedding band on the young patient. She wore a ring on her left hand, but, he said, it was a chastity ring, not a wedding band.

He discovered that the patient often exchanged e-mail with her father and that her favorite Bible verse was Joshua 1:9, so he printed out a copy of it and pasted it onto the wall above her bed. He also played Christian music for her and spoke to her, repeating the verse that had inspired and sustained her.

“Be strong and of good courage,” he said. “Do not be afraid, nor be dismayed, for the Lord your God is with you wherever you go.”

 

[big bad john]

http://www.armytimes.com/story.php?f=1-292236-1687858.php

Lt. Col. Joseph McClain, 40, cardiothoracic surgeon




Lt. Col. Joseph McClain — James J. Lee / Times staff

“This hospital has everything I need to do state-of-the-art surgery,” said Lt. Col. Joseph McClain, a cardiothoracic, trauma and general surgeon who is near the end of his six-month rotation in Iraq.

He’s been at the 10th Combat Support Hospital in Baghdad since October. The seven years he spent working at Brooke Army Medical Center, Fort Sam Houston, Texas, in trauma surgery and the last three years working as a cardiac surgeon and professor at Virginia Commonwealth University in Richmond, Va., only partly prepared him: McClain is not accustomed to seeing some of his patients die.

“I think it hits me harder than some guys around here. It bugs me,” he said.

“Everyone thinks, ‘Oh, he’s a cardiac surgeon, he’s tough, blah, blah, blah.’ But the fact is that the cardiac patient death rate is less than 3 percent. … I gotta tell you, man, here these guys come in and they just die. They’re blown apart.”

It’s McClain’s first rotation in Iraq, and knowing he was headed to the country’s busiest trauma center, he expected to be treating a lot more Americans. In fact, about 75 percent of the patients at this hospital, known locally as the Ibn Sina Hospital, are Iraqi.

“I’m glad we’re not seeing more Americans because that means the Iraqi army is standing up,” he said. Even so, the stream of U.S. troops and the nature of their injuries has stirred him unexpectedly.

“I didn’t think it would emotionally drain me because I’ve been doing it so long,” said McClain, who has become the hospital’s go-to surgeon.

On Tuesdays — “just for fun,” he said — “I cover ICU because I have an interest in critical care.”

One day in the ICU, he was examining a soldier’s badly wounded leg and trying to figure out whether it would have to be amputated. The soldier “couldn’t talk,” McClain recalled, “so he writes me a note and it says, ‘Please save my leg,’ and it just killed me.”

 
McClain was able to save the leg.

 

[big bad john]

http://www.armytimes.com/story.php?f=1-292236-1687855.php

Capt. Michelle Wells, 36, operating room nurse




Capt. Michelle Wells — James J. Lee / Times staff

“We hate quiet days, when one or two days go by, because we know something’s coming,” said Capt. Michelle Wells, an operating room nurse working at the 10th Combat Support Hospital in Baghdad, where she’s been on duty since November.

She came to the CSH from Fort Hood, Texas, which has a trauma center, but most trauma cases there, she said, are referred to a civilian hospital off post.

Preparing for deployment, Wells took part in a field training exercise with the 10th CSH last summer. Other than that, she said, the Baghdad gig “has definitely been kind of a hands-on experience.”

Less than a month after she arrived, nine badly wounded Marines were brought in at once, victims of an explosion west of Baghdad that killed 10.

“That was horrible,” she recalled. “Eight had bilateral amputations. They were fresh out of the field with mud and dirt and shrapnel embedded in their wounds. From a professional standpoint, it was overwhelming. Just to see one of your fellow — well, they’re not called soldiers — but, you think of Marines as the most hard-core … and when you see them sitting there screaming in pain, you think, ‘My God, what can happen to the other guys?’”

Wells has adapted to the pace in the operating room and developed mechanisms to deal with what she sees every day.

She’s particularly sensitive to the women because, she said, she comes from “the old Army,” where there was always a front line and women didn’t go there.

Wells remembers a female soldier crying out in pain in the moments before she was anesthetized for surgery.

“She just wanted to hold someone’s hand,” Wells said. “She was reaching out. We thought it was the drugs, but she was looking for a hand.”

 

[big bad john]

http://www.armytimes.com/story.php?f=1-292236-1687852.php

Maj. Don Nance, 45, certified registered nurse anesthetist




Maj. Don Nance — James J. Lee / Times staff

“The Iraqis call this the house of miracles,” Maj. Don Nance, a certified registered nurse anesthetist, said of the U.S.-run Ibn Sina Hospital in Baghdad. “In the Iraqi hospitals, they say there are cats and mice in the hallways and there are no nurses. It’s a pay-as-you-go system.”

Nance is on his seventh rotation to the theater of operations, with turns on a forward surgical team in Afghanistan and Iraq and now at the 10th Combat Support Hospital in Baghdad.

Before coming to Baghdad on this rotation, he spent two months and five days in Ramadi, where he and the rest of a forward surgical team expanded the surgical capabilities at Camp Ramadi with two operating tables.

“You can’t really say you’ve lived in the Army or done everything until you’ve worked [at Ibn Sina Hospital] once. This is the pinnacle of wartime anesthesia,” said Nance, who described himself as being “in the right job for the right reasons.

“We don’t want any of this bad stuff to go on, but if it’s got to go on, we want to be right there. I couldn’t think of a more deserving customer than these soldiers who think nothing of getting in that vehicle and going outside that wire,” he said.

Some cases are tougher than others, such as when a female soldier is brought in with catastrophic injuries.

“For some reason, that hits us a little harder,” Nance said. “It’s a rarity. It’s just a wake-up because you say ‘soldier,’ and what you have in your head is not that picture. … For some reason, with a 38-year-old first sergeant, you’re like, ‘Hey buddy, we’re going to do everything we can.’ But when it’s a 19-year-old female, it’s tough.”

 

[big bad john]

http://www.armytimes.com/story.php?f=1-292236-1687851.php

Capt. Larry Blevins, 35, physician assistant




Capt. Larry Blevins — James J. Lee / Times staff

“This is probably the best teaching hospital in the world,” Capt. Larry Blevins said of the 10th Combat Support Hospital, the Fort Carson, Colo.-based unit working at the Ibn Sina Hospital through November.

Blevins, a physician assistant with Corps Artillery at the XVIIIth Airborne Corps, Fort Bragg, N.C., is an anomaly at the CSH — a student, possibly the first of his kind in Iraq. He’s earning his master’s degree in trauma and surgery from the University of Nebraska by completing 900 hours of hands-on work in the emergency and operating rooms at this hospital, the busiest trauma hospital in Iraq.

He’d been trying to get the internship for two years because the Army doesn’t offer graduate programs in trauma and surgery. The unit in charge of the hospital before the 10th CSH turned him down, as did the unit before that.

“It’s hard to get a master’s in trauma,” said Blevins, a prior enlisted soldier who had completed about half the hours needed for the degree when he talked to Army Times in March.

The experience, he said, is literally worth losing sleep over.

“I go to bed at night and I don’t want to sleep because I hear another bird coming in and I’m afraid I’ll miss something I’ll never get to see again,” he said, recalling one time when he ate only two apples in two days and another time he went three days with no sleep.

“You don’t have this level of trauma anywhere in the states. This is a more penetrating trauma — people have multiple injuries, and the staff here is a collection of the best of the best in the Army. When a patient comes in, they’ve got all these specialists working on them.”

He says the surgeons he’s worked with have inspired him to go even further and perhaps become a surgeon himself.

“For somebody like me to get the exposure to the minds here is by far the most enriching experience I’ve had,” Blevins said.

 

[big bad john]

http://www.armytimes.com/story.php?f=1-292236-1687854.php

Spc. Justin Luther, 27, combat medic




Spc. Justin Luther — James J. Lee / Times staff

“When they come in off the battlefield, sometimes they don’t know how bad they’re hurt,” Spc. Justin Luther, a combat medic working in the emergency room at the 10th Combat Support Hospital in Baghdad, said of the soldiers and Marines who come in daily. “Some are a little bit scared, but for the most part, they feel confident.”

When soldiers or Marines come into the emergency room in bad shape, the key is keeping them calm, Luther said.

“Whether you believe [they’re going to survive] or not, you have to make them believe it, you have to reassure them because it helps them stay calm. The faster your heart rate goes, the quicker you lose blood and the quicker you go into decompensated shock,” he said, describing the condition that precedes death. “The process of reassurance really starts on the battlefield with that first line medic.”

Luther’s true nature, he said, is to be one of those line medics.

“I’m the kind of person who likes to be more active,” he said. “The guys out there, they get to experience an entire culture. The bad side is the fighting, but they get more involved with the Iraq people.”

His job can be stressful and being away from family is hard, he said, but he never forgets the soldiers on the front lines.

“Our goal is to make sure they go home to their families. That’s what we’re here for,” said Luther, who has two children and a wife back home at Fort Carson, Colo. “If you come in here after fighting for me and my family, I’m going to fight to get you back to yours.”