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This firsthand account of navy nurses' work during Operation Iraqi Freedom reveals the essence of military nursing.
ON JANUARY 6, 2003, the USNS COMFORT left her home port of Baltimore, Md., for the Persian Gulf in preparation for Operation Iraqi Freedom (OIF). Setting sail were a minimal crew of about 300 medical personnel charged with preparing the 1,000+-bed floating hospital and 60 Military Sealift Command civilian mariners to operate the 894-foot ship. By March 7, 690 additional crew and staff members joined the ship off the coast of Bahrain, leaving just 12 days to organize, train, and simulate mass casualty scenarios in preparation for the pending war. The nearly 700 casualties, some critically wounded, who'd cross her decks in the next 2 months would include coalition troops, Iraqi civilians, and enemy prisoners of war (EPWs).
On March 20, the war began. Within days, the overhead speakers blared: "Flight quarters, flight quarters, set flight quarters." To the background whirring of incoming choppers, we prepared ourselves to receive injured coalition soldiers. The flight deck crew swung into action, every move finely orchestrated to land the helicopters, unload the injured, and clear the deck for the next chopper that was circling. Quickly moved to the casualty receiving unit, our patients wore torn and dirty blood-soaked uniforms; their dog tags were their only belongings. Many hadn't had a shower or hot meal in weeks. Our team of physicians, nurses, and corpsmen assessed and stabilized all patients and transported them to the operating room, intensive care unit, or the medical/surgical unit, as indicated.
As patients arrived in the medical/surgical unit-often several patients at a time-we quickly placed them in lower bunks, gave them a focused assessment, and provided them with immediate care as needed. Many troops had multiple injuries ranging from minor to severe. Some injuries were sustained when vehicles were hit by rocket-propelled grenades, so shattered bones, traumatic amputations, blast injuries, and burns were common. Our staff performed 590 surgical procedures on board COMFORT, including setting fractures, applying external fixators, debriding wounds, grafting skin, and repairing major abdominal and chest wounds.
On a typical shift, two or three nurses and three corpsmen would care for about 30 patients. We nurses needed to rely on corpsmen, and training them was critical to the success of the mission. They were often our eyes and ears.
As ward staff, we had a unique opportunity to see firsthand the direct impact of life-altering injuries. Regardless of the severity of the wounds, a question that resounded was, "When can I get back to my unit?" Even a marine with a planned lower-leg amputation asked this question. The harsh reality was that his injuries would require long-term care and rehabilitation. We'd put injured marines from the same unit close to each other whenever possible so they could encourage one another, especially during difficult and painful procedures. How often we'd see one marine in a wheelchair and another on crutches, offering each other an arm to grip onto through the pain. They'd tell their fellow marine, "This isn't any worse than going through boot camp. Come on, buddy. Be strong."
We nurses felt humble providing care to these patients who gave so much for their country. No request was too great. Whether it was assisting them with their first phone call home or transporting them four decks up for some sunshine, we were there to help, and we did it with enthusiasm. For many of us, this service defined navy nursing. It was why most of us joined. The pride and admiration we felt was indescribable as we watched nine injured marines awarded Purple Hearts for injuries sustained in battle.
Just the same, our challenges were many. Helicopters arrived irregularly to pick up stable patients needing more definitive care off the ship. At times we didn't know when the next helicopter would arrive or which patients would be leaving. Often with less than 30 minutes' notice, we'd scramble to gather medical records, X-rays, and 3 days worth of medications and supplies to see a patient through the journey home. We needed to allow time for good-byes among injured marines from the same unit.
As days went by, we began to see injured Iraqis, some civilians, some not. Suddenly, "setting flight quarters" meant something entirely different: receiving Iraqi patients. They arrived on the flight deck, their faces filled with terror, pain, and confusion, and were quickly searched for weapons. Then they were divided into civilian casualties, which included men, women, and children, and EPWs, who all were men. Like the coalition troops, these patients had injuries that ranged from multiple gunshot wounds and blast and crush injuries to burns, traumatic amputations, head wounds, and complicated orthopedic injuries.
Several wards on the forward part of the ship were designated for the Iraqis, including "the Village," a ward for only women and children, and an EPW ward. Our focus changed as some of us transferred there. We dealt with new patient-care concerns, including communication problems, environmental and personal concerns, and wound care challenges.
* Breaking down communication barriers. Covered in dirt, lacking identification, and unable to speak English, the Iraqi people were difficult to understand. We implemented a "John Doe" (that is, JD #102) naming system to minimize confusion and help identify them. With few translators available, we learned to use simple gestures, rudimentary sign language, and a list of common Arabic words to communicate with them. Building trust was essential so painful procedures weren't perceived as torture.
* Developing personal safeguards. "Remember; this isn't just a patient, this is your enemy." Statements like this reminded us that personal safety was the priority. Learning to practice nursing in an enemy environment meant a complete change in perspective. Wards of Iraqi patients were locked, and the ship's staff removed any items that could be used as weapons-call-light cords, detachable side rails, intravenous poles, medication pumps, and supply carts.The ship's security forces ensured the safety of the ship's personnel. These specially trained armed men and women (called masters-at-arms) instructed the staff in how to protect themselves before entering the locked wards. Removing our belts, pens, hard plastic name tags, and anything sharp was the common practice before each shift. Providing care to the EPWs meant never turning away, always approaching the patient in pairs, and minimizing time at the bedside. We were instructed to limit verbal interactions and refrain from developing any personal connection with the patients.We kept the overhead lights on at all times-even during the night shift-so the security team and staff could monitor the EPW patients for suspicious activity. To prevent patient combativeness and ensure staff safety, the staff implemented standing orders for sleeping aids to reduce the effects of sleep deprivation.As a security measure, EPW patients were required to stay in their bunks, increasing the risk of complications related to immobility. One ward developed a creative way to minimize these problems. With security's approval, the ward implemented daily 15-minute aerobic sessions to music for ambulatory patients and those in wheelchairs and on crutches.
* Meeting wound care challenges. The staff was quickly overwhelmed by the need to manage complex wounds, so our wound care specialist trained four teams to provide continuous wound care. Most wounds were extensive-open and dirty-and required numerous dressing changes. Some of the wounds were so complex that debriding and dressing a single wound could take several hours.
Wound care management was further complicated by the rampant growth of Acinetobacter baumannii, a nonfermenting, Gram-negative, aerobic coccobacillus found extensively in Iraqi soil. This bacterium was a prime culprit in delaying wound healing and increased consumption of available resources, such as antibiotics, opioids, and dressings.
Because of the ship's size, even a routine trip through the facility was arduous. We used elevators only to get supplies or transport patients, so a visit to the pharmacy, lab, or blood bank required a five- to seven-story stair climb several times per shift. More than 600 units of blood were transfused, translating to many trips up the stairs to the blood bank.
Because the ship didn't have built-in wall-unit suction or oxygen, we needed to chain large-cylinder oxygen tanks between the bunk bed units. Crawling through a 2-foot space to reach a patient or change a tank required gymnastic-like contortions and positions that many of us have been unable to do since.
Several staff members suffered back injuries when trying to move and care for patients who were lying on immovable bunk beds bolted into place. The distance between the edge of a stretcher and a bunk bed was less than 2 feet. We needed at least four staff members to move a patient on and off a stretcher.
COMFORT's presence during OIF was an intense 2 months. Environmental stresses were constant. Although treating the Iraqi people presented many challenges, our natural response was to help those in need. Simply put, we were human beings caring for human beings.
Providing care to the American service men and women was the highlight of our mission. It brought together our years of training, experience, knowledge, and being part of a greater cause-the call to serve our country. As John F. Kennedy stated, "I can imagine a no more rewarding career. And any man who may be asked in this century what he did to make his life worthwhile, I can respond with a good deal of pride and satisfaction: 'I served in the United States Navy.'"
The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. Navy Nurse Corps, the Department of Defense, or the U.S. Government.
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