Military nurses in Iraq face heart-wrenching decisions head-on as they provide top-notch care for their patients.

WE SEND OUR American patients home-sometimes on their feet, sometimes in wheelchairs or on crutches or stretchers. Some of our patients are badly disfigured, and some have horrendous scars that can't be seen. Others we send home in black body bags, after we lovingly wrap their bodies in woolen Army blankets. But send them home we do. We're nurses of the 31st Combat Support Hospital in Baghdad, Iraq, and soldiers pass through our hands by the hundreds.

Besides American soldiers and marines, we care for coalition troops, Iraqi and foreign dignitaries, and ordinary civilians, including children and babies. We also take care of Iraqi soldiers, whether friend or foe. They all need our caring and our compassion, so we push ourselves to do more than we'd ever have thought possible.

War takes no holidays

We work at least 12 hours a day, 6 days a week, helping victims of mass casualties, mortar fire, car bombs, and military operations. Our job is endless: We provide nursing care through Easter and Independence Day, through Memorial Day and Thanksgiving, through Ramadan and the hajj. We work through our wedding anniversaries and our children's first steps, birthdays, and first days of school.

We console ourselves and our loved ones with long-distance phone calls. To get through it, we share prayers with chaplains and tears with friends.

When a soldier is dying, we hold his hand and promise not to let go first. We stay by his side and thank him for his sacrifices. Each death leaves us tearful and empty.

Our nights are broken by sounds of nearby mortars, the drone of medevac helicopters, and endless nightmares. Each new day brings us more patients who wrench our hearts. Then we get up and do it all over again.

We've become intimately familiar with the brutalities of war. First Lieutenant Cristina Pansoy of the intermediate care ward remembers one night when she took care of an American soldier. "He asked me why I kept checking on him and asking him if he had any pain. I told him that he and his fellow soldiers risk their lives every day by going out on patrols through dangerous streets. The least that I could do in return was to make sure he was comfortable and not in any pain. Despite extensive injuries, he said, 'Thank you, ma'am. I'm okay right now.' That soldier was later awarded the Purple Heart at his bedside."

Courageous and competent care

Nurses need equal measures of courage and competence to fly out of Baghdad with injured patients as they make the first leg of their long flight home. Captain Birgit Nosalik describes accompanying a critically injured patient on a ventilator through a hostile area. "You're 'it' while you're on the flight caring for the patient. Not only are you caring for someone whose status could change at any moment, but you're also flying in a helicopter through territory occupied by insurgents aiming directly at you."

Even when a patient has almost no chance of surviving, we may do everything possible to save his life. Major Lisa Snyder of the intensive care unit recalls one such patient: "This soldier was twentysomething, as most are, and had been hurt in an improvised explosive device attack. Burned over 25% of his body, he also had severe crushing injuries. On arrival, he was alert and talking, but with shortness of breath. He was quickly intubated and spent the next few hours being continuously suctioned for blood in his lungs while receiving enormous amounts of blood products. When he unexpectedly made it through the first 24 hours, we started to have a glimmer of hope that this soldier was a fighter who'd pull himself out of what we considered a hopeless situation. But after 3 or 4 days of aggressive resuscitation, it became apparent that his injuries were too extensive. His skin began to turn black on his face and neck, and he had no pulses in his extremities. The surgeons took him to surgery to amputate his injured arm at the elbow, hoping that removing the dead tissue would help this soldier continue to fight.

"When he continued to deteriorate, we questioned whether we were acting in his best interest by treating him so aggressively. Would he want us to continue to do whatever we could to save him, no matter what the cost? Or was it in this patient's best interest to let him die with dignity?

"I asked the doctors at what point we'd consider letting him go. Some doctors felt our efforts to save him were becoming futile, but others said they'd want to live at any cost to see their children graduate from high school. These perspectives indicate that quality of life means something different for everyone.

"In the end, the patient made the decision for us. We were at his bedside when he passed away, having made an impression on all of our hearts in the way he fought and in how we all fought for him in different ways."

Heart-wrenching triage

Our hearts also break for ill or injured Iraqi civilians. Each day we have to make decisions about whom we can care for and whom we must send away. Our resources are limited, and our primary mission is the care of the American soldier. For others, we must ask, "Is it life, limb, or eyesight?"

Lieutenant Colonel Gregory Kidwell of the emergency department dutifully enforces the eligibility policy when he's on triage duty at the hospital's front gate. He knows that we must judiciously manage our limited resources, but these decisions still tear at his heart. He's spent many sleepless nights worrying about people he sent away that day. Did the elderly Iraqi man with apparently noncardiac chest pain get proper care at another hospital? Was turning him away the right decision?

Turning away the wounded always hurts, but it's especially wrenching when the patient is a child. One little girl was brought to the hospital with a jagged laceration from razor wire. Her wound needed to be irrigated and sutured and she needed a tetanus shot-routine care back in the States. But Lieutenant Colonel Kidwell had to send her away, explaining to her father, "Sorry, this isn't an emergency because you can get her to an Iraqi facility before something really bad happens to this wound." Lieutenant Colonel Kidwell knew he'd executed the triage policy flawlessly, but it still hurt.

A nurse's oath

The combat environment adds a new twist to blood donation. We start an emergency blood drive when a patient needs platelets. One night we had an emergency blood drive for a patient with B-positive blood. First Lieutenant Pansoy learned that the patient who needed the blood was an enemy detainee, someone who may have shot or killed American soldiers. Nevertheless, she donated her blood because it could save his life. She lived up to the vow she'd made in nursing school: to provide the best nursing care to her patients, no matter what the circumstances.

First Lieutenant Lindsay Towe remembers her first day in the intermediate care ward when she was caring for detainees. She was very intimidated by her patients-Iraqi men, some old and some young, all rough and worn looking. Secured to their beds by leather restraints, none of them spoke English. Most had been there for months because their wounds were severe and they had nowhere else to go.

One detainee had lost both limbs on one side of his body when the backpack full of explosives he was wearing exploded. Another was blinded from the back blast of a rocket-propelled grenade launcher as another combatant fired it toward Americans.

Knowing that they'd hurt her fellow soldiers, First Lieutenant Towe was initially angry with the men in this ward. But she remembered her responsibility to treat everyone with dignity. She decided that it's better not to know what they might have done.

Another patient in this ward was a 10-year-old boy who hadn't put down his gun when soldiers came to search his house. The boy was shot in the legs, which were later amputated.

Two jobs for one nurse

Specialist Robert Duncan has conflicting responsibilities. A nurse in the detainee ward, he also sometimes works as a machine gunner who protects people and supplies as they move outside our gates. In his role as a machine gunner, he's prepared to shoot at the very people he may wind up caring for the next day.

Difficult experiences teach us many lessons, but some leave us with only more questions. When we wrestle with ethical dilemmas, we're rarely rewarded with hard and fast rules that can guide us in the future.

But one image that will stay with us forever is the American flag. We're used to seeing the flag flying over schools and businesses and even at football games. Now when we see it on the sleeve of a wounded soldier or gently draped over a coffin, it has a deeper meaning. To us, the American flag symbolizes freedom and sacrifice. But most important, it reminds us of hope and of home, where all of our American patients will someday return.

At the time this article was written, the authors were serving as nurses at the 31st Combat Support Hospital in Baghdad, Iraq.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.