1. Debias, Gwen RN, BSN, CEN

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As a nurse with 12 years of civilian ED experience prior to joining the Army, I thought I'd seen it all. I've worked at Level I, II, & III trauma centers in Illinois and Wisconsin, city and suburban. I've had staff ED nurse jobs, was the clinical coordinator in a Level II trauma center, acted as charge nurse, worked agency, and did a couple years of travel nursing. Reaching a crossroads in my career, I made the choice to join the Army. I decided that I didn't want to be one of those nurses with 20 years in the ED that were stuck with no further advancement than being a head nurse or a hospital educator. Be careful what you wish for [horizontal ellipsis].


My first assignment in the Army was Brooke Army Medical Center (BAMC) in San Antonio, Texas, also a Level I Trauma Center. Again, I had an ED nurse staff job. This military hospital was the closest thing I could imagine to a civilian job back up north [horizontal ellipsis] busy nights, a growing elderly population, lots of medical stuff and some trauma thrown in between. Motor vehicle crashes, stabbings, gunshot wounds, near-drownings, and the occasional snakebite would come our way. It's a teaching institution so you have medical students, interns, and residents as well. Overall, not a bad gig as far as nursing goes, lots of sick people and very little downtime. I'll say at this point that I thought I might have seen it all [horizontal ellipsis] not so fast.


My deployment orders did not come as a surprise. I'd spent over a year at BAMC living the good life and watching over my shoulder constantly, waiting for word that I'd be sent to the "sandbox." Now that's a crazy child's way to refer to a place of war in the cradle of civilization. I never enjoyed that reference, it minimized to me what I thought would be the most difficult time in my nursing career. Difficult doesn't even begin to describe what this past year has been for me. Someone described the situation to me as the best and worst experiences of your life [horizontal ellipsis] that couldn't be more true. The highs coupled with the extreme lows were challenging to deal with, to say the least. The sadness of being away from everything I knew gradually evolved to a feeling of extreme pride for what I've been involved in here.


My view of patient care has also evolved in the past year. In my wildest dreams, I never imagined what deploying to Iraq would be like. After finally arriving at our destination in Baghdad in October 2005, I was scared to death. Seeing the place that I would call home for the next year was a humbling experience. If I closed my eyes and looked around, the lights, the moon, and the stars appeared just as they would at home. The difference here was that I was carrying a weapon and acutely aware of the fact that I was now in a war zone.


I was certainly not prepared for December 7, 2005. As the assistant head nurse in the Emergency Medical Treatment Section of the 10th Combat Support Hospital, I was in charge on night shift and received a phone call from another location in Iraq that we'd be receiving eight Marines with extremity amputations from an IED blast. My heart dropped and I went into charge nurse mini mass casualty mode. The staff and I raced to get everything ready [horizontal ellipsis] rapid-sequence intubation drugs, checking O2 and intubation supplies, notifying on-call ED staff, the nursing supervisor, surgery, radiology, lab, and pharmacy. Oh, and did I mention that my boss was stranded at another location waiting for a ride back? The challenges of caring for all of these patients with a still relatively junior staff (most with less than 6 months' total nursing experience, let alone ED nursing experience) were magnifying themselves in my mind throughout the preparations. I had a feeling of impending doom like never before in my 12 years of emergency nursing. I'm sure that I overcompensated by being especially bossy with the hospital staff, it was fight or flight for me and I sure wasn't walking away. With everyone in place, the Marines began arriving. One by one, they were carried into the ED on litters from the helipad. Each man seemed to be a lot sicker than the last guy. Most of these Marines were awake with gray ghostly faces looking up at us and begging us not to let them die. They were horribly volume depleted, hypoxic, and had vital signs that are nearly incompatible with life. The staff went to work to fix them so that they could be afforded the blessing of another day.


As a charge nurse, my job was to make sure that the ED staff had what they needed to save their patients' lives. I went from bed to bed, making sure that airways were secured, tourniquets placed or reinforced, blood was being transfused, labs were sent, and that patients were sent to the OR or ICU as indicated. The fact that four more patients were coming in the next 30 min increased my level of anxiety to get the first group out. One patient was pronounced dead and quickly moved out of the trauma room. The staff worked effectively and efficiently to ensure that the bed was ready for the next injured Marine to come through the door.


I don't quite know how to put into words what was going through my head throughout this hour of my life. To look down at a Marine with no lower extremities was one of the saddest moments in my life. These tough guys, when asked how they were doing, replied, "It's just another day at the office, Ma'am." I was truly humbled by the fact that they were so strong in the face of such horrific injuries. That night I realized very quickly that this military that I had joined is a family and when one person goes down, we all suffer. Never in my life would I experience trauma like this, nothing and everything in my experience as an emergency nurse had prepared me for this one moment.


I breathed for the first time that night and continued on with what was required of me, making sure that things would run as smoothly with the second round of casualties. As the second group came in, I breathed a sigh of relief that only two were missing a leg. How sad is that? They were not as critically injured as the first set of guys. All but one still needed to be intubated and resuscitated with blood and intravenous fluid, but they weren't dying in front of us. The three most seriously wounded were fixed up and later admitted either to the ICU or the OR for further treatment.


My communication with the nursing supervisor and his subsequent dispersal of all the information was critical. Utilizing anesthesia staff to get airways and lines in these guys was also important. The ancillary departments all stepped up and were literally running back and forth to their departments from the EMT to make things happen quickly. Surgery worked tirelessly to address the needs of all of these patients and get them definitive care as rapidly as possible. We meshed together that night, in a way that I've never experienced before and I realized that I was part of something big.


As charge nurse in the EMT, I facilitated the staff getting what they needed in order to do their jobs well. The uniqueness of being in a war zone and having people available literally at a moment's notice allowed us to have the staff to handle these critical patients. The multiple limb amputations were truly horrific. The fact that a fairly junior staff of nurses, doctors, and medics were able to dig in and do what was necessary to save the lives of fallen comrades is nothing short of remarkable. One man died of his injuries, but seven more would have died if not for the quick thinking of the staff on duty. My role in all of this is small. I consider myself to be a facilitator, a communicator, and most importantly, a trouble shooter. If casualties come into the 10th CSH EMT section, things should flow relatively seamlessly. My job is to eliminate roadblocks for the staff and to ensure that they have the proper tools to save lives. Fortunately, on this particular night, the chain of survival remained intact. But we will never forget the life lost that night, he was a hero.