Physicians who visit U.S. military or Western hospitals and witness the successes possible in infection control, nursing care, medication administration, and medical documentation return to Afghanistan excited about the skills introduced to them. “They see that the provision of really good medical care is more dependent on having a clean space, a well-organized system, good communication, and solid basic medical care,” Dr. Wilson says.
Contrast to Care Continuity
Col. Walt Franz, MD, of U.S. Army Medical Corps headquartered in Amarah/Al Kut, Iraq, has just begun the work of partnering with Iraqi physicians and nurses for the first time since 2003. In 2004, as a public health team leader, his primary task was helping Iraqi providers with hospital and clinic projects. The projects ranged in cost from $40,000 (for securing an X-ray machine) to $5,000 for such smaller repairs and fix-ups as securing parts to make an elevator run. In fact, patients were being carried up several flights of stairs in the local, six-story hospital.
For about five months in 2008, Dr. Franz was deputy commander for clinical services for hospital and outpatient medical care at a combat support hospital. Since the beginning of 2009, he has been the commander of the 945th Forward Surgical Team at a small forward base in Amarah, near the Iraq-Iran border. “Our mission here is to provide urgent surgical resuscitation for the critically wounded and evac[uation] by helo [helicopter],” Dr. Franz says.
When he’s at home and working at the Mayo Clinic in Rochester, Minn., he practices primarily as a family physician. With nearly 30 years of clinical practice under his belt, Dr. Franz also puts in plenty of hours as a hospitalist. He has practiced during four deployments: three to Iraq and one to Germany.
“Active duty in a war zone presents experiences ranging from the inspiring to the absolutely tragic,” Dr. Franz says. “There is nothing worse than a casualty coming in on a medevac. It’s someone’s son or daughter or husband or wife, and nothing approaches the joy of helping a soldier. In fact, as a civilian, we scrupulously follow the Geneva Convention requirements.” (The treaty affords wounded and sick soldiers to be cared for and protected even though they may become prisoners of war.)
After you eliminate the dangers of enemy fire, there are still big differences between combat versus civilian medicine, he says. One is that combat medicine is usually acute care with little or no followup in the theater of operation, Dr. Franz says. Combat medicine has a strong foundation in echelons of care and evacuations away from the initial point of care. It runs concurrent to the civilian premise of continuity, and the limited number of specialists in theater usually means the Army relies on evacuation or electronic consults.
Maysan Province, where Dr. Franz is stationed, is the poorest part of Iraq. Because of its large Shia population, its citizens were devastated during the Iran-Iraq war and brutalized by Saddam Hussein. “The docs here are very street-smart; their work ethic is great and they have done without for a long time,” Dr. Franz says. Providers at the 540-bed hospital in Al Amarah see 200 patients per day in the ED; several hundred outpatients are triaged, and senior staff physicians see 75 or more cases daily. “One young doc told me it was not unusual to have 500 patients present to a regional ED in a 24-hour period, making triage and care almost overwhelming,” he says.
The biggest problem Dr. Franz witnesses in Iraqi hospitals is the lack of specialty nurses. His teams are teaching classes and training trainers in ED triage, basic ICU care, and the ultrasound FAST (Focused Assessment with Sonography in Trauma) exam skills Iraqi providers can use anywhere in the hospital.