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Care and duty

Medics in Afghanistan 
January 31, 2010 -- Today the BBC News site posted a good report by Jackie Bird, of the television show Reporting Scotland, about the last training exercise held for a large team of Scottish medics before they leave to take over a field hospital in war-torn Afghanistan. Bird's report features extended comment by three of these reserve Army medics, and two are nurses:  Col. David McArthur, who will be the commander of the Camp Bastion hospital in Helmand Province, and Capt. Margot McCrone, a theater (OR) nurse who has never been deployed before. The report also gives considerable space to a surgeon, Graham Sunderland. Bird's description of the intense 48-hour simulation exercise gives readers a pretty good sense of what the team is facing--and the fact that they are doing so as a team, not a group of physicians with perhaps a few nameless helpers, which is how health missions to unstable parts of the world are often presented in the mass media. The report does seem to fall into the common misconception that nursing occurs only at the bedside, describing Col. McArthur as a "former nurse turned charity boss," as if he could not be a health leader and a nurse at the same time. And the piece is short on details of what the nurses actually do for the kind of critically injured patients they will see. But the report does a good job conveying that nurses are articulate professionals who play a vital role in this kind of care, and even that they can play a leadership role. We thank those responsible.

The report is "'For Care and Duty' - medics on the front line," and it is linked to television reports Bird and her crew will provide as they follow the team to Afghanistan, as well as a BBC One Scotland television program about the medics. Bird begins with a description of the simulation. The exercise features a highly realistic barrage of fake wounded at a warehouse on an Army base in Scotland, a setting Bird compares to a "Quentin Tarantino horror movie," as dozens of medics prepare to assume control of "what is effectively the busiest A&E [accident and emergency unit] on the planet." The medics "include surgeons, anaesthetists, pharmacists, nurses, physiotherapists and blood specialists" who are "members of the Territorial Army, that band of part-time soldiers once pejoratively known as 'weekend warriors,' but whose role is now vital in an overstretched regular Army." The exercise includes the sounds of helicopters bringing in more patients, and "bullet wounds, burns and explosion injuries [that] are the result of detailed prosthetic make up.  Often real amputees are involved." The report says that the real hospital in Bastion, part of the British headquarters in the Afghan desert, "has never been busier," caring for allied troops as well as Afghan military and civilians. Many of the wounded have injuries resulting from "the Taliban's use of IEDs - improvised explosive devices - which often cause multiple limb loss and major chest and abdominal injuries." But battlefield medics are increasingly able to treat the wounded not only within the Golden Hour, but within the "Platinum Ten" (the first 10 minutes), so more are surviving what would have been fatal injuries in the past.

Much of the piece is based on comment from the three medics. The first is McArthur, to whom the report devotes considerable space:

In charge is Col. David McArthur, a former nurse turned charity boss who is the commanding officer of 205 Field Hospital, Scotland's only dedicated volunteer Field Hospital. His soldier-medics are on loan from most of Scotland's healthcare trusts... Gesturing to a nearby operating table, where a blood-soaked "soldier" is surrounded by medics and technology that would be the envy of any hospital in the [National Health Service], David McArthur explains:

"Each person around this table has an individual clinical field of expertise. The challenge of this exercise is to mesh those skills together. Here is where the mistakes are made, where new procedures are tried. The aim here is to build competence and confidence. We've got the physical bits in place. Now we're working on what we call the 'moral component.' Everyone has to get the mind-set right. Exercises like this replicate what's going on in Bastion. It's all about the 'what if'; moral, ethical elements. Everything from badly injured Afghans to how do I get my washing done."

This is generally very good, setting McArthur up as the knowledgeable, articulate commander of a sophisticated life-saving enterprise. The report tells readers that nurses can be authoritative leaders in war zones, and of course that they can be men. In fact, we especially liked the fact that Bird drew no special attention to those elements (a nurse in charge?! unbelievable!), as if there was nothing surprising about them--of course nurses can be leaders. There's not much in the way of specific technical health care expertise on display here, but that would not necessarily figure heavily in the broader message a large unit's commander would give to a reporter anyway.

The only problem is the "former nurse" part, which does suggest that nursing is primarily a physical endeavor that occurs only at the bedside, rather than a modern scientific profession whose members may hold leadership positions in health practice, policy, and academics without losing their professional status. We doubt that the piece would have referred to such a hospital commander as a "former physician," even if his or her regular civilian job was leading a charity.

The report also includes quotes from "Capt. Margot McCrone," the theatre nurse. The focus with her is far more on personal experiences and feelings, as Bird discusses McCrone's concerns as well as those of her "friends and family" (because this is her first deployment? because she's female?). But the piece also notes that the new assignment is very different from McCrone's "full-time job as a team leader in orthopaedic surgery at the Golden Jubilee Hospital in Clydebank," a description that does underline her expertise and authority. And though McCrone is frank about her concerns, she also projects confidence in her skills and adaptability.

I'm apprehensive; it's not something I've done before. I'm out of my comfort zone but I think I'll very quickly settle into the routine. The experience will add vastly to my clinical skills and it'll enhance my ability to think fast and work with a small team. ... [My parents are] worried, but they don't have the Army experience. My mum wouldn't actually talk about it for a while but now she does. As parents do, they worry. I consider it a privilege that I'm going to be able to do my job for these guys. They're out on the front line.

Of the three medics who comment, the article gives by far the most space to Glasgow "consultant colorectal surgeon" Graham Sunderland (but of course, he is the only physician quoted). His "day job" is far removed from what he is heading for in the Afghan desert, but he is a "medical veteran of the second Iraq war." With Sunderland, Bird focuses on the "dichotomous" roles of the medics heading for Afghanistan, both in the sense that they seem to be both medics and soldiers (the unit's motto is "For Care and Duty"), and also in the sense that they will treat enemy combatants as well as allied soldiers. Sunderland assures Bird that he is a medic first, and that as a physician he has been "taught to treat people on medical priority, so that makes it much easier" to care for enemy combatants. Bird does seem to indulge in a bit of stereotyping when she notes that "even for a surgeon war brings its emotional challenges"--meaning surgeons are always tough and unflinching, unlike, say, those emotional nurses? But Sunderland admits that seeing badly wounded children is hard for him, noting that he's "not that comfortable with anyone dying, but for some reason it's much more so (emotional) if it's a child."

Medics in AfghanistanOn the whole, Bird's BBC report is valuable both for what it does, presenting nurses as important players in the advanced trauma care given in war zones who even play leadership roles, and also for what it resists doing, never suggesting that physicians are more important and the only real life-savers, or that the nurses are simply there to help them. Jackie Bird (right) and her colleagues seem to have shown up at the Army base pretty much without regressive assumptions about health care roles. Then they looked around, told us what they saw, and let the medics talk. The result is a good, if general, glimpse of the roles nurses can play in this important type of health care.

Click here to send a message of thanks to reporter Jackie Bird.

See the article "'For Care and Duty' - medics on the front line," by Jackie Bird, posted on the BBC website on January 31, 2010.