MASH unit learns you can perform surgery anywhere

Battling sand and dirt, staff focused on saving lives

Could you perform surgery if patients had their hands tied together and were being watched by armed soldiers? Can you imagine treating patients in rooms that are coated regularly with dirt and sand?

These were the experiences faced by members of a mobile army surgical hospital (MASH) unit in Iraq. The staff thought they would be performing surgery only on American soldiers, but they also performed procedures on Iraqi soldiers and Iraqi civilians: men, women, and children.

"Sometimes, the soldier was in one bed, and next to him was a POW Iraqi soldier — who knows, maybe the one who tried to kill him earlier," says Maj. Lillian Cardona, RN, head nurse of central material services (CMS) for the operating room in the Army’s 212th MASH from Miesau, Germany.

Maj. George P. Lawrence, BSN, head nurse of the operating room/CMS, says, "We treated them all, but it was difficult performing surgery on the Iraqis because they had to have an armed guard on them at all times and [the soldiers’] hands were tied together with zip ties."

Lawrence says he and his staff learned several lessons that can be benefit his civilian peers. For example, if you have to make do with what you have, you can perform surgery just about anywhere while attempting to maintain sterility as best you can, he says. His staff learned to conserve supplies. In fact, they wouldn’t use any supplies that weren’t absolutely necessary, Lawrence says.

"We never received any resupply, and we sometimes had to substitute similar items," he says. "For example, we ran out of bulb syringes and had to use catheter tip syringes. We ran out of disposable universal packs and started sterilizing linen drapes that we brought along."

Also, expect the unexpected, because you never know what can happen with even the smallest procedure, Lawrence says. "It may appear to be a simple procedure and turn into a nightmare because in Iraq, we were lucky to get any kind of history and no physical," he explains.

Also, there were no latex allergy precautions, because there wasn’t adequate time or supplies to address that concern, he says.

"Anything can go wrong, and you have to stay on your toes and be prepared and anticipate the possibilities," Lawrence stresses.

Capt. Gregory Hubbs, RN, BSN, CCRN, head nurse of intensive care unit (ICU) No. 2, agrees that flexibility is key, regardless of whether you’re performing surgery in the Iraqi desert or in a snug suburban surgery center.

"Always have contingency plans," he advises.

The unit crossed into Iraq on March 22 and stayed two months. "Because the main supply roads and towns were not secure, it took us about 78 hours to convoy the hospital 260 miles to outside of Baghdad," Lawrence says.

For the convoy, nurses and doctors were driving 5-ton trucks while maintaining a perimeter of security, because there was no support, Cardona explains. The MASH staff watched the sky become illuminated with rocket missiles and heard nearby bombs detonate, she says.

Cardona describes the experience as "nerve-wracking and exciting at the same time."

The 36-bed hospital was set up. Three expandable boxes created the OR with two tables, lab, and CMS with four sterilizers. The rest of the hospital was made of tents. There were 18 OR staff members, including technicians and anesthesia staff. The MASH also included X-ray, lab, emergency medical treatment (EMT) area, three ICUs, pharmacy, dining facility, shower and bath, power team (personnel who handled power cables, generator power, and air exchanges), medical maintenance, and a motor pool.

Once the hospital was set up, patients started coming. "Communication wasn’t the best in the world, and we received anywhere between four and 14 patients at a time," Lawrence adds.

Almost all of the patients required surgery, and the physicians had to triage them to see who went first, he says. "As they came into the EMT area, if they needed surgery immediately, they would go directly to surgery as soon as their airway was stabilized and they had an IV in place," he explains.

Patients who were stable but needed surgery were taken to the ICU until hose in critical condition were treated. The injuries and procedures included amputations; debridement of open wounds; high velocity wounds from gunshots; blast injuries from artillery, rockets, mortars, and mines; injuries from vehicle accidents; spine and crush injuries on downed helicopter crews; head wounds; torso wounds from shrapnel; feet that were partially dismembered; and burns. "You never what was coming in your door, and you had to pull the instruments and supplies when you found out what the injuries were," Lawrence adds.

The two operating tables were side by side with no divider. They often had patients on them at the same time. "The surgeries are different in the field because, although we do maintain a sterile environment, we are operating under harsh conditions in the mist of sand, dirt, and who knows what else," Cardona says. The space was tight, and sometimes sterility might "go out the window, but we are treating very dirty cases, so cleanliness is not what we concentrated on," she notes. "Our job was to save lives." The environment was fast-paced, but care and vigilance always were shown to the patients, Cardona says. The team members came together as one, she adds.

Hubbs also witnessed great unity. When a large number of patients arrived, "everyone stepped up and helped each other out," he says.

One cardiothoracic surgeon even mopped the OR floor between cases, Cardona says. The physicians acted differently in Iraq, she says. "All of the sudden, they really see what’s important. They don’t worry about the little things and learn that supplies are precious items and things are not opened, just because/maybe [we] will need it,’" Cardona adds.

Fatigue was an issue, Hubbs says. "We went seven days a week working 14- to 16-hour days, sometimes longer," he says. "We tried to take advantage of every opportunity we had to rest and relax." The staff also experienced some emotional exhaustion, Hubbs continues. "It was difficult at times seeing so many wounded soldiers," he says. "We cared for everything from minor lacerations to traumatic amputations. It was a very challenging experience."

In one three-week period, in addition to surgeries, the unit treated 700 minor injuries. If the patients could be cleaned and bandaged without going to the OR, they were treated in the EMT area and sent to the ICU to wait for evacuation. The MASH unit is not designed to hold any patient for more than 72 hours. After being treated, patients were evacuated to a combat-support hospital.

"Our job is to stabilize and evacuate out as soon as possible to make room for more incoming casualties," Lawrence says.

While several staff members previously had performed outpatient surgery in the United States as civilians, they faced many differences in how care was provided in Iraq. However, some areas, such as time between cases, were similar. "We had a very fast turnover evacuating patients to hospitals in Kuwait," Hubbs says.

And even near the battlefield in Iraq, you can’t escape paperwork, Cardona says. "We performed 101 [surgical] cases and kept accurate documentation on them," she says. 

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