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By Lieutenant Kathleen A. Brooks, Nurse Corps, U.S. Naval Reserve, and Lieutenant Nancy H. Fraser, Nurse Corps, U.S. Naval Reserve
As the last of our troops leave Saudi Arabia and Iraq, it’s time to look at the lessons of the Gulf War and incorporate them into our preparation and planning for future conflicts. Total-quality combat care implies continuous improvement of its processes, and, in that spirit, we must improve the selection of reserve nurses for mobilization, by identifying nurse specialties and making appropriate combat-related assignments based on those specialties.
We are two Naval Reserve nurses who were recalled to active duty in December 1990. By mid-January 1991, we were at Fort Dix, New Jersey, for a week of intensive training, meant to prepare us for our assignment.
We were assigned to Fleet Hospital Fifteen, near A1 Jubayl, Saudi Arabia, where we arrived the end of January. This 500-bed trauma hospital, comprised entirely of tents, was located 118 miles south of Kuwait. Our mission as a third-echelon hospital was to receive and sort casualties and provide temporary medical and surgical care; continue emergency resuscitation, including blood administration; conduct minor initial reparative surgical interventions requiring no more than 72 hours holding; treat minor illnesses; provide emergency dental care; render limited psychiatric treatment; and maintain and stabilize patients for transportation, including MedEvac to Europe and the United States.
Our fleet hospital received 78% of all U.S. Marine Corps casualties. In the three months the hospital was in operation, we saw 10,000 patients (including sick call and admissions). Our patients received excellent care, but we believe if casualties had reached the estimate of 70-80 per hour for the first 72 hours after the start of the ground campaign, we would have been overwhelmed.
One hundred and fifty-one nurses were assigned to Fleet Hospital Fifteen. During our Fort Dix training, we were requested to complete a questionnaire that included an inquiry about our nursing specialties. Of the 151 nurses assigned,
121 completed this part of the questionnaire. Only 54 listed their specialty areas as trauma/emergency, intensive care, cardiac care, orthopedics, anesthesia, postanesthesia care, burns, or psychiatry—the skills most needed in nurses assigned to fleet hospitals.
If, as our numbers show, only 45% of the nursing staff possessed appropriate specialties, what of the remaining 55%? These misassigned nurses’ specialties included maternity care, pediatrics, community health, education, research, and home health care.
We are taught very early in nursing education to become patient advocates. This entails doing what is best for the patient, no matter what. We are being patient advocates once again—this time for future military patients. If your son or daughter needed care at one of these fleet hospi- I tals, wouldn’t you want the best-qualified individual taking care of them? Would you take a traffic accident victim to a maternity ward for emergency care?
We were two of the misassigned nurses. One of us has spent the last five years working in pediatric nursing—the other, 12 years in maternal' newborn nursing. We went to Saudi Arabia with positive attitudes and provided quality nursing care, but we felt the most we could contribute, because of our specialties, was basic nursing, individual energy, and sound judgment. Along with more than half of the nursing staff, we definitely were not the best-qualified nurses fof a combat-zone trauma hospital.
As reserve nurses, we have always been told we would backfill for active-duty nurses. We would be assigned to stateside Navy hospitals> while active-duty nurses with the nee- essary trauma skills would be assigned to forward-deployed units- We lacked fleet-hospital training* combat-casualty-care training, and most importantly, recent intensive' care/cardiac-care or emergency-roofl1 experience. Individuals in our oWi1 hospital-based reserve unit, trained
t
and prepared to go to a fleet hospital, were not mobilized.
To correct this situation for future mobilizations, one more category should be added to the existing reserve nurses’ data base, which presently includes name, rank, social security number, and reserve-center assignment. Nursing specialty codes, which are in place for active- duty nurses, need to be made available to the reserve community as well. With the use of asterisks and superscripted numbers, the detailer would also know whether the individual has fleet-hospital training, has attended the combat-casualty-care course, or has fleet hospital experience. With fewer than 2,800 Naval Reserve nurses on the rolls, this additional data could be compiled and entered by one or two individuals on annual training duty.
If reserve nurse roles continue to include forward deployment, we also would recommend more focused training in combat-casualty care and fleet-hospital operations for all nursing specialties.
Lieutenant Brooks is a registered nurse specialist, managing and coordinating nursing/medical care for pediatric clients for the Department of Health and Rehabilitative Services for the State of Florida. Lieutenant Fraser is director of maternal/newborn nursing at Sacred Heart Hospital in Pensacola, Florida. Both Lieutenants Brooks and Fraser joined their present reserve unit, Naval Hospital 410 Pensacola, in 1989.
Total-Quality: A Postscript
By Rear Admiral Maryanne T. Ibach, Nurse Corps, U.S. Naval Reserve
It is a pleasure to share some thoughts on total-quality combat care, from the perspective of another war more than 25 years ago— as tempered by changes in medicine during the intervening years.
The significant differences between Vietnam and the recent war in the Gulf should be obvious. What may not be apparent are the remarkable changes that have taken place in the interim. For example, nursing was not the highly specialized profession it is today. When the USS Repose (AH-16) was pulled out of mothballs and •irst staffed for Vietnam, 17 of the 29 nurses initially assigned were Pediatric nurses. It was felt they had a multisystem orientation that enhanced their ability to anticipate and monitor changes in critically 'njured patients. There were no critical care or trauma nurse specialists then.
Another difference was that the reserves were never mobilized for Vietnam; there was no system to 'dentify quickly Navy medical reserves available for mobilization, hi 1978, only 187 Naval Reserve Nurse Corps officers were in a drilling status. By 1990, the expansion of the Naval Reserve Nledical Department was almost complete, with the number of reserve nurses approaching 2,750.
Most of these officers have impressive credentials, skills, and motivation. Without exception, those mobilized for Desert Shield and Desert Storm possessed basic nursing skills, individual energy, and sound nursing judgment.
What more could we ask as a starting point?
The fact that nearly 1,400 reserve nurses reported for duty during the buildup and conflict in the Gulf, with hundreds more on standby—ready to go—shows how dramatically the program has grown during the last few years. The number of reserve nurses recalled was twice the number of any other medical department officers and six times any other non-medical officer community.
A fleet hospital requires multiple specialties within its organizational structure. In reality, it functions more like a community hospital, with the capability to handle large numbers of trauma casualties. It would not function well if staffed only with trauma specialists—assuming the military could recruit, train, and retain what has become a highly specialized group of medical professionals. Even our inner-city hospitals, which routinely handle large numbers of emergency trauma cases, are staffed with a broad cross section of nursing specialties.
The experience of our fleet hospitals during Desert Shield and Desert Storm substantiates the desirability of the nursing mix, although that point may not have been well articulated to those called upon to serve. Ambulatory care, patient and staff education, community health, and mental health are some of the services nurses provide in addition to medical, surgical, and trauma nursing. Realistically, any field hospital, even if staffed completely by trauma specialists, would be overwhelmed by 70-80 casualties per hour, sustained over a period of time.
Building on the lessons learned in the Gulf, Navy medicine is implementing a variety of programs to address most of the classification and assignment issues. Adding to the personnel management challenge is the uncertainty of the future as the Navy and other DoD components downsize. During the 1980s, reserve medical programs were upgraded and expanded,acknowledging the critical military role of adequate medical-treatment resources. The war in the Gulf could not have been executed without the mobilization of the reserve medical resources. What the future reserve versus regular medical mix will be is now being debated. The outcome
of those discussions will shape the Naval Reserve’s health-care capabilities into the next century.
In the meantime, we are pressing ahead with major efforts to improve the billet/body mix, moving toward management by subspecialty code. One of the constraints on our ability to manage reserve nursing assets has been a lack of computer capacity and programs to track the required information. That shortfall is being corrected. Some of the current initiatives include:
► Reserve billet descriptions, modified to include subspecialty codes (SSCs). This change will require reservists to obtain the codes associated with their Naval Officer Billet Classification (NOBC).
>■ A Bureau of Medicine & Surgery instruction on NOBCs/SSCs is being drafted by MED-07. It will provide general guidelines for medical department reserve officers on acquiring and updating their billet classifications and necessary subspecialty codes.
► The proposed instruction will include a requirement to review periodically all medical department reserve NOBCs and SSCs to ensure that they accurately reflect the current clinical ability of each officer. There will have to be a reasonable assurance of current competence to ensure that a reservist recalled to active duty can perform fully the duties of the billet.
Emphasis will continue to be placed on training, with a goal of basic combat-casualty-care exposure for all nurses assigned to fleet hospitals and units assigned with the Marines. Training courses are attended by regular as well as reserve officers. Some of the courses available include Combat Casualty Care, Combat Casualty Care Management, and Strategic Medical Readiness Contingency. Every effort is being made to tap the creativity and resourcefulness of the medical community for innovative ways to provide realistic, operationally oriented training for
reserve medical personnel.
As I visit the medical training conferences sponsored by the Reserve Readiness Command Regions, I am impressed by the clinical and academic credentials of Reserve Nurse Corps officers. As a community, the Nurse Corps exhibits a refreshing energy level and dedication to the Navy. Naval leadership must accept the challenge of training, motivating, and retaining these professionals in an uncertain environment. With their help, input, and support, we will build on the lessons of the Gulf War as we move the Naval Reserve medical community to greater levels of readiness, while supporting the naval medical mission worldwide.
A Special Edition of Naval History Magazine
When the Bombs Fell on Us
Pearl Harbor, Hawaii: 7 December 1941— Never since the war of 1812 had Americans felt the horrors of a foreign attack on their own soil. In a mere few hours that Sunday morning Japanese carrier-based fighters, bombers, and torpedo planes had executed the boldest provocation for war in the Pacific.
To commemorate the 50th Anniversary of that unforgettable day, the editors of Naval History magazine have woven together 96 pages of on-the-scene photography, original color paintings, and first-hand accounts—a trademark of U.S. Naval Institute publications—of what fighting for your life was like on Battleship Row; how the Japanese felt
issue of Naval History. Go back with us 50 years, and experience the shock, the heroics, and the outrage that would inspire the American people never to let this happen again.
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