- Email: [email protected]
peace keeping missions
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Peace making/peace keeping missions Role of the U.S. Army nurse Linda H. Yoder, PhD, MBA, RN a,*, Sandra L. Brunken, MSN, RN b a
Walter Reed Nursing Research Service, Walter Reed Army Medical Center, 6900 Georgia Avenue N.W., Washington, DC 20307, USA b United States Army Forces Command (FORSCOM), 1777 Hardee Avenue S.W., Fort McPherson, GA 30330-1062, USA Since 1993, I longed to speak to the families of the soldiers who died in Mogadishu. I wanted them to know how hard we tried to save their lives, and how we wish we could change the past. In retrospect, I realize that my assignment while serving with the 46th Combat Support Hospital in Somalia has helped me understand what an Army Nurse Corps officer should be: one that should be prepared for duty, selfsacrifice, and selfless service [1].
Military nurses clearly face extreme challenges when serving in a peace making (PM) or peace keeping (PK) mission, especially when events do not take place as planned. With an ever-increasing number of military operations in support of peace initiatives worldwide, military personnel can become involved with peace operations at a moments notice [2]. PM and PK missions are components of military operations other than war (MOOTW). MOOTW focus on promoting peace, deterring war, resolving conflict, and supporting civil authorities in response to domestic crises. PK and PM missions provide an opportunity for military healthcare teams to provide expert care in unique settings [3]; however, MOOTW overlap the combat and noncombat spectrum of activities because of often volatile, uncertain, complex, and ambiguous environments. During Operation Restore Hope in Somalia, when two nonmilitary
The views expressed herein are solely those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the U.S. Government. * Corresponding author. 15136 Deer Valley Terrace, Silver Spring, MD, 20906. E-mail address: [email protected] (L.H. Yoder). 0899-5885/03/$ – see front matter, Published by Elsevier Inc. PII: S 0 8 9 9 - 5 8 8 5 ( 0 2 ) 0 0 0 5 5 - 2
patients died on the operating table from gunshot wounds, a nurse remarked, ‘‘ I think it was that day that it really sunk into everyone’s mind that we were in a very unsafe environment. It opened a lot of eyes.’’ [4]
Deployed nurses must understand military doctrine The goals of MOOTW are to prevent, preempt, or limit potential hostilities and to achieve national objectives as quickly as possible in order to conclude military operations in a manner that is favorable to the United States (U.S.) and its allies [5]. MOOTW operations that use military forces to continue to promote peace and alleviate human suffering include, but are not limited to, disaster relief, nation assistance, foreign humanitarian assistance, support to counterdrug activities, assistance to civil authorities, and support to diplomatic peace activities [6]. PK operations are ostensibly neutral and undertaken with the consent of the disputing parties. They are designed to monitor and facilitate implementation of an agreement (eg, truce) and support long-term diplomatic efforts to reach a political settlement. PM is a process of diplomacy, mediation, negotiation, or other forms of peaceful settlement that end disputes and resolve the issues that led to the conflict. PM activities include military to military programs as well as various components of military expertise [6 – 8]. Medical operations support MOOTW to protect U.S. and Allied personnel and enhance our ability to perform the mission. PK and PM operations have become more complex because the U.S. works
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in collaboration with the United Nations (UN), allied forces in the host nation, and coalition partners. Increasingly, nongovernmental (NGOs), private voluntary (PVOs), and international organizations (IOs) also must be considered. These organizations typically already work within the region and can assist in successfully accomplishing the mission. For example, Operation Restore Hope in Somalia was one of the most diverse PK operations undertaken by U.S. military forces. This operation served as an example of interagency cooperation because the military coordinated the activities of 49 different UN and humanitarian relief agencies, none of who were obligated to follow military directives [9,10].
Considerations for medical planning When entering a PK/PM environment, military nursing personnel cannot merely focus on the provision of care, they also must be keenly aware of the political and cultural influences of the region and the perception of the U.S. military role. Nurses involved in planning care for multinational peace operations must consider the location and organization of host nation medical facilities. Key considerations in medical support planning are presented in Table 1 [11] Additionally, the following factors must be evaluated: political climate, language barriers, cultural backgrounds, military capabilities and training, equipment interoperability, and supply/logistic support systems of the host nation and all coalition partners. [9,12].
Levels of medical support The UN and the North Atlantic Treaty Organization (NATO) have adopted a multilevel concept of medical support, ranging from first aid to definitive, tertiary level medical care. There are five successive levels of structured medical support in the UN multiechelon concept (basic plus levels 1 – 4) (Table 2) [11]. An example of a level 2 unit is the 240th Forward Support Team (FST) at Camp Able Sentry in Macedonia, which is staffed with 25 personnel and augmented with medics and nurses from other units. The winter in Macedonia can be harsh and often impedes all modes of transportation. Prior to the deployment of the 240th FST, all trauma surgeries were air-evacuated to Camp Bondsteel, Kosovo. The 240th is now able to surgically stabilize and monitor critical care patients until evacuation is possible [13]. Examples of level 3 facilities include the UN Protection Force in the former Yugoslavia (UNPROFOR), the UN Assistance Mission in Rwanda (UNAMIR) [11], and more recently, Task Force MED FALCON V at Camp Bondsteel, Kosovo. Life at Camp Bondsteel, a level 3 medical unit, was summarized by an Army Nurse: Our experience has been both varied and exciting at times. We are serving soldiers from the U.S., the U.K., Norway, Sweden, Finland, Spain, Italy, Russia, and Poland. We also provide care to local contractors, DOD [Department of Defense] employees and local civilians on an emergency basis. The ages and backgrounds of our patients range from pediatrics to
Table 1 UN considerations for medical support planning UN peacekeeping mandate
Type and size of peacekeeping operation
Existing medical and civil infrastructures
Geographic factors
Assessed medical threats
There is no obligation to provide medical services to the local population, although such care is sometimes rendered based on the dictates of international humanitarian law and the ethical code of the medical profession. Occasionally, the mandate for a mission may extend to include humanitarian assistance to the local population, as in the case of the UN interim force in Lebanon. The level of care and the number of medical units vary, based on the overall troop strength and the type of peacekeeping activity; high-risk operations place greater demands on the medical system. In many countries where PK missions take place, the civilian medical infrastructure has deteriorated due to lack of funding or destruction in war. An important concern is the accessibility of medical care to the intended patients; therefore, climate, terrain, and road conditions are of primary concern. Accidents are the major cause of fatalities and serious injuries in most PK missions; medical units must be able to manage severe trauma and mass casualty situations as well as minor ailments and endemic infectious diseases.
Table 2 UN levels of medical support Type of care
Facility
Personnel
Population supported
Basic Level
Immediate first aid by buddy or trained medic
In the field/initial injury location
Immediate military unit
Level 1
Primary health care and emergency treatment — Battalion Aid Station
Tents/existing facilities/ field ambulance
All UN peacekeepers are expected to have basic knowledge of common first aid skills such as control of bleeding, wound dressing, immobilization of fractures, and CPR Medical team consisting of 8 to 12 medical personnel, including at least 2 physicians
Level 2
Primary care, advanced life support, basic surgery, intensive care, and limited patient holding capacity. Deployed only when medical infrastructure is poor and there is high risk of injury or illness among peacekeepers. Needed when there is no immediate access to hospitals meeting UN standards of care. Emergency and definitive medical-surgical treatment, intensive care, specialist medical and dental services, inpatient ward facilities. Radiological, laboratory, and pharmacy services that provide standard of care Same as above
Tents or temporary facilities; ancillary laboratory and radiology areas, a dental unit, and hospital support elements.
35 medical and support staff
Multidisciplinary general hospital
Contracted civilian/military hospitals in the country or neighboring countries.
5000 + personnel
80 to 100 medical and support staff
Tents or deployable medical systems (DEPMEDS)
Up to 5000 personnel; provide approximately 60 outpatient visits per day; perform 10 general surgery and orthopedic procedures; 10 dental procedures per day and inpatient ward facilities for up to 50 patients for 30 days. Secondary elective surgical procedures, reconstruction, rehabilitation, and convalescence for conditions that become chronic.
Level 3 (contracted care)
Level 3 (field hospital)
Level 4
Definitive medical care and specialized treatment unavailable or impractical within the mission area.
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Military medical center in services members home country. May use neighboring country medical centers if U.S. standards of care are met.
500 – 600 people capacity to treat at least 20 ambulatory patients per day and have short-term ward facilities for approximately 5 patients 1000 personnel or more and should have the capacity to perform at least 4 surgeries, 5 to 10 dental procedures, and 40 outpatient visits per day, with inpatient beds for up to 20 patients.
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Level
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L.H. Yoder, S.L. Brunken / Crit Care Nurs Clin N Am 15 (2003) 265–273 the older adult. We have helped to care for patients with a wide range of illnesses and injuries ranging from appendectomies to rule out MIs [myocardial infarctions] and acute trauma. Although language barriers exist in many cases, the U.S./U.K. nursing care we provide is second to none [14].
It is important to note that the mission dictates the unit requirements. The changing needs of the population served require ongoing reassessment of the scope of practice available as the resources in the region change based on the evolution or resolution of the situation [3]. The U.S. military generally provides a more robust medical force than other nations, so the usual course of events leads to the U.S. being the lead agent or the overall authority responsible for medical support and standard of care to the theater of operations (the geographic area where the military is carrying out it’s work). This does not mean the other nations do not support their area of the theater or their own personnel and provide the same standard of care; however, having a lead agent keeps the theater from being overwhelmed with unplanned medical personnel and allows for standardized patient reporting, treating, epidemiologic tracking, and evacuation policies. Nursing roles Army Nurse Corps officers typically serve in the same types of positions as civilian nurses when they are in traditional hospitals; however, Army nurses must always be prepared to serve in the nontraditional field environment. Although, the focus in this article is primarily on the Army, all U.S. military services have in-hospital and field (deployed) nursing roles. When nursing personnel are deployed, they must use skills not ordinarily used in a U.S. hospital, often moving between specialized versus generalist roles, high to low technology, and automated to manual equipment, and they must practice across a diverse range of clinical scenarios [15]. Deployment nursing requires alterations in one’s skill set, adaptation to an austere environment, the need for flexibility, and proficiency with unfamiliar communication systems [16]. Additionally, nurses who deploy must master basic soldiering skills such as the use of weapons, personal defense, and field skills related to living in an austere environment, and provide nursing care to people of a different culture with different values. A nurse in Operation Restore Hope remarked that the austere environment in Somalia made everything ten times more difficult than her previous experience in Operation Desert
Storm [4]. Likewise, the nurses in Operation Joint Endeavor arrived in Bosnia and Hungary during the worst winter in 32 years. Water problems made the availability of running water sporadic and prevented them from having showers for 54 days! Because there were no toilet facilities in the field hospital, patients, including postoperative patients, had to use the portable toilets outside the hospital. The staff and patients were required to wear their helmets and flak vests when leaving the hospital tents [17]. In the past, there was little preparation available for nurses deploying to a multinational PM/PK role. Multiple ‘‘lessons learned’’ files are now available, including manuals about individual service roles and Joint Medical Planning and Operations, Title X (Health Affairs guidelines), Standard NATO Agreements (STANAGS), and journal articles [3,4,10,11,18 – 21]. The involvement of military nurses staffing and managing the nursing care in the medical units within PK/PM operations begins before ever leaving the U.S. Nurses should be involved intimately with planning medical assets, understanding the capabilities of medical units assigned and their placement within the theater, the timelines of medical unit movements, and the date of entrance into the region. The senior nurse provides clinical oversight and keeps the Command informed of clinical issues within the area supported by the unit. Nurses within assigned field units perform many of the tasks listed in the box in addition to their clinical functions. Preplanning, education, awareness, and coordination are absolutely essential to arriving in the theater and beginning the mission of medical support to the soldier [20].
Nursing tasks related to medical planning Analyzing the mission for the coordination of appropriate unit and individual soldier selection. Coordinating logistical requirements to review availability, modernization, and supportability of medical equipment and supplies to meet the mission intent. Interpreting and providing feedback about rules that will define the medical role of each U.S. military service and the various nations involved. This also involves estab-
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lishing contacts and liaisons with the joint services and other nations’ medical staffs to allay conflict and clarify role definition. Coordinating with Civil Affairs to attain an overview of the area of operations, the country, the current medical structure, the culture and religious influences, government overview, current available and operational host nation medical facilities, translation capability, and available NGOs, PVOs, and IOs within the area. Coordinating with legal advisors for law and doctrine supporting the mission, rules of engagement, Geneva Convention, Command policies, and any international aspect that could affect the medical mission. Ensuring staff members understand the mission, role, and method of supporting the medical structure within the deployed area. Gaining knowledge about the medical intelligence of the theater; the environment, diseases, health condition of the populace, and the medical and combat threat to military personnel going to the theater. Obtaining NATO and UN disease and injury predictions based on location, time of year, type of overall mission, and number of personnel deployed to the area. Credential verification of licensed providers — not only the active component, but also any reservist being activated. Clinical training for all levels of providers to ensure their ability to provide healthcare using field medical equipment versus equipment used on a daily basis at ‘‘home’’ medical facilities.
Who gets care? The primary medical mission within the theater is the support of any military personnel, government contractors, and government paid ancillary staff. The only host nation or civilian population support
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authorized is for life saving emergencies or injuries caused by the action of soldiers (eg, a civilian hit by a military vehicle). Medical supplies are programmed in amounts sufficient to only support those authorized for care [10,22,23]. Every theater has a cap on the total number of military personnel allowed. This enables the sustainment of military personnel in the best manner and prevents an overloading of nonessential personnel. Because of this cap, each healthcare position is selected according to the individual’s skill set and rank, authorizing only those people required to perform the mission. Therefore, the staffing is based solely on the mission intent and the number of personnel that may receive care. At times, nurses must be creative with staffing challenges. For example, in mass casualty situations it is not uncommon for staff to work 30 hours straight, or more [4]. At other times nursing personnel must fill their time with useful activities such as training soldiers in nearby units about buddy aid and basic resuscitation measures. The value of this training cannot be underestimated, as displayed by this letter from a soldier to a nurse who had provided buddy aid training. I’m not sure if you remember me. I took the combat lifesaver course with your unit prior to our deployment to Kosovo. I wrote down your address because you were interested to hear if we used any of our lifesaving skills. Well I am proud to say that I successfully gave an I.V. to a TMK soldier that we were working with. The TMK are the unofficial Albanian army or formerly known as the NLA. As you might know at anytime the temp is 100 degrees while we work and the TMK are far from used to that. The day was 98 degrees on its own and the TMK drink sodas so they don’t drink a lot of water. Anyhow it was bound to happen, the soldier took on almost all the symptoms of heat stroke, so I took the proper steps and treated him, and evaluated him the rest of the day. Later that day the interpreter reported the soldier was feeling much better and was grateful. Thank you LT and your team for taking the time to teach us in depth, how to perform the right way, buddy aid tasks. Keep up the good work [24].
Once the services and participating nations are established, coordination of care takes place. The U.S. government has well-developed criteria and standards of care that must be met to ensure the quality of care to be delivered to U.S. military personnel. Therefore, each nation’s facilities must be evaluated to ascertain their standard of care/quality and what procedures, if any, will be authorized for U.S. military personnel. Each nation provides a list-
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ing of services they can support. An overview of the entire theater medical structure is developed to demonstrate locations, types, and levels of medical support available on any given day. By doing this, delays of care and multiple movements of patients can be avoided or decreased by transporting the patient to the correctly resourced facility. For example, if the U.S. facility is short of orthopedic surgeons and the Norwegian facility has orthopedic surgeons, a patient with severe orthopedic injuries, no matter what nationality, might be directed to the Norwegian facility immediately. The number, type, staffed, and operational beds in the theater, as well as the number and type of ground and air evacuations within and outside the theater must be carefully tracked. Nurses from the various U.S. services and coalition nations may be required to accompany patients during evacuation, based on the extent of the patients’ injuries and the level of care needed. It may be difficult to discern the patient’s needs based on the request from an operations center because the request may have been conveyed through several languages and it may have undergone several translations that may or may not have changed the clinical picture of the patient. Therefore, a nurse is usually sent to evaluate the extent of the patient’s injuries. Knowing the evacuation equipment being used in the region is helpful. A nurse from Task Force Eagle remarked, Within our first month of operation, we have experienced training with several mass casualty incidents, some with only a few patients and some with as many as 20. We have also participated in training with some of our NATO allies, utilizing a Danish armored ambulance, a British CH-47 Chinook helicopter, and patients from Turkey, Russia, and Canada [25].
Another area of significant importance is standardization of care, reporting, and patient care material among the participating nations. Standardization of care needs to be assessed quickly upon establishment of the theater and may continue to evolve over time. Standardization of medical material is aimed at products used for patient care and therefore is of particular interest to nursing. For example, standardization will create a system where all intravenous (IV) catheter hubs and endotracheal tube connectors have a standardized size to allow any IV tubing or ambu bag to be attached without restarting an IV or reintubating a patient. Lack of standardization has been a problem in PK operations in which multiple nations provide medical care and transport patients between facilities.
Accurate reporting is of utmost necessity. The British have established an excellent international reporting system. An analysis of the complete data set of hospitalizations of British troops in Bosnia during 1996 revealed that (1) hospital data from current missions should be more complete and include all hospitalizations, not just those lasting 24 hours or more; (2) paper-based morbidity surveillance during military missions should be replaced by electronic clinical information systems, ensuring the capture of all clinically important data; and (3) all surgical procedures should be coded and entered into an electronic patient record locally. The software files created from this analysis were adopted as the NATO standard for use during all military missions [19]. Training, training, and more training As the PK theater matures and becomes well established, ongoing medical training comes to the forefront. Certifications begin to expire, skill sets deteriorate if medical activity is slow, and personnel become bored. Critical skills must be reinforced. For example, burn care was performed in nearly all surgical hospitals that deployed from 1995 to 1999 in support of the PK mission in Bosnia [3]. Clearly, nurses on surgical teams and in ICUs should always be prepared to care for burn victims. The nurses also must track ongoing theater medical training at each subordinate unit. Some training requires intense resources, such as Advanced Trauma Life Support (ATLS), Advanced Cardiac Life Support (ACLS), and seminars spanning 1 or more days. Therefore, these events may need to be planned with the involvement of higher headquarters in the theater and offered across the theater to qualified personnel, both American and multinational [25]. For example, the emergency section nurses assigned to Joint Task Force-Bravo in Honduras hosted a comprehensive nursing seminar for 38 Honduran nurses from six different hospitals. The classes addressed topics ranging from basic nursing care to ACLS; the American nurses planned each presentation, coordinated classroom space and necessary equipment, and provided visitors with lunch in the dining facility. These simple arrangements can become complicated in an austere environment in which resources are limited. Additionally, on the spot revisions to course content may be necessary. For example, when a nutrition presentation was being given to the Honduran nurses they commented that they do not teach their patients the four food groups we use in the U.S. because many Hondurans do not have access to meat, poultry, eggs, or dairy products. Rather, they teach
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their patients the best ways to use what they have available [26]. Training by multinational forces to host nation hospitals also may be needed. For example, in Bosnia many of the experienced local providers were killed and the remaining staff were experienced only in performing amputations, but not reconstructive care. A training program was established to provide experienced multinational staff for the education and guidance of local providers concerning reconstructive surgery and care. During the host nation medical facility assessment, nurses often work with NGOs to exchange information about the findings [27]. The NGOs are well prepared to step in and assist where needed. The intent is not for military personnel to do the work for or replace the host nation system, but to reestablish it to a functional entity. Host nations should not be left with a system they cannot support after the departure of NGOs or occupying force(s) [21]. Some services may need to be completely reestablished. Nursing personnel providing care in PK environments continue to be concerned about quality of care issues. The nurses also attempt to anticipate ethical issues. One ethical case occurred when all available ventilators in the ICU were being used for Somali patients, the nurses questioned what would happen if the next patient needing a ventilator happened to be a U.S. soldier. Fortunately, this situation never presented itself, but it made the staff question how they might handle such a situation in the future [4]. Nurses also conducted chart reviews and critiqued their care (yes—they even have performance improvement initiatives in the field!); they conducted preoperative and postoperative interviews; and they developed competency-based orientations for their replacements [22]. Nurses deployed in PM/PK operations supported by numerous countries have remarked that finding translators who could communicate medical terminology often proved to be challenging. Often translators did their best to convey the diagnosis or steps of a medical procedure to the patients from different countries, and it was not uncommon for nurses to resort to drawing pictures or demonstrating the use of medical equipment. Fortunately, surgical consent for life-saving emergencies is not required in a field environment and this allowed the operating room staff to give prompt care even in situations with language barriers [22]. Nurses working in PK environments also constantly find ways to improve the experience and care. For example, nurses at Eagle Base, Bosnia-Herzegovina, created their own web site and served as web-
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masters, keeping their colleagues informed about the events at the facility. Several of these nurses also served as the Task Force Public Affairs Officer and developed monthly newsletters that were attached to the web page. The web page also helped to keep deployed staff members’ families aware of activities at the unit. Host nation support was provided by some of the nurses when they were asked to administer flu shots to local school children as well as when members of the U.S. healthcare team took part in a 30-km road march sponsored by the Danish Army [28]. Serving as a nurse during a PK/PM mission is challenging and diversified, but most nurses who have had these experiences agree that the assignments are extremely rewarding [21,22]. Nurses who were deployed to recent PM/PK operations stated that all nurses in the unit must be prepared to learn skills in other areas. For example, the nurse anesthetists helped ICU and medical-surgical nurses learn optimal ways to recover patients because no nurses with post anesthesia care unit (PACU) experience were part of the team. The nurses in these deployments reported being highly trained concerning Automatic External Defibrillators and using the LIFEPAK 12 as a monitoring and pacing device because other equipment was too outdated. At the same time, the nurses learned to use older equipment and sharpen their nursing assessment and critical thinking skills because they could not rely on technology in the same manner they would in a hospital ICU or emergency department. When touring facilities of other countries, however, Army nurses in Bosnia realized how fortunate they were, The Russian hospital was small, converted from what had been a fire department. It consisted of an exam room, one functional operating room with a one bed ICU next to it, a desk, a pharmacy, dental chair, and a ward for about 8 patients. The ward was poorly lit, space between the beds was limited and the equipment was very outdated. This facility sharply contrasted to our hospital, making us all realize just how fortunate we were. . .[29].
Nurses in deployed units often were encouraged to come into the operating room and learn more about how various field surgical procedures are performed so they could better understand the postoperative needs of their patients. Depending on the size of the unit, providing care to patients requiring ventilator support could be challenging when the nurses were accustomed to using high technology ventilators at home and the unit ventilator was of the ‘‘babybird’’ variety, requiring much more extensive nursing
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assessment of the patient, as settings were changed based on the patient’s condition. Several critical care nurses commented about their surprise at the number of U.S. and Allied force psychiatric cases requiring hospitalization or evacuation. These nurses quickly learned to contact stress management team members, and they added to their own knowledge regarding the care of these patients. The exposure to healthcare teams with varying skill levels, the sharing of new knowledge, and the broadening of nursing skills often require tremendous creativity and provide additional experiences and knowledge that cannot be fully quantified. Working in a multinational and joint service environment is extremely enriching and provides practice challenges. Military nurses must be open minded, assertive, forward thinking, flexible, and change agents in order to be successful and enjoy the experience [22]. Nurses in deployed PM/PK environments must possess communication skills that allow them to traverse across cultural and language barriers, and they must coordinate the care of patients across countries and, at times, continents. They must learn to assess pain and evaluate attitudes toward illness among service members from diverse areas of the world. Of equal importance is the ability of a highly technically skilled nurse to convey a sense of expertise, calm, caring, and compassion in an environment that can rapidly change from boring to frenetic. ‘‘As a deployed soldier, the first lesson I learned is that we must all be extremely adaptable. Orders may change, deployment dates modified, supplies may not arrive on time. Thinking out of the box in a potentially hostile environment may save your life and those around you. The second lesson learned is the importance of teamwork. You are only somebody because of the person next to you. Remember to have faith in those around you! A chain is only as strong as its weakest link. The final lesson is the importance of believing in your soldiers. Most of all, never take for granted those who are precious to you. Live each day to it’s fullest [1].’’
Acknowledgements The authors wish to extend a special thanks to the Army nurses serving throughout the world, supporting the healthcare needs of military personnel in challenging environments. A special thanks to those who shared their experiences with me: COL Nancy Hodge, AN; LTC Kathleen O’Leary, AN; MAJ Ed Yackel, AN; and CPT Paul Crum, AN.
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[26] Wassum E. Honduran Nursing Seminar, JTF-Bravo, Honduras. Army Nurse Corps Newsletter 2001; 2(3):12. [27] Samuels GL. Army community health nurses’ role in humanitarian relief effort, Operation Sea Signal, Guantanamo Bay, Cuba. Mil Med 1997;162:190 – 3. [28] Lindner CG. Task Force MED EAGLE, Eagle Base, Bosnia-Herzegovina. Army Nurse Corps Newsletter 2002;2(5):12. [29] Pattison C, Barlow R, Mack T. Update from the Army Nurses of Task Force MED EAGLE. Army Nurse Corps Newsletter 2000;99(3):8 – 9.
Peace making/peace keeping missions Role of the U.S. Army nurse Linda H. Yoder, PhD, MBA, RN a,*, Sandra L. Brunken, MSN, RN b a
Walter Reed Nursing Research Service, Walter Reed Army Medical Center, 6900 Georgia Avenue N.W., Washington, DC 20307, USA b United States Army Forces Command (FORSCOM), 1777 Hardee Avenue S.W., Fort McPherson, GA 30330-1062, USA Since 1993, I longed to speak to the families of the soldiers who died in Mogadishu. I wanted them to know how hard we tried to save their lives, and how we wish we could change the past. In retrospect, I realize that my assignment while serving with the 46th Combat Support Hospital in Somalia has helped me understand what an Army Nurse Corps officer should be: one that should be prepared for duty, selfsacrifice, and selfless service [1].
Military nurses clearly face extreme challenges when serving in a peace making (PM) or peace keeping (PK) mission, especially when events do not take place as planned. With an ever-increasing number of military operations in support of peace initiatives worldwide, military personnel can become involved with peace operations at a moments notice [2]. PM and PK missions are components of military operations other than war (MOOTW). MOOTW focus on promoting peace, deterring war, resolving conflict, and supporting civil authorities in response to domestic crises. PK and PM missions provide an opportunity for military healthcare teams to provide expert care in unique settings [3]; however, MOOTW overlap the combat and noncombat spectrum of activities because of often volatile, uncertain, complex, and ambiguous environments. During Operation Restore Hope in Somalia, when two nonmilitary
The views expressed herein are solely those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the U.S. Government. * Corresponding author. 15136 Deer Valley Terrace, Silver Spring, MD, 20906. E-mail address: [email protected] (L.H. Yoder). 0899-5885/03/$ – see front matter, Published by Elsevier Inc. PII: S 0 8 9 9 - 5 8 8 5 ( 0 2 ) 0 0 0 5 5 - 2
patients died on the operating table from gunshot wounds, a nurse remarked, ‘‘ I think it was that day that it really sunk into everyone’s mind that we were in a very unsafe environment. It opened a lot of eyes.’’ [4]
Deployed nurses must understand military doctrine The goals of MOOTW are to prevent, preempt, or limit potential hostilities and to achieve national objectives as quickly as possible in order to conclude military operations in a manner that is favorable to the United States (U.S.) and its allies [5]. MOOTW operations that use military forces to continue to promote peace and alleviate human suffering include, but are not limited to, disaster relief, nation assistance, foreign humanitarian assistance, support to counterdrug activities, assistance to civil authorities, and support to diplomatic peace activities [6]. PK operations are ostensibly neutral and undertaken with the consent of the disputing parties. They are designed to monitor and facilitate implementation of an agreement (eg, truce) and support long-term diplomatic efforts to reach a political settlement. PM is a process of diplomacy, mediation, negotiation, or other forms of peaceful settlement that end disputes and resolve the issues that led to the conflict. PM activities include military to military programs as well as various components of military expertise [6 – 8]. Medical operations support MOOTW to protect U.S. and Allied personnel and enhance our ability to perform the mission. PK and PM operations have become more complex because the U.S. works
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in collaboration with the United Nations (UN), allied forces in the host nation, and coalition partners. Increasingly, nongovernmental (NGOs), private voluntary (PVOs), and international organizations (IOs) also must be considered. These organizations typically already work within the region and can assist in successfully accomplishing the mission. For example, Operation Restore Hope in Somalia was one of the most diverse PK operations undertaken by U.S. military forces. This operation served as an example of interagency cooperation because the military coordinated the activities of 49 different UN and humanitarian relief agencies, none of who were obligated to follow military directives [9,10].
Considerations for medical planning When entering a PK/PM environment, military nursing personnel cannot merely focus on the provision of care, they also must be keenly aware of the political and cultural influences of the region and the perception of the U.S. military role. Nurses involved in planning care for multinational peace operations must consider the location and organization of host nation medical facilities. Key considerations in medical support planning are presented in Table 1 [11] Additionally, the following factors must be evaluated: political climate, language barriers, cultural backgrounds, military capabilities and training, equipment interoperability, and supply/logistic support systems of the host nation and all coalition partners. [9,12].
Levels of medical support The UN and the North Atlantic Treaty Organization (NATO) have adopted a multilevel concept of medical support, ranging from first aid to definitive, tertiary level medical care. There are five successive levels of structured medical support in the UN multiechelon concept (basic plus levels 1 – 4) (Table 2) [11]. An example of a level 2 unit is the 240th Forward Support Team (FST) at Camp Able Sentry in Macedonia, which is staffed with 25 personnel and augmented with medics and nurses from other units. The winter in Macedonia can be harsh and often impedes all modes of transportation. Prior to the deployment of the 240th FST, all trauma surgeries were air-evacuated to Camp Bondsteel, Kosovo. The 240th is now able to surgically stabilize and monitor critical care patients until evacuation is possible [13]. Examples of level 3 facilities include the UN Protection Force in the former Yugoslavia (UNPROFOR), the UN Assistance Mission in Rwanda (UNAMIR) [11], and more recently, Task Force MED FALCON V at Camp Bondsteel, Kosovo. Life at Camp Bondsteel, a level 3 medical unit, was summarized by an Army Nurse: Our experience has been both varied and exciting at times. We are serving soldiers from the U.S., the U.K., Norway, Sweden, Finland, Spain, Italy, Russia, and Poland. We also provide care to local contractors, DOD [Department of Defense] employees and local civilians on an emergency basis. The ages and backgrounds of our patients range from pediatrics to
Table 1 UN considerations for medical support planning UN peacekeeping mandate
Type and size of peacekeeping operation
Existing medical and civil infrastructures
Geographic factors
Assessed medical threats
There is no obligation to provide medical services to the local population, although such care is sometimes rendered based on the dictates of international humanitarian law and the ethical code of the medical profession. Occasionally, the mandate for a mission may extend to include humanitarian assistance to the local population, as in the case of the UN interim force in Lebanon. The level of care and the number of medical units vary, based on the overall troop strength and the type of peacekeeping activity; high-risk operations place greater demands on the medical system. In many countries where PK missions take place, the civilian medical infrastructure has deteriorated due to lack of funding or destruction in war. An important concern is the accessibility of medical care to the intended patients; therefore, climate, terrain, and road conditions are of primary concern. Accidents are the major cause of fatalities and serious injuries in most PK missions; medical units must be able to manage severe trauma and mass casualty situations as well as minor ailments and endemic infectious diseases.
Table 2 UN levels of medical support Type of care
Facility
Personnel
Population supported
Basic Level
Immediate first aid by buddy or trained medic
In the field/initial injury location
Immediate military unit
Level 1
Primary health care and emergency treatment — Battalion Aid Station
Tents/existing facilities/ field ambulance
All UN peacekeepers are expected to have basic knowledge of common first aid skills such as control of bleeding, wound dressing, immobilization of fractures, and CPR Medical team consisting of 8 to 12 medical personnel, including at least 2 physicians
Level 2
Primary care, advanced life support, basic surgery, intensive care, and limited patient holding capacity. Deployed only when medical infrastructure is poor and there is high risk of injury or illness among peacekeepers. Needed when there is no immediate access to hospitals meeting UN standards of care. Emergency and definitive medical-surgical treatment, intensive care, specialist medical and dental services, inpatient ward facilities. Radiological, laboratory, and pharmacy services that provide standard of care Same as above
Tents or temporary facilities; ancillary laboratory and radiology areas, a dental unit, and hospital support elements.
35 medical and support staff
Multidisciplinary general hospital
Contracted civilian/military hospitals in the country or neighboring countries.
5000 + personnel
80 to 100 medical and support staff
Tents or deployable medical systems (DEPMEDS)
Up to 5000 personnel; provide approximately 60 outpatient visits per day; perform 10 general surgery and orthopedic procedures; 10 dental procedures per day and inpatient ward facilities for up to 50 patients for 30 days. Secondary elective surgical procedures, reconstruction, rehabilitation, and convalescence for conditions that become chronic.
Level 3 (contracted care)
Level 3 (field hospital)
Level 4
Definitive medical care and specialized treatment unavailable or impractical within the mission area.
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Military medical center in services members home country. May use neighboring country medical centers if U.S. standards of care are met.
500 – 600 people capacity to treat at least 20 ambulatory patients per day and have short-term ward facilities for approximately 5 patients 1000 personnel or more and should have the capacity to perform at least 4 surgeries, 5 to 10 dental procedures, and 40 outpatient visits per day, with inpatient beds for up to 20 patients.
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Level
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L.H. Yoder, S.L. Brunken / Crit Care Nurs Clin N Am 15 (2003) 265–273 the older adult. We have helped to care for patients with a wide range of illnesses and injuries ranging from appendectomies to rule out MIs [myocardial infarctions] and acute trauma. Although language barriers exist in many cases, the U.S./U.K. nursing care we provide is second to none [14].
It is important to note that the mission dictates the unit requirements. The changing needs of the population served require ongoing reassessment of the scope of practice available as the resources in the region change based on the evolution or resolution of the situation [3]. The U.S. military generally provides a more robust medical force than other nations, so the usual course of events leads to the U.S. being the lead agent or the overall authority responsible for medical support and standard of care to the theater of operations (the geographic area where the military is carrying out it’s work). This does not mean the other nations do not support their area of the theater or their own personnel and provide the same standard of care; however, having a lead agent keeps the theater from being overwhelmed with unplanned medical personnel and allows for standardized patient reporting, treating, epidemiologic tracking, and evacuation policies. Nursing roles Army Nurse Corps officers typically serve in the same types of positions as civilian nurses when they are in traditional hospitals; however, Army nurses must always be prepared to serve in the nontraditional field environment. Although, the focus in this article is primarily on the Army, all U.S. military services have in-hospital and field (deployed) nursing roles. When nursing personnel are deployed, they must use skills not ordinarily used in a U.S. hospital, often moving between specialized versus generalist roles, high to low technology, and automated to manual equipment, and they must practice across a diverse range of clinical scenarios [15]. Deployment nursing requires alterations in one’s skill set, adaptation to an austere environment, the need for flexibility, and proficiency with unfamiliar communication systems [16]. Additionally, nurses who deploy must master basic soldiering skills such as the use of weapons, personal defense, and field skills related to living in an austere environment, and provide nursing care to people of a different culture with different values. A nurse in Operation Restore Hope remarked that the austere environment in Somalia made everything ten times more difficult than her previous experience in Operation Desert
Storm [4]. Likewise, the nurses in Operation Joint Endeavor arrived in Bosnia and Hungary during the worst winter in 32 years. Water problems made the availability of running water sporadic and prevented them from having showers for 54 days! Because there were no toilet facilities in the field hospital, patients, including postoperative patients, had to use the portable toilets outside the hospital. The staff and patients were required to wear their helmets and flak vests when leaving the hospital tents [17]. In the past, there was little preparation available for nurses deploying to a multinational PM/PK role. Multiple ‘‘lessons learned’’ files are now available, including manuals about individual service roles and Joint Medical Planning and Operations, Title X (Health Affairs guidelines), Standard NATO Agreements (STANAGS), and journal articles [3,4,10,11,18 – 21]. The involvement of military nurses staffing and managing the nursing care in the medical units within PK/PM operations begins before ever leaving the U.S. Nurses should be involved intimately with planning medical assets, understanding the capabilities of medical units assigned and their placement within the theater, the timelines of medical unit movements, and the date of entrance into the region. The senior nurse provides clinical oversight and keeps the Command informed of clinical issues within the area supported by the unit. Nurses within assigned field units perform many of the tasks listed in the box in addition to their clinical functions. Preplanning, education, awareness, and coordination are absolutely essential to arriving in the theater and beginning the mission of medical support to the soldier [20].
Nursing tasks related to medical planning Analyzing the mission for the coordination of appropriate unit and individual soldier selection. Coordinating logistical requirements to review availability, modernization, and supportability of medical equipment and supplies to meet the mission intent. Interpreting and providing feedback about rules that will define the medical role of each U.S. military service and the various nations involved. This also involves estab-
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lishing contacts and liaisons with the joint services and other nations’ medical staffs to allay conflict and clarify role definition. Coordinating with Civil Affairs to attain an overview of the area of operations, the country, the current medical structure, the culture and religious influences, government overview, current available and operational host nation medical facilities, translation capability, and available NGOs, PVOs, and IOs within the area. Coordinating with legal advisors for law and doctrine supporting the mission, rules of engagement, Geneva Convention, Command policies, and any international aspect that could affect the medical mission. Ensuring staff members understand the mission, role, and method of supporting the medical structure within the deployed area. Gaining knowledge about the medical intelligence of the theater; the environment, diseases, health condition of the populace, and the medical and combat threat to military personnel going to the theater. Obtaining NATO and UN disease and injury predictions based on location, time of year, type of overall mission, and number of personnel deployed to the area. Credential verification of licensed providers — not only the active component, but also any reservist being activated. Clinical training for all levels of providers to ensure their ability to provide healthcare using field medical equipment versus equipment used on a daily basis at ‘‘home’’ medical facilities.
Who gets care? The primary medical mission within the theater is the support of any military personnel, government contractors, and government paid ancillary staff. The only host nation or civilian population support
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authorized is for life saving emergencies or injuries caused by the action of soldiers (eg, a civilian hit by a military vehicle). Medical supplies are programmed in amounts sufficient to only support those authorized for care [10,22,23]. Every theater has a cap on the total number of military personnel allowed. This enables the sustainment of military personnel in the best manner and prevents an overloading of nonessential personnel. Because of this cap, each healthcare position is selected according to the individual’s skill set and rank, authorizing only those people required to perform the mission. Therefore, the staffing is based solely on the mission intent and the number of personnel that may receive care. At times, nurses must be creative with staffing challenges. For example, in mass casualty situations it is not uncommon for staff to work 30 hours straight, or more [4]. At other times nursing personnel must fill their time with useful activities such as training soldiers in nearby units about buddy aid and basic resuscitation measures. The value of this training cannot be underestimated, as displayed by this letter from a soldier to a nurse who had provided buddy aid training. I’m not sure if you remember me. I took the combat lifesaver course with your unit prior to our deployment to Kosovo. I wrote down your address because you were interested to hear if we used any of our lifesaving skills. Well I am proud to say that I successfully gave an I.V. to a TMK soldier that we were working with. The TMK are the unofficial Albanian army or formerly known as the NLA. As you might know at anytime the temp is 100 degrees while we work and the TMK are far from used to that. The day was 98 degrees on its own and the TMK drink sodas so they don’t drink a lot of water. Anyhow it was bound to happen, the soldier took on almost all the symptoms of heat stroke, so I took the proper steps and treated him, and evaluated him the rest of the day. Later that day the interpreter reported the soldier was feeling much better and was grateful. Thank you LT and your team for taking the time to teach us in depth, how to perform the right way, buddy aid tasks. Keep up the good work [24].
Once the services and participating nations are established, coordination of care takes place. The U.S. government has well-developed criteria and standards of care that must be met to ensure the quality of care to be delivered to U.S. military personnel. Therefore, each nation’s facilities must be evaluated to ascertain their standard of care/quality and what procedures, if any, will be authorized for U.S. military personnel. Each nation provides a list-
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ing of services they can support. An overview of the entire theater medical structure is developed to demonstrate locations, types, and levels of medical support available on any given day. By doing this, delays of care and multiple movements of patients can be avoided or decreased by transporting the patient to the correctly resourced facility. For example, if the U.S. facility is short of orthopedic surgeons and the Norwegian facility has orthopedic surgeons, a patient with severe orthopedic injuries, no matter what nationality, might be directed to the Norwegian facility immediately. The number, type, staffed, and operational beds in the theater, as well as the number and type of ground and air evacuations within and outside the theater must be carefully tracked. Nurses from the various U.S. services and coalition nations may be required to accompany patients during evacuation, based on the extent of the patients’ injuries and the level of care needed. It may be difficult to discern the patient’s needs based on the request from an operations center because the request may have been conveyed through several languages and it may have undergone several translations that may or may not have changed the clinical picture of the patient. Therefore, a nurse is usually sent to evaluate the extent of the patient’s injuries. Knowing the evacuation equipment being used in the region is helpful. A nurse from Task Force Eagle remarked, Within our first month of operation, we have experienced training with several mass casualty incidents, some with only a few patients and some with as many as 20. We have also participated in training with some of our NATO allies, utilizing a Danish armored ambulance, a British CH-47 Chinook helicopter, and patients from Turkey, Russia, and Canada [25].
Another area of significant importance is standardization of care, reporting, and patient care material among the participating nations. Standardization of care needs to be assessed quickly upon establishment of the theater and may continue to evolve over time. Standardization of medical material is aimed at products used for patient care and therefore is of particular interest to nursing. For example, standardization will create a system where all intravenous (IV) catheter hubs and endotracheal tube connectors have a standardized size to allow any IV tubing or ambu bag to be attached without restarting an IV or reintubating a patient. Lack of standardization has been a problem in PK operations in which multiple nations provide medical care and transport patients between facilities.
Accurate reporting is of utmost necessity. The British have established an excellent international reporting system. An analysis of the complete data set of hospitalizations of British troops in Bosnia during 1996 revealed that (1) hospital data from current missions should be more complete and include all hospitalizations, not just those lasting 24 hours or more; (2) paper-based morbidity surveillance during military missions should be replaced by electronic clinical information systems, ensuring the capture of all clinically important data; and (3) all surgical procedures should be coded and entered into an electronic patient record locally. The software files created from this analysis were adopted as the NATO standard for use during all military missions [19]. Training, training, and more training As the PK theater matures and becomes well established, ongoing medical training comes to the forefront. Certifications begin to expire, skill sets deteriorate if medical activity is slow, and personnel become bored. Critical skills must be reinforced. For example, burn care was performed in nearly all surgical hospitals that deployed from 1995 to 1999 in support of the PK mission in Bosnia [3]. Clearly, nurses on surgical teams and in ICUs should always be prepared to care for burn victims. The nurses also must track ongoing theater medical training at each subordinate unit. Some training requires intense resources, such as Advanced Trauma Life Support (ATLS), Advanced Cardiac Life Support (ACLS), and seminars spanning 1 or more days. Therefore, these events may need to be planned with the involvement of higher headquarters in the theater and offered across the theater to qualified personnel, both American and multinational [25]. For example, the emergency section nurses assigned to Joint Task Force-Bravo in Honduras hosted a comprehensive nursing seminar for 38 Honduran nurses from six different hospitals. The classes addressed topics ranging from basic nursing care to ACLS; the American nurses planned each presentation, coordinated classroom space and necessary equipment, and provided visitors with lunch in the dining facility. These simple arrangements can become complicated in an austere environment in which resources are limited. Additionally, on the spot revisions to course content may be necessary. For example, when a nutrition presentation was being given to the Honduran nurses they commented that they do not teach their patients the four food groups we use in the U.S. because many Hondurans do not have access to meat, poultry, eggs, or dairy products. Rather, they teach
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their patients the best ways to use what they have available [26]. Training by multinational forces to host nation hospitals also may be needed. For example, in Bosnia many of the experienced local providers were killed and the remaining staff were experienced only in performing amputations, but not reconstructive care. A training program was established to provide experienced multinational staff for the education and guidance of local providers concerning reconstructive surgery and care. During the host nation medical facility assessment, nurses often work with NGOs to exchange information about the findings [27]. The NGOs are well prepared to step in and assist where needed. The intent is not for military personnel to do the work for or replace the host nation system, but to reestablish it to a functional entity. Host nations should not be left with a system they cannot support after the departure of NGOs or occupying force(s) [21]. Some services may need to be completely reestablished. Nursing personnel providing care in PK environments continue to be concerned about quality of care issues. The nurses also attempt to anticipate ethical issues. One ethical case occurred when all available ventilators in the ICU were being used for Somali patients, the nurses questioned what would happen if the next patient needing a ventilator happened to be a U.S. soldier. Fortunately, this situation never presented itself, but it made the staff question how they might handle such a situation in the future [4]. Nurses also conducted chart reviews and critiqued their care (yes—they even have performance improvement initiatives in the field!); they conducted preoperative and postoperative interviews; and they developed competency-based orientations for their replacements [22]. Nurses deployed in PM/PK operations supported by numerous countries have remarked that finding translators who could communicate medical terminology often proved to be challenging. Often translators did their best to convey the diagnosis or steps of a medical procedure to the patients from different countries, and it was not uncommon for nurses to resort to drawing pictures or demonstrating the use of medical equipment. Fortunately, surgical consent for life-saving emergencies is not required in a field environment and this allowed the operating room staff to give prompt care even in situations with language barriers [22]. Nurses working in PK environments also constantly find ways to improve the experience and care. For example, nurses at Eagle Base, Bosnia-Herzegovina, created their own web site and served as web-
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masters, keeping their colleagues informed about the events at the facility. Several of these nurses also served as the Task Force Public Affairs Officer and developed monthly newsletters that were attached to the web page. The web page also helped to keep deployed staff members’ families aware of activities at the unit. Host nation support was provided by some of the nurses when they were asked to administer flu shots to local school children as well as when members of the U.S. healthcare team took part in a 30-km road march sponsored by the Danish Army [28]. Serving as a nurse during a PK/PM mission is challenging and diversified, but most nurses who have had these experiences agree that the assignments are extremely rewarding [21,22]. Nurses who were deployed to recent PM/PK operations stated that all nurses in the unit must be prepared to learn skills in other areas. For example, the nurse anesthetists helped ICU and medical-surgical nurses learn optimal ways to recover patients because no nurses with post anesthesia care unit (PACU) experience were part of the team. The nurses in these deployments reported being highly trained concerning Automatic External Defibrillators and using the LIFEPAK 12 as a monitoring and pacing device because other equipment was too outdated. At the same time, the nurses learned to use older equipment and sharpen their nursing assessment and critical thinking skills because they could not rely on technology in the same manner they would in a hospital ICU or emergency department. When touring facilities of other countries, however, Army nurses in Bosnia realized how fortunate they were, The Russian hospital was small, converted from what had been a fire department. It consisted of an exam room, one functional operating room with a one bed ICU next to it, a desk, a pharmacy, dental chair, and a ward for about 8 patients. The ward was poorly lit, space between the beds was limited and the equipment was very outdated. This facility sharply contrasted to our hospital, making us all realize just how fortunate we were. . .[29].
Nurses in deployed units often were encouraged to come into the operating room and learn more about how various field surgical procedures are performed so they could better understand the postoperative needs of their patients. Depending on the size of the unit, providing care to patients requiring ventilator support could be challenging when the nurses were accustomed to using high technology ventilators at home and the unit ventilator was of the ‘‘babybird’’ variety, requiring much more extensive nursing
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assessment of the patient, as settings were changed based on the patient’s condition. Several critical care nurses commented about their surprise at the number of U.S. and Allied force psychiatric cases requiring hospitalization or evacuation. These nurses quickly learned to contact stress management team members, and they added to their own knowledge regarding the care of these patients. The exposure to healthcare teams with varying skill levels, the sharing of new knowledge, and the broadening of nursing skills often require tremendous creativity and provide additional experiences and knowledge that cannot be fully quantified. Working in a multinational and joint service environment is extremely enriching and provides practice challenges. Military nurses must be open minded, assertive, forward thinking, flexible, and change agents in order to be successful and enjoy the experience [22]. Nurses in deployed PM/PK environments must possess communication skills that allow them to traverse across cultural and language barriers, and they must coordinate the care of patients across countries and, at times, continents. They must learn to assess pain and evaluate attitudes toward illness among service members from diverse areas of the world. Of equal importance is the ability of a highly technically skilled nurse to convey a sense of expertise, calm, caring, and compassion in an environment that can rapidly change from boring to frenetic. ‘‘As a deployed soldier, the first lesson I learned is that we must all be extremely adaptable. Orders may change, deployment dates modified, supplies may not arrive on time. Thinking out of the box in a potentially hostile environment may save your life and those around you. The second lesson learned is the importance of teamwork. You are only somebody because of the person next to you. Remember to have faith in those around you! A chain is only as strong as its weakest link. The final lesson is the importance of believing in your soldiers. Most of all, never take for granted those who are precious to you. Live each day to it’s fullest [1].’’
Acknowledgements The authors wish to extend a special thanks to the Army nurses serving throughout the world, supporting the healthcare needs of military personnel in challenging environments. A special thanks to those who shared their experiences with me: COL Nancy Hodge, AN; LTC Kathleen O’Leary, AN; MAJ Ed Yackel, AN; and CPT Paul Crum, AN.
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[26] Wassum E. Honduran Nursing Seminar, JTF-Bravo, Honduras. Army Nurse Corps Newsletter 2001; 2(3):12. [27] Samuels GL. Army community health nurses’ role in humanitarian relief effort, Operation Sea Signal, Guantanamo Bay, Cuba. Mil Med 1997;162:190 – 3. [28] Lindner CG. Task Force MED EAGLE, Eagle Base, Bosnia-Herzegovina. Army Nurse Corps Newsletter 2002;2(5):12. [29] Pattison C, Barlow R, Mack T. Update from the Army Nurses of Task Force MED EAGLE. Army Nurse Corps Newsletter 2000;99(3):8 – 9.