Military nurses: Rescuing soldiers and saving lives under fire

by Ron Rajecki

"I stand at the altar of the murdered men, and, while I live, I fight their cause."— Florence Nightingale (1820-1910)

All nurses remember certain patients who have left lingering impressions on their souls. In military nursing, with its large numbers of young trauma victims, those impressions can be deep and numerous. It’s not for everyone. But for those who choose it, the rewards can run deep.

Lt. Col. Kathleen Flarity, ARNP, PhD, has been a military nurse her entire adult life. Now the commander of the 34th Aeromed Evac Squadron, based at Peterson Air Force Base in Colorado, her perspective has changed dramatically over the 28 years since she joined the military to help pay for college.

"There’s something special about caring for wounded warriors. Our mission carries with it an awesome responsibility," Col. Flarity told RN. "It’s not just about flag and country, it’s about those whom we care for in uniform. They’re called soldiers, sailors, airmen, and Marines. However, to those at home, there are other names for them, like mom and dad, son and daughter, brother and sister. There’s no more rewarding mission than helping them."

Being in the military puts you at the forefront of innovative care practices that eventually become adopted by civilian hospitals, Col. Flarity adds.

"Much of the care that we do now in civilian practice is based on things we’ve learned caring for wounded warriors in different conflicts throughout history," she said. This includes procedures such as damage control surgery, limb salvaging procedures, and temporary vascular shunting, all of which are being done in forward-unit combat hospitals now.

"What we’re doing on the battlefront now will come out over the next few years in medical and nursing journals," Col. Flarity said. "We’re finding things that work better and more efficiently for the patients there, and those things will ultimately translate to civilian nursing."

NOT FOR THE FAINT OF HEART Caring for the wounded during the height of combat is not for the faint of heart. Lt. Col. Bill White, CFRN, echoes Col. Flarity’s assessment that being a front-line military nurse takes a special kind of individual. The large red crosses on the sides of evacuation vehicles offer little protection in combat. Insurgent forces apparently are not deterred from firing on what are clearly rescue—not attack—vehicles. "In fact, we have a nickname for those crosses. We call them ‘bullet catchers,’" said Col. White, director for trauma education of the Defense Medical Readiness Training Institute, and state military chairman for the Emergency Nurses Association.

White, who also hosted the MSNBC "Wounded Warrior" miniseries, was chief flight nurse for the 20th Combat Support Hospital in Iraq, and participated in more than 300 evacuation flights during the 15 months he was stationed there. He estimates that on 40% to 50% of the flights, his aircraft came under fire from small arms or rocket-propelled grenades.

"It’s a whole different mindset when you’re under fire," Col. White told RN. "It’s 110 degrees in the helicopter, you’re in full body armor, your patient’s on a ventilator, a heat sensor has gone off so you’ve lost your CO2 monitoring capability, and now you’re under fire, so your helicopter is pitching left and right and back and forth." At even a level-one civilian hospital trauma center, nurses may see only a small percentage of what Col. White calls "real" trauma. In combat, it’s close to 95%.

"In combat, the vast majority of your patients are coming in with amputations, high-caliber gunshot wounds, and burns. To see all these young soldiers so seriously injured takes a toll on the combat medical staffs," Col. White said. In addition, military nurses also are called upon to treat civilian casualties of military conflicts—in some cases, children. Obviously, that can affect even the toughest nurse.

Virtually everyone is familiar with the concept of combat-related post-traumatic stress disorder, and the military keeps a careful eye on soldiers, sailors, airmen, and Marines for signs that they are suffering from its effects. Healthcare workers in the military also are subject to difficult psychological and emotional challenges. There is a separate term for this type of caregiver stress: compassion fatigue. The military also extends to nurses any counseling and psychological help they may need. Psychiatrists and combat stress teams are always on hand throughout the combat theater.

SUPER SUPPORT SYSTEM "At some point, people wonder, ‘Why would I choose Baghdad instead of Chicago or San Francisco?’" Col. White asks. The answer, he said, is teamwork. "It’s about what you believe in and what you really want to do with your life. It takes a special person to be in the military, to know that you’re contributing to the soldiers, sailors, airmen, and Marines. There’s some excitement, and there’s a huge amount of support.

"For example, you’re going to live in another country, let’s say Germany, for two or three years. You’re going to be assigned a sponsor, you’re going to have a paycheck coming in, you’re going to have a place to live, and you’re going to learn another culture. You’re also going to be surrounded by a support system that understands what it’s like to move every three years, and what it’s like to try to communicate with people in a different language. You’ll always have someone to depend on."

Col. Flarity agrees. "I think there are many reasons why people join the military, but then there are many other reasons people stay in," she said. "One major reason is that the team concept is huge. Everyone participates in the collective wisdom of the team. It’s not like working with a physician in the civilian arena, where he’s the doctor and I’m the nurse. In the military, I have the rank, which shows experience. You see the team concept everywhere here, because you can’t do your job without everybody working together."

The team concept permeates the military, and once nurses are exposed to it, they find it makes their efforts worthwhile in a way that civilian nurses may never know.

Said Col. White: "Not once have I ever heard a soldier, sailor, airman, or Marine say, ‘I’m injured, take care of me first.’ They always say, ‘Go to my soldier’ or ‘Go to my Marine,’ or ‘Go to my buddy, they need you more than I do.’ And not one of them wanted to go home. They want to go right back in the fight. They want to go back to their unit. They don’t want to let the rest of their team down. You see that mentality of selfless service day in and day out."

REQUIREMENTS & REWARDS The military is not immune to the nursing shortage. According to Col. White, there are no specific certifications that you need to become a nurse in the military, aside from a BSN degree. There are certain age limitations, and you must be in good medical and physical condition. From there, the military will train you. Col. Flarity adds that for some assignments, the military will look for individuals with at least one year of RN experience, but the military strongly believes in the concept of hiring individuals for their interest and attitude, and training for aptitude.

A nurse joining the military with a BSN enters as an officer. "One of the things I love about the military is that it provides many leadership opportunities, and they grow you and mentor you in that process. And I mean that holistically, to be a better person, not just in terms of your nursing skills. … And no matter what specialty of civilian nursing you’re interested in, you can find it in the military."

Ultimately, there is a deeper reason that nurses choose military service. As Col. Flarity said, "In military nursing, you get to briefly cross paths with the heroes of this nation. I’m old enough to be their mother, and sometimes when I’m caring for them, I’m just so humbled by what they do. I find it interesting that people talk about World War II and the ‘Greatest Generation,’ but I don’t think people know how great our current generation is."

Sadly, Florence Nightingale’s words still hold true today—and the end isn’t in sight. However, those who answer the call to tend to the injured warriors and other victims of mankind’s conflicts are writing their own legacies of greatness.

AS OF DECEMBER 2008, 26-year-old 2nd Lt. David J. Baure had been an RN for two years. Baure was born in western Washington, and was raised in the Seattle area and San Francisco. He began to consider military nursing in his senior year of nursing school, and took his oath as a commissioned officer Aug. 7, 2007. Now he splits his nursing time between the ED at Good Samaritan Hospital in Puyallup, WA, and the 446 Aeromedical Evacuation Squadron at McChord Air Force Base near Tacoma. Courtesy of Lt. Baure, here’s a firsthand look inside the world of military nursing:

I feel as if my story is actually rather unique in that I am in no way what one may think of as the traditional Air Force officer or Air Force reservist.

In August 2007, I was a long-haired, bearded vegetarian who had just bought a condo in Seattle’s Capitol Hill neighborhood. I had been a nurse for a year at a community hospital, Good Samaritan in Puyallup. During that year, I also was going through the process of becoming a flight nurse in the Air Force Reserve.

A recruiter had approached me at a career fair during my senior year of Pacific Lutheran University’s School of Nursing. As the recruiter talked to me about military nursing, I eyed the photo that showed the inside of a C-17 transport plane, with nurses hard at work with a wounded soldier. This greatly appealed to me.

I had been an emergency medical technician for six years as I put myself through nursing school. This work experience afforded countless opportunities to interface with many helicopter flight nurses. I idolized these nurses. They were confident and smart, and got to wear snazzy-looking jumpsuits. That was something I felt was essential: doing a good job and looking good doing it.

So I started to consider becoming a flight nurse in the U.S. Air Force Reserve. I was a senior, and graduation was just around the corner. One of my goals is to become a nursing professor, and it seemed all of the professors that I admired most had one thing in common—a military background. So I was ready to call the recruiter, when he called and told me that the opportunity was going to be sweetened by a $75,000 sign-up bonus to be a commissioned officer in the USAF Reserve.

I was stunned, but cautious. I spent the next year transitioning into the hospital’s ED, but took the time to visit the nearby Aerovac squadron. I found out what exactly they did, and spoke to Aerovac nurses who weren’t waving $75,000 in my face. One nurse, Maj. C.J. Newhouse, gave me the real deal, sugarcoating nothing. She had broken her leg on a mission overseas. "I get the cast off this Friday, before our next mission. We’re going to ceremoniously burn it in the parking lot and have a barbecue. You should come!"

This small interaction with Maj. Newhouse was my solidifying moment. I realized I wasn’t put off by the fear of deployment. Rather, I was more engaged than ever. I wanted to be in a place that fostered ideas to elevate nursing to the science and art that I felt it needed to be.

I had always thought my social philosophy was in sharp contrast to the military. I was a liberal thinker who had marched in environmental rallies, and had a broken relationship with my brother, an Army drill instructor. I hated guns, and loathed the idea of cutting my hair. So I kept the idea of joining the Air Force secret for a very long time. I didn’t tell a single co-worker from my civilian ED and involved only my closest friends and family. They supported me, but frequently told me, "The military just doesn’t seem like a good fit for you." But I knew sacrifices had to be made to maximize my nursing career and personal goals.

To prepare for my first reservist weekend, I cut my hair and shaved. Even though my father was in the Army, the initiation was incredibly foreign to me. I didn’t have a uniform yet, and the squadron hadn’t had a new lieutenant fresh off the streets, with no prior service, in years. I was overwhelmed with new acronyms, new faces, and new customs.

Ultimately, however, it turned out well. The camaraderie in the Air Force is incredible. People saw I was struggling and stepped up to help. This made me work harder, and I began to embrace my "officership" as I entered a long, rewarding year of training. April was officer training school, July was flight nursing school, September was survival school, and November was ground training, which brings me to now. I am in the midst of becoming a qualified flight nurse, being put to the test on training missions with patient scenarios in an airborne environment, as well as aircraft emergencies.

How has my experience changed me? As I have become comfortable with my place in the Air Force, I’ve begun to integrate it into my life. The skills I learn as a leader, I take back to my civilian job; and the nursing skills I get there, I take back to flying with Aeromedical Evacuation. Not only that, I’m getting intense experience in a short time. I’m paying off my school debt and planning a year with a steady position as charge nurse of the civilian ED, and a year in which I’ll play a bigger role in training exercises for the Air Force Aeromedical Evacuation missions. Also, I finally got that sharp flight suit.

The realities of flight nursing and military compared with my expectations are light years apart. There’s so much more involved than I expected, so much more to know and do. You never stop working on being a better nurse, a better officer, and a better citizen of the world. Before joining, I thought, "I’ll go in, do my thing, take only the missions I want, and go home." I had no idea I would want to be a good representative for the Air Force and for America, as I do now.

Nursing has so many nuances, and the military culture really tempers your care for people. You understand people on an entirely different level. They are not your patients; they are your fellow airmen.

Military nursing affords tremendous autonomy and insight into humanity. It allows you to connect with science, Western medicine, the human condition, and communities, and meld them together for your practice. Military nursing has transformed me. It can transform you.