Notes From Kuwait: An NP in the War Zone

Peggy Dryden, RN, MSN, MBA


July 02, 2003

Editor's Note

In our search to interview nurses with interesting stories to share, we have been fortunate to meet Maureen Peters, RN, NP (Figure 1), whose most recent experience takes us to the Middle East. Maureen, an Army nurse practitioner (NP) stationed in Kuwait, gives us a glimpse of what it is like to be part of a military medical team stationed in a war zone.

Maureen Peters and her husband at the clinic in Kuwait.

Question: Maureen, would you describe your position as an Army NP?

Response: My current position as an Army NP involves providing care to military and Department of Defense civilian personnel in a troop medical clinic (TMC) setting in Kuwait. Since December 2002, I have worked at 2 sites in Qatar and 2 in Kuwait.

A TMC is much like a small town emergency room in that you take care of minor illnesses and injuries. At times, we get critically ill/severely injured patients with acute myocardial infarctions or a motor vehicle accident. These patients are initially cared for in the TMC and then are transferred to a higher level of care such as the combat surgical hospital. I work alongside physicians and physician assistants, treating the same patient load that they do. We average 200 patients per day for 4-5 providers. We have a good team in that we all have different strengths and work collaboratively together.

My past nursing experience has included multiple roles in an intensive care unit, a cardiac catheterization lab, hospital supervision, and clinic management. As a family NP, I have practiced in a rural health clinic and in a dermatology practice. In my current practice at a Veterans Administration facility, I am involved in a variety of roles including urgent care, dermatology, and disability evaluations. I have served in the Missouri National Guard for 17 years, and traveled to Honduras and Ecuador to provide medical support for various missions.

My interests lie in meeting people from around the globe and examining traditional healthcare systems. I have been fortunate to be able to do this in the Peruvian Amazon and Andes, Kenya, and Madagascar. A portion of my clinical practicum while in the NP program was spent on a Navajo Reservation working in an environment that brought together traditional Native American beliefs with modern medicine. Unfortunately, due to the current political environment in Kuwait, I have not been able to be permitted off the military instillations. However, I have been able to meet and work side by side with our coalition forces from Britain and Australia.

Question: Is an NP position in the Army similar in scope and responsibilities to an NP position in civilian life? Is there any additional special training you have received beyond your educational training?

Response: Depending on the state in which the NP practices, the military NP scope of practice may be somewhat broader. For example, a Missouri NP is restricted to a collaborative practice agreement and nonscheduled medications whereas the military permits NPs to prescribe scheduled medications.

The additional training and skills include basic soldier training, including such things as weapons qualification. I was given an M16 machine gun assignment. Trainees have to develop a degree of target and night firing accuracy, as well as the ability to fire the weapon while wearing a gas mask. Training also included developing the ability to don a protective suit and mask within a preset time, learning land navigation skills such as map reading and the use of a compass, and developing a familiarization with radio communication, which is important when requesting evacuation of wounded personnel.

Question: What would an average day be like for you? What kinds of activities/procedures do you perform? What kinds of cases/patients do you see?

Response: A typical patient day would consist of treating people with upper respiratory complaints such as asthma exacerbation (Kuwait and Iraq have the world's largest concentration of airborne particulate matter), or other medical problems such as ankle sprains, finger lacerations, elbow dislocations, bug bites, gastroenteritis, and dehydration.

These patients are seen in addition to the mass immunizations initiative we are involved with that began in the theater of operations in January 2003 for smallpox vaccine and continuing for the anthrax and hepatitis vaccine. We have sometimes administered up to 800 vaccines in a day. For example, with the smallpox vaccine initiative, we have 4-6 providers screening, 4-5 medics administering the vaccine, and 2 medics/clerical personnel handing out educational materials and documenting records. We also have one RN providing traffic control as well as conducting patient briefings for up to 200 patients at a time. For the anthrax and hepatitis vaccines, we usually have 3-4 medics providing the immunizations and 1 provider nearby in case of any reactions.

Depending on the worksite and time, supplies can be bountiful (usually when you don't need them) or in demand (when you do need them). Most of the folks are pretty adaptable, and we make do or use an alternate drug or supply. For example, because of formulary restrictions, we have had to switch short acting beta blockers (Atenolol) for long acting ones (Toprol XL).

We have been near the front of the supply line, so that has not been as critical an issue as it has for some folks. However, because of the limited laboratory capabilities, we also have to rely on physical exam skills to a greater degree than in other settings. As an example, we saw a large number of soldiers with abdominal pain. There were 4 main causes: acute appendicitis, acute gastroenteritis (either viral or bacterial), constipation, and kidney stones. Because of a lack of laboratory controls, the accuracy of WBC counts was in question. As a result, we were unable to get a manual differential on our CBCs. Consequently, the physical examination findings were the main criteria we used in determining when to transfer patients.

Question: What has been your most memorable patient situation?

Response: The most memorable patient experience this tour was being involved with the repatriation of the American POWs. The night they came in to the TMC, you could not help but feel pride as an American soldier and pride for the Marines who rescued them from their captors and never left their side until safely brought to Germany. Medically, we played a smaller part in providing physical exams, housing, nutrition, showers, and clothing, but it was still one of those memories I will never forget.

This same story of courage is repeated on a daily basis when talking with soldiers about their experiences in Iraq, their kindness to the local people in providing food and water, and their continued placement in harm's way.

Question: Can you tell our readers about your living arrangements? Where do you sleep and eat?

Response: Living arrangements vary greatly depending on the worksite. I have lived in and provided care in a tent (Figure 2) and a warehouse. Presently, I am residing in a huge warehouse with 1000 other soldiers. The warehouse is divided up into walled off sections (each housing approximately 100 soldiers), so that there are roughly 50 sets of bunk beds per section; each section has 8-foot walls around it. Three to 4 people share a space of 4 feet by 10 feet.

Housing tents in Kuwait.

If you are fortunate, you have a wall locker to store things in. Because so many people are working different shifts, alarm clocks start going off around 4 AM until nearly 8 AM. We eat meals in the mess hall or dining facility, which at Camp Doha serves around 50,000 meals per day. At various times throughout the tour, we had "meals ready to eat" or MREs for 1 to 3 meals per day.

Question: How would you describe your work/life prior to the war and what kinds of things have changed since the war?

Response: Before going to Kuwait, I managed to get all of our affairs in order within 3 days of being notified I would be mobilized for up to a year. My friends could not even imagine how they would pack for a year. It's easy when you only have 2 duffle bags and a "ruck" or back pack and have a long list of required items. You see, both my husband and I were mobilized with only a 3-day notification. We were both sent to the Middle East, initially to different locations and later to the same site. This experience has made me appreciate the luxuries we left air conditioning, plenty of hot and cold water, and the ability to shower when I want.

From January through March 2003, my husband and I were located in facilities that were about 30 miles apart. During this time, I saw him 3 times (briefly) while on official missions at his camp. Because of the increased tensions, we could only travel for official business. After March, however, we were stationed in the same facility.

In general, so much of who we are here is what we do. We work 12-hour days every day. So, in our off hours, we usually wander back down the TMC to lend morale support to the others. Otherwise, we might watch TV or attempt to use the telephone or computer if it's available.

Question: Finally, do you have any suggestions for those readers interested in a position like yours? Do you have any recommendations about who to contact for more information about being an Army NP?

Response: If any readers are interested in a career in Army nursing, they should contact their local Army reserve or the Army National Guard office for information regarding opportunities. My most valuable training experience for this deployment came from working with a well-seasoned family practitioner physician in rural Missouri who served as my mentor and taught me how to be adaptable. It is important to have a sense of dedication, and most of all, lots of patience.