BILOXI, MS (WLOX) - by Steve Pivnick
81st Medical Group Public Affairs
BILOXI, MS (KAFB) - Col. Susan Bassett's year in Afghanistan may have seemed like a trip back in time.
Colonel Bassett, who assumed command of the 81st Inpatient Operations Squadron July 1, served in the southern Afghanistan province of Kandahar from January-December 2008, assigned to an embedded medical hospital mentoring team for the newly-opened Afghan Army hospital. The then-lieutenant colonel was there to mentor the facility's chief nurse.
As the only nurse outside the operating room, she found she had "little choice but to become a mentor to all 30 of the Afghan nurses assigned to the facility."
The U.S. Air Force medical mentoring presence in Afghanistan comes under the umbrella of the Combined Security Transition Command. The command surgeon general's goals are to develop better trained and resourced medical personnel in the Afghan Army Medical Service.
The U.S. Air Force team consisted of 15 medics, each an expert in a specific section of the hospital. They were housed in a small American compound adjacent to the Afghan 205th Headquarters base.
Although Afghan men had cultural customs regarding women, Colonel Bassett observed, "The Afghans treated the two younger (enlisted) gals like favored little sisters, bringing them gifts and small treats. My situation was a little different because I talked a lot about my husband, children and grandchildren. The Afghan men saw me in a more matriarchal light. Furthermore, the Afghan Army's chief nurse in Kabul was a woman so the men were accustomed to having a strong women in lead nursing roles. The mentoring role just fit for me and I felt very respected."
She did note, however, that several Afghan patients questioned how someone carrying a weapon (they noticed the ever-present sidearm in her holster) could possibly be a woman."
The Kandahar hospital opened its doors in December 2007. The hospital, built by the U.S. Army Corps of Engineers, was a 50-bed facility with four, eight-bed wards. There were two operating rooms and a three-stretcher emergency room. There are plans for all of the four regional Afghan Army hospitals to add additional beds; this is moving forward very quickly in the Kandahar region due to dire necessity.
The colonel continued, "When I first saw the facility, to me it looked like a community hospital you would see in an American small town."
However, (Afghan) President (Hamid) Karzai proudly called it the 'Shining Star Trauma Center of Afghanistan.' The Afghan medical personnel provided service 9 a.m. to 3 p.m. daily, except from noon Thursday through Saturday morning when they closed for the Friday religious day.
As the spring and summer progressed so did the fighting and so did the Afghan casualties in and around Kandahar and Helmund provinces.
"We actually did do more trauma care than Kabul's 400-bed Afghan Army hospital," Colonel Bassett commented. "One day I was standing at the door to one of the eight-patient rooms. (Among those eight patients) I saw 11 new amputations and five patients with sealed-suction treatment for chest wounds. At that point, I said to myself 'this obviously is no normal American community hospital!'"
Having spent 14 years working in Veterans Affairs hospitals before entering the Air Force, the colonel saw the need for lift equipment to get patients out of bed and proper wheelchairs to care for the severely-immobilized patients.
Colonel Bassett related that physical therapy in the hospital was a whole new concept for the Afghans. Even getting patients out of bed was frowned upon.
Discussing the actual nursing issues she encountered, Colonel Bassett said, "The nursing practice was of a 1940s style. They organized under a functional model -- one nurse gave all meds, one nurse did transports, one nurse did wound care, etc. Although there were female nurses in the community, it just wasn't safe in that region of the country for women to attempt to work outside the home."
She noted, "The Afghan nurses' training averaged about nine months. They did not learn anatomy and physiology. They did not learn about diseases; that was 'doctor business.' They did not learn about drugs; that was 'pharmacy business.' And they did not have patient contact during training. So what did they learn? They learned to do procedures the doctor might request, to start an IV or do an EKG or bandage a wound."
The colonel continued, "Regarding medication administration, basically all meds were left at the patient's bedside, marked with hash marks to tell him how many pills to take each day. It was not the nurses' job to give the patient medication, only to deliver it to him and explain what the doctor had ordered.
"So who cared for the patients? The housekeepers, of course. These guys, for $10 per week, were pretty awesome. They cleaned (a bit), they did the laundry (except for stains), they gardened, they ran errands and when it was meal time, the housekeepers cooked and served the food to both patients and staff."
The embedded training team was there to help the Afghans understand the new-style machines and procedures in the new hospital, the colonel explained, "so our medical technician, Tech. Sgt. Tony Garcia, and I started with adult-learning, on-the-job teaching. However, it immediately became apparent these nurses simply did not have the basic knowledge to understand what they were doing or why. And they certainly did not have assessment skills enough to support any real decision-making."
Just six weeks into the deployment, the violence spiked and casualties started rolling in. Feb. 17, a car bombing at a dog fight downtown resulted in 70 killed and 70 more wounded.
Colonel Bassett said, "Our 50-bed hospital received 48 patients in 90 minutes -- and not one was 'walking wounded.' A mass-casualty with no one speaking English is pretty close to a nightmare. But we all pitched in -- Afghans, our team, U.S. Army Special Forces medics and even British and Canadian mentors in the area. We all just did our best to save lives."
The violence continued throughout the summer with many improvised explosive device blast victims, rocket-propelled grenade attacks, shootings and vehicle accidents. The hospital saw about 90 percent surgical/orthopedic patients.
"Our team was very proud of the medevac missions. Early on, we built a landing pad on the Afghan compound. By July we had our very first Afghan helicopter (an old Russian Mi17), piloted by Afghan pilots, bringing Afghan soldiers straight from the battlefield to be transported in their ambulances to their hospital for care by an Afghan staff. This truly was a very proud day for all of us mentors," the colonel recalled.
However, the basic problem remained. The nurses, mostly very close to illiterate themselves, remained vastly undereducated for the tasks put before them.
With the help of staff from the "schoolhouse"' at Sheppard Air Force Base, Texas, Colonel Bassett launched a 36-module basic nursing course. Each module was 20 minutes long and contained 10-12 slides, mostly pictures. Every word or bullet had to be fully translated into Dari, the local dialect.
Colonel Bassett commented, "These guys had never experienced our kind of classroom education. They put their bare feet up on the table, they interrupted to ask how much longer I would be talking, they were quick to grab for the papers and pens that I handed out (a sign of a highly-respected "educated man" in their society) whether they could read and write or not!"
The colonel continued, "I had very good attendance, more people than I had on the nursing staff, probably because I employed elementary school techniques of bribes for attendance. On suction- module day I handed out suckers and on unit-dose day I handed out Tootsie Rolls."
The 36-module basic nursing education was adopted across the country and subsequent mentors have continued to work on developing performance checklists and reference materials for all the Afghan military nurses. The Afghan hospital commander wanted his more senior nurses to get involved in teaching.
Colonel Bassett recalled, "At first I was pretty reluctant to think they would be teaching each other. But they were so proud when I trusted them to teach! I asked Lt. Col. Manan, my 'peer' lieutenant colonel, to teach on infection control. Once he completed the class, he said, 'I will be teaching about fractures next ... and you can make up one of those fancy American PowerPoint shows to go along with my talk.' I was so proud, and so was he!"
She continued, "The Canadians were responsible for the NATO health care in this region, but the staff volunteered on their days off to come and help me interact with the Afghans and demonstrate that lots of different educated nurses live by the wild and crazy things (like charting and infection control) that 'Mama Bassett' was introducing!
"'Ma ma' in Dari is the word for a favored elderly uncle so it was easy for the guys to say and there was no better way to grab my attention than to call out 'Mama,'" she added.
Statistics for the mentoring team showed 654 hours of basic nurse training classes, 500 hours of didactic medical lectures and labs, 300 hours of medical terminology classes, 200+ hours of ancillary training, pharmacology, radiology, etc., and untold hours of hands-on supervision.
Some of the clinical accomplishments realized in those 12 months included the hospital staff seeing 14,744 outpatients and 748 inpatients, 24 mass casualties resulting in 168 multiple-trauma patients and 193 emergency surgeries. They also supported 44 medevac missions involving 89 patients.
In spite of the cultural differences, Colonel Bassett developed a close relationship with the 70+ Afghan professional staff.
"I knew them all by name and they would talk to me -- but not to each other -- about their wives and children. I grew to care a lot about them all," she recalled.
The colonel mentioned that cultural differences could be frustrating. One evening she and the team physician went to the nearby home of an Afghan doctor. The doctor was immediately shuffled into a gathering of male doctors while Colonel Bassett was escorted to the kitchen with the host's wife and children.
The only time the women were evident was when they served the food. The wife sat on the kitchen floor cooking over a single-burner propane tank "stove" and the colonel sat rocking the babies to sleep while the men had dinner out front.
Overall, Colonel Bassett looks back fondly on her experience, saying, "I believe I was put in the exact place I needed to be. What a privilege to be able to make such a difference!"