Working in a conflict area

Interview with Maarten van der Burgh (general military nurse)

What is it like to work in a conflict area? Medical aspects, ethical dilemmas, logistical challenges, cultural differences, politics and security all combine to make it an interesting field of work. Maarten van der Burgh, general military nurse (GMN), talks about his work during his missions to Afghanistan in 2007 and 2009 and the Patriot mission in Turkey in 2016.

What motivated you to become a military nurse?

During my first mission in 1999, I was a foot soldier combined with being a Combat Life Saver (CLS) as an additional task. This aroused my interest. Becoming a GMN while having experience on the ground as part of the infantry is a good combination, because you can understand what someone in the field experiences.

What characteristics does a gmn need? What makes one suitable for the job?

You have to be a team player and in good physical and mental shape. Above all, you have to realise what you are signing up for. From early on, you will be trained in mental hardness; the exercises are designed to prepare you for difficult circumstances, in order to experience what your reaction might be. You have to be the type that does not give up easily. Also, it helps if you are a calm person who does not get stressed, because you are the person who is in charge and gives orders in a trauma setting. At the same time, you will have to be prepared to accept the choices that are made at a higher level, whether financial, logistical or political. The consequences of these choices could give you a feeling of impotence, for example if you are with a wounded child and do not have a trauma package suitable for children.

What is the composition of the medical team?

The composition varies according to the area. For example, a Patriot mission is on safe ground, which differs from being in Afghanistan. There are three different roles. Role 1, the first trauma care, is the responsibility of the operational unit. For role 2 and role 3 (the hospital care), agreements are made at the international level regarding who is responsible for delivering which type of care and resources.

There are approximately 3 nurses for each unit of 120 people. As a GMN, you work closely together with the rest of the staff. You are acquainted with the whole team, and they know where to find you if they have any problems. In a way, you are a confidant.

Besides the nurse, the operational units have personnel with additional medical tasks. There are Combat Life Savers (CLS), who are foot soldiers with lifesaving skills. They are the first responders and can perform the first lifesaving techniques. Every soldier has a medical kit, but the CLS has an additional basic trauma kit. They are trained by the Ministry of Defence, but it is the responsibility of the GMN and military doctor to keep their knowledge and training up to date.

All military staff receive basic medical training in the so-called ‘self-help care for comrades’, such as placing a tourniquet. The content of the training is based on experiences acquired by the British in the Falklands war and by the United States in Iraq. Analysis of casualties made it clear that most casualties occur as a result of massive bleeding, so every military person is equipped with a tourniquet, compression bandages and other styptic resources.

How do you prepare for a mission?

First of all, you gain information from your predecessors, for example on logistics. As for the medical preparations, you receive specific information about the most common diseases in the area where you are heading.

And regarding cultural and political issues?

You take part in a training which is specific for your mission. This is a mandatory element in the preparation, in which you receive information regarding the political situation and cultural differences. You are informed of the local situation and the expectations of the local population. Also, you discuss what to do in difficult situations. If you prepare yourself for these experiences, you can reduce the chance of developing Post Traumatic Stress Syndrome (PTSS) and related complaints.

Can you give an example of a difficult situation that you could encounter?

During a patrol, you see a crowd stoning a woman. What do you do? Will you act or not? You have to be careful not to project your own morals and values on the local population. Another example: both an Afghan and Dutch person are severely wounded. Whom will you attend to first? These are things which you need to discuss beforehand.

How do you prepare mentally?

With your partner at home, you discuss how you will keep in contact, to prevent the other from worrying unnecessarily. Also, you prepare a manual for the bereaved for the event of your death. That’s about it, because in reality, it’s difficult to prepare yourself mentally.

I DO NOT REGRET MY CHOICE

What is your role as a gmn? Do you go on patrol or do you stay at base camp?

That differs. In Afghanistan I went to a post outside the main camp, where I stayed for 2 or 3 weeks. Your role there is to provide trauma care (role 1). In the first place, this is for the military, but you can also use it to tend to the local population. From this outpost, the unit goes on patrol in the area. The requirement is for the GMN to be present within 10 minutes in case of casualties. So, depending on their distance from the post, this means we sometimes have to go on patrol with the soldiers, and in other cases we can remain at the base. We can then use modes of transport to reach the soldiers as quickly as possible, for example an armoured ambulance. Before each assignment, we plan the best possible scenario for providing medical assistance, together with the commander.

This means that you can only plan to a certain extent, leaving the rest to improvisation?

For example, if you have nine causalities at the same time, triage is necessary, as is communication with the other layers (role 2 and 3), ensuring they can anticipate and send helicopters or a surgical team.

Did you feel safe on your missions?

Yes. In Afghanistan, we slept in armoured containers, which are generally quite safe.

When on patrol, were you, as a nurse, also armed?

Yes, we have a saying, ‘Every man, a rifleman’, which means that as a team you first ensure that the situation is safe in order to prevent more casualties. We practice difficult situations at our skills labs, where we can simulate all kind of circumstances with the use of smoke, sound and smell.

On mission, do you have spare time?

Free time is scarce, as you are always on call, 24/7. At camp, anything can happen – an accident or medical complaints of staff members. There are moments to unwind, but relaxation is always relative. We have a room where we can relax, and often there is a gym, or we put up a volleyball net outside. There is internet and email, and you can watch a movie or read. Also sessions are organized for reflection.

What is the average duration of a mission?

In general, it’s 4 months and 3 weeks, or 6 months. The norm is that you are not sent on a mission for the period of double the duration of the mission. Unless you voluntarily apply for an earlier assignment.

Can you preserve medical neutrality as a gmn?

Your medical background ensures your neutrality, regarding all patients being equal, whether from your own coalition party or the opposite party. This can be difficult, for example in a situation where both your colleague and the enemy attacking him are wounded at the same time.

With regard to attending to health care needs of the local population, we may only perform ‘life-, limb- and eyesight-saving’ actions. You are not supposed to send them to your own role 1 trauma post, as many locals would then ask for your help, thereby undermining the local health care system.

While in the netherlands between missions, what is your role, and can you describe an average day?

Partly you are on leave, and partly you perform tasks with your operational unit. You participate in exercises, teach and take care of the maintenance of your equipment. When the unit goes on military practice, they will need medical assistance. Also, you can do an internship at an emergency department or an ambulance unit to gain experience for future missions.

On average, we do sports at least 4 times a week. We receive training from a medical doctor or we train each other. Logistics keeps us busy, because equipment such as vehicles and aggregates require maintenance. There are meetings and practice sessions. Also, you are in charge of your personnel, so you have to attend to human resource business, such as performance interviews etc.

Are there things which have changed you as a person, things you will never forget?

I went on a large military mission in Afghanistan. You have some good experiences, but also quite horrific ones. You learn to put things in perspective. The beauty of our work is that we work as a team, which helps keep the balance. Overall, I do not regret my choice.

Explanation of Role 1, 2 and 3:
Role 1 medical post: Basic care, first trauma life support
Role 2 hospital: Surgical capacity with operation rooms for damage control surgery and sometimes basic intensive care. There is also a blood bank and a pharmacy.
Role 3 hospital: More advanced surgical and diagnostic facilities (MRI etc.)