When Duty Calls

As an Army Reserve emergency nurse, Major Randall Mitchell is committed to providing the best patient care possible in his home state of Florida, as well as to fellow soldiers. During his recent 20-month deployment to Iraq, from May 2008 to February 2010, he worked in three emergency departments in various parts of Iraq, providing medical care to injured soldiers, Iraqi civilians and insurgents.

Mitchell's EMS career began back in El Dorado, KS, in the 1970s, when he began work at his father's wrecker service as a high school student.

"We didn't have an organized heavy rescue/extrication service in our county," he explains, "so if somebody was trapped in a car, my dad took out two wreckers and they pulled the car apart and got the victims out. About that time, a friend and I got interested in EMS and began hanging out at the local ambulance service. We went to EMT school together and I learned how to use extrication equipment to get people out of cars in a more patient-friendly way. In 1975, we formed a volunteer rescue squad in our county, and I was its leader for 13 years. When our family business had to close, I went to nursing school and have been an ED nurse since 1988."

During his time in nursing school, Mitchell had an opportunity to go into the Navy Reserves for two years and then transferred to the Army Reserve, where he remains. Twenty-one years after becoming an Army nurse, his unit, the 345th Combat Support Hospital out of Gainesville, FL, was deployed to Iraq. The idea, says Mitchell, was exciting and a bit frightening.

"When you've trained so long for something, it's exciting to finally do what you trained for, but I won't say there wasn't some apprehension," he says. "When I joined the Navy Reserves, I had been married for 5 years, and I told my wife I wouldn't join without her support. I also told her if I was ever called for active duty I would go--no questions asked--but only if she would support me. She said she would, although I don't know how much she believed I would get called. It was a long time later, but she and my grown daughters supported me wholeheartedly. I'm very patriotic, and there was never a question of going. It was just the apprehension of where I was going and what I was going to do."

Training was a unique and frustrating experience, says Mitchell. Normally, a group that was going to deploy in December would be sent to a mobilization station 60 days beforehand, undergo training and then go to Iraq or Afghanistan. In his case, the Army decided to try something new: training farther in advance with more time at home in between.

"The November before my deployment date, I went for 2 weeks of special training to be a flight nurse in a combat area," he says. "In January, we went to Fort Leonard Wood, MO, to work on warrior skills and practiced clearing buildings, firing different weapons and convoy operations. And, we went to a week-long trauma course in San Antonio, TX. We did all that piecemeal before deploying in April. It drove our families and employers crazy because they didn't know if we were coming or going."

Battlefield Care

There's no question that war injuries are horrific. The difference, says Mitchell, is that many of the patients were brought in alive.

"A lot of similar injuries we see here in the United States probably would have been fatal because of the time it takes for response vehicles," he says. "In Iraq, body armor saves the torso a bit better, so we were saving soldiers who probably would have died back in the States."

In the beginning, Mitchell was head nurse of the emergency department at the base hospital on Al Asad Air Base.

"When we arrived in theater in May 2009, we were at the end of the surge, but we were fairly busy with combat injuries, and then the pace just dropped," he says. "We didn't see many battle injuries, but we had lots of sports injuries. It was a large Marine base, with more than 5,000 Marines, and they play hard and fight hard. We also had lots of skin infections, but our highest number of surgeries was probably appendectomies. The Marines are tough and didn't want to seem weak, so they would get belly pain and try to stick it out, and then come in with a burst appendix."

After spending six months at Al Asad and then near Tikrit, the unit was sent to Mosul in northern Iraq to fill the gap between the active duty 86th Cache leaving and the 47th coming in. That was one of the last hot spots, says Mitchell, and there were a lot of battle injuries.

"Some of the medics hadn't seen much action, and that was quite a change for them," he says. "On Christmas Day 2008, 24 rockets were fired onto our base. One of them landed in back of the hospital, right in front of some of the living quarters, and one of our surgeons from Pennsylvania was killed. He had been there less than a week."

Not all of the patients were military personnel, says Mitchell.

"If the coalition forces caused civilian injuries, we had to treat them. There were occasions when insurgents injured civilians and, if the local hospital couldn't take care of them, we took them until they were well enough to go back to their local hospital."

As for safety, there was less concern about the civilian patients than about their families.

"If a family came in, it heightened our awareness, because we never knew how much information they might leave with," he says. "Al Asad Air Base was very safe. It was out in the middle of nowhere and you had to go through checkpoints to get on the base, so there wasn't much civilian traffic coming and going. If a civilian patient and family came in, they were escorted from the time they entered the gate until they left."

Medical Procedures

Many believe that modern EMS was influenced by the Vietnam War. So what techniques might carry over to the U.S. from Iraq and Afghanistan?

"If there's an injury to a bleeding extremity or a traumatic amputation, tourniquets are the first-line treatment," says Mitchell. "Also, crystalloid fluids are not pushed as much; whole blood or packed red cells are your first line. Medics aren't pushing 4 or 5 liters of fluid while they're getting patients to the hospital. They give 1 liter at the scene and, when they get to the hospital, they get whole blood."

Because the rate of injuries sometimes dropped and there is a time limit for keeping blood, there was usually an ample supply of O-positive and O-negative, but little else, says Mitchell. As a result, the hospitals set up "walking blood banks."

"If an A-positive patient came in with traumatic injuries, we might not have many units, so a call would go out over the whole base for anyone who was Type A-positive," he says. "They would do a quick screening, start drawing blood right there and give it to the injured soldier. Whole blood is really good for resuscitation because it has all the clotting factors and other components in it. Because military personnel are so thoroughly screened prior to joining for diseases like HIV or hepatitis, they are basically healthy, so they don't go through the extensive screening like that required in the U.S."

Supplies were usually adequate, says Mitchell, and there was no shortage of specialists like cardiologists, urologists, gastroenterologists and others, who were able to restore soldiers to health without having to send them off base.

The entire experience is very rewarding for EMTs and paramedics, says Mitchell, because they get to do and see a lot of things they don't see in the States.

"I don't think any medics came back regretting that they had gone," he says.

Mitchell is not necessarily standing in line to go back, but if the country needs him, he won't hesitate to answer the call.

"It was a very rewarding, humbling experience to help the injured soldiers who are fighting for our country," he says. "It makes you appreciate those soldiers, sailors and marines much more when you see firsthand what they're going through, and I was glad to be able to help them through their crisis."

Since his return from Iraq in May, Major Mitchell has resumed his civilian job as director of the ED at Florida Memorial Hospital Medical Center in Daytona Beach, FL.