Nursing in a War Zone: A Q & A with Fred Barton, MS ’18
This summer, Fred Barton, MS ’18, spent four weeks in Ukraine, working in the ICU and OR of a military field hospital. An emergency nurse practitioner (NP), Barton volunteered through the World Health Organization.
Q: What was it like to be a nurse in a war zone?
A: In many ways, nursing in a war zone is no different than in a civilian setting. Our job, first and foremost, is to provide compassionate and quality care. Our patients are scared, disoriented, and surrounded by strangers. They need someone to ask their name, squeeze their hand, and tell them we will take care of them. These tiny gestures can lift a visible weight from their shoulders. One difference in a war zone is that it’s imperative to watch for mistakes by colleagues. We have had no rest, no showers, and little to eat for days. It is easy to miss things, but by working together can we minimize oversights.
Q: Was there anything unexpected about your experience in Ukraine?
A: The experience was not what I expected in three ways. First, traveling through Lviv, Dnipro, and Kiev, you would never know there is a war. People are going out, bars are open, and there are no soldiers, air raid sirens, or signs of conflict. The only reminder I saw was a number of captured Russian tanks sitting in the main square of Lviv, along with a bust of Putin that Ukrainian children shot at with paintball guns. Second, this is not a war of infantry. During the month I was there, I saw three gunshot wounds and only one was a Ukrainian shot by a Russian in combat. The injuries were mostly caused by shrapnel from bombs, rockets, shells, and land mines. In over a decade of practicing emergency medicine as a 911 paramedic, SWAT medic, and emergency NP, I have never seen injuries as viscerally terrible as those caused by anti-personnel mines. The final major surprise was the volunteers themselves. Almost every volunteer I met was a veteran. I worked with retired Navy SEALS, a Green Beret, ex-GIGN [the French national police’s elite tactical unit], and a member of the 101st Airborne. These were all soldiers who volunteered their time and put themselves at risk to help people they did not know; they had also agreed to forgo any income for at least a month. It was humbling to work with such kind and caring people.
Q: How did your Columbia Nursing education prepare you for this role?
A: It’s the foundation of my care. Health care is absolutely a human right; all people, regardless of race, sex, belief, or culture, deserve access to the highest levels of compassionate care. Ukrainians are fighting a war to protect their friends, family, and nation. In many cases, they have not seen their families since the war began. Similarly, providers there are exhausted, overworked, and operating at critically low staffing levels. These people deserve our compassion. I have no ties to Ukraine; I volunteered because it was the right thing to do. They need help—and proof that the international community supports them.
Q: Can you describe the equipment available in Ukraine, and how the scarcity of resources underscored the importance of physical assessment?
A: In the field hospital, diagnostic tools were functionally non-existent. We had an X-ray machine built in Czechoslovakia in the ’80s, but I saw it used only twice. No lab work was available at all. Even obtaining vital signs was rare. Patients in surgery had a monitor for blood pressure and pulse oximetry. Outside the OR, however, it was not standard of care to obtain vitals, so we did without. We were practicing based almost entirely on physical assessment and our knowledge of anatomy, even when intubating a patient or placing chest tubes or central lines. It was a stark contrast to the U.S. For example, last summer, just before I went to Ukraine, I saw a 10-year-old girl who was thrown from an ATV and struck a tree without a helmet. She had a brain bleed and required a burr hole. We consulted pediatric neurosurgery, and a head CT was ordered and labs obtained prior to the procedure. In Ukraine, I had a gentleman who’d been struck in the head by shrapnel and also needed a burr hole. No consults. No labs. No imaging. It was imperative that we be confident in our physical assessments, as they were the basis of almost all our clinical decisions.
Q: Could you talk about using your personal ultrasound and how it helped open up communication with Ukrainian medics?
A: I believe very strongly in the utility of point of care ultrasound (POCUS) and have dedicated a significant amount of time to learning how to effectively utilize it. In a setting like that, with no other diagnostics, it was invaluable. We used it to quickly determine the severity and extent of injuries, for difficult IVs on burn patients, for central line placements and regional nerve blocks, to rule out pneumothoraxes, and for pericardial tamponades.
It was also key to our developing relationships with the Ukrainian surgeons. They had some experience with POCUS from other volunteer groups but were not well versed in its use. My team entered every trauma with the ultrasound and performed an exam, verbalizing positives and negatives. The Ukrainian surgeons asked us questions: Why were we assessing the aorta? How did we know the patient did not have a pneumothorax? What were we looking at on the screen? This gave us an opening to teach and improve care. And it is a skill they can continue to use. I actually donated my personal Butterfly ultrasound to the Ukrainian team when I left.
Q: What trauma care expertise were you and your colleagues able to share?
In Ukraine, providers don’t specialize in emergency medicine, so trauma patients are managed very differently. During mass casualty events, my team utilized Advanced Trauma Life Support guidelines to assess and treat patients. We were very deliberate in performing primary and secondary surveys, obtaining POCUS exams, and rapidly stabilizing patients. We did the same with surgical patients. It was much faster than the approach used prior to our arrival. Patients who would have been worked on for five to six hours could be stabilized in one hour.
Q: What were the most important things you learned?
A: Most of the Ukrainians currently fighting are not soldiers. They are civilians who volunteered because it was the right thing to do. I met IT professionals, entrepreneurs, chefs, delivery drivers, and lawyers fighting to protect their nation. One man was an elementary schoolteacher. He volunteered to defend his students. He was given a machine gun and sent to the front lines, where he was struck with artillery shrapnel. I met him in the hospital. He was kind, compassionate, and could not wait to return to fighting—to do his part to end the war so his students could go back to school.
Q: Do you plan to return to Ukraine?
A: I do. I hope to return to the field hospitals for another month. In the meantime, I will volunteer in Haiti and Mexico.
Q: When you asked Ukrainians what they wanted people in the U.S. to know, what did they say?
A: Ukrainians have three things they wish to share with the world. First and foremost, they want more weapons and ammunition, rather than money, medical supplies, or people. Second, they believe this is a
crisis for the world, not just Ukraine. They do not believe Russia will be content with taking just Ukraine. Finally, they warned us about the strength of the Russian propaganda machine.
Q: Is there anything else you’d like to share?
A: I had one of the most surreal experiences of my life there. One evening, we had an influx of patients following a nearby counteroffensive. My teammate and I were performing an exploratory laparotomy, when multiple rockets struck all around us, blowing out the windows of the OR. Another member of our team entered the OR to let us know there were heavy casualties, as an apartment complex across the street had been hit. I walked out into the hallway, which was filled with smoke, to find large numbers of soldiers, many with guns in hand, bringing in wounded. You could see fires outside, but the hospital itself was very quiet. Patients were not screaming or crying. Providers were moving quickly but speaking softly. Everyone was doing their part to manage the emergency to the best of their abilities. I walked through the halls, triaging and providing stabilizing measures, while our surgeon returned to the OR. Three hours later, we were back in our room, on the top floor of the hospital, trying to sleep and hoping the next rockets wouldn’t hit us.
Q: Describe the value of nurse practitioners on the front lines of conflict.
A: As nurses, we are used to reading a room and getting along with all types of people. We are prepared to be humble and not allow hubris to get in the way of caring for our patients. Going into a war zone with the aim of bolstering a health system already in place requires such a mindset. We cannot enter thinking our way is best. Additionally, we must be prepared to assist in any manner required. Wiping down beds between patients and cleaning instruments is just as important as performing surgeries. We have to earn the respect of the Ukrainians before being able to truly assist them. Nurse practitioners are experts at this. We are good at making friends, gaining trust, and showing compassion: this is exactly what’s needed amid the terrors of war.