The Mission

Rick Johnson, for HealthLeaders News, December 20, 2007
She sees the loss of life and limb firsthand. Some of the cases that stand out in Lisa Zacher's mind involve amputees. Despite their battle wounds, many of these soldiers want to return quickly to duty with their comrades. And they are crestfallen when told they cannot.

"There is an unspoken closeness [among soldiers] that you sense but cannot truly understand," she says.

Col. Zacher is an intensivist and chief of critical care services deployed with the 28th and 86th Combat Support Hospitals (CHS) in Baghdad, Iraq. She's run the intensive care units there since August 8, 2007.

"We have definitely noticed a decrease in the overall number of casualties recently," says the 18-year Army veteran. "But the acuity still remains high--and we have to ensure that we maintain constant readiness for the mass casualty event."

Frequently I include my discussions with industry insiders in this space, but as we approach the holiday season, I decided that it is fitting to share with you some thoughts from a physician leader who is serving our country in Operation Iraqi Freedom. Below are the highlights of an e-mail conversation I had with Zacher.

RJ: Tell me a little about the mission of your assignment?

LZ: My main role is to be the physician in charge of the ICUs, but I work closely with nursing, patient administration and other ancillary services to optimize care and disposition of our patients. For the surgical patients, I work very closely with the surgeons and serve as the primary physician for patients with medical emergencies. It is a nice partnership with the surgeons--especially in mass casualty situations. Often the initial surgery is called "damage control" where the surgeons stop the bleeding and do life saving resuscitation in the emergency room and operating room. The patients are then brought to the ICU for further resuscitation which usually includes lots of blood products and warming the patient. Once the patient is more stable they go back to the OR for more definitive surgery. A study done at Ibn Sina comparing patient outcomes before using intensivists with [outcomes] after using these specialists showed a definite survival benefit. I believe in part this is because it becomes a focused, priority mission for the intensivist, who interfaces on a daily basis with the ICU team of nurses and respiratory therapists with resultant improved communication and multidisciplinary care.

RJ: Give me a sense of how many cases your team attends.

LZ: On a daily basis our census fluctuates from three to 12 patients, with an average of about five or six. The numbers might be a little misleading because the patients have such a short length of stay. If they are Americans, we are stabilizing and moving them rapidly forward in the theatre of operation. If they are host nation, we are stabilizing and returning them to the Iraqi healthcare system.

RJ: Contrast what it's like to serve in a combat support hospital with challenges at a U.S. facility?

LZ: Probably the biggest difference is the unit cohesiveness since we live, eat, and breathe together. We are very dependent upon each other and the individual skill sets that each one of us brings to the theatre. "Turf" battles go away and mission takes precedence over everything else. Our mission in the CSH is first and foremost trauma care, which means that we are in constant triage mode. It is not uncommon for the surgeons to do elective surgeries in the middle of the night to facilitate discharge the following day or to ensure that the ORs are available for incoming traumas. Even when our census is low, we have to concentrate on stabilizing patients for evacuation forward in the theatre.

RJ: What do you feel is the role of a physician leader for the CSH?

LZ: Ensuring that with turnover of personnel and fluctuations in casualty numbers that we stay focused on our primary mission, which is world class trauma care. In the months of June and July, this little hospital was one of the busiest trauma centers in the world. More recently, our daily census has decreased compared to the previous year; however, it becomes even more important not to become complacent and lose focus. Keeping in mind this mission refocuses our entire physician group on the truly important features of our day. The physician leaders have also prioritized working with the Iraqi physicians in Baghdad that are on the receiving end of many of the host nation patients that we stabilize and in boosting the training and capabilities of the healthcare available to Iraqis in the International Zone. Enhanced communication with our Iraqi colleagues have also given us a greater understanding of the significant challenges that these dedicated clinicians face on a daily basis in taking care of their patients. They are constantly struggling with shortages of supplies and medications. Additionally, they have a huge shortage of trained nurses and other ancillary support staff. The physicians themselves are very knowledgeable and most have trained in the British system. It really makes you appreciate the support (logistics and trained personnel) that we receive as Army physicians--even in a combat zone.

RJ: Is the hospital performing as effectively and efficiently as it could?

LZ: Yes in regards to trauma care--especially of our soldiers and coalition forces which is our primary mission. We don't perform some of the more sophisticated procedures, such as heart catheterizations and hemodialysis, or elective procedures due to the complex nature of the intervention.

RJ: How do you keep the clinical staff motivated?

LZ: Our physician staff is very close, and we keep close tabs on each other. We break the monotony with real exercise and the occasional wiffleball game in the motor pool area. A 180-day rotation is very doable. The bigger concerns are the 15-month deployers, who deal with more stress related to being away from home and family--but still manage to perform admirably. I believe that trying to keep rounds academic, acknowledging and also expanding and challenging the expertise of our nurses, is also key. Hopefully they will come out of this deployment with an expanded skill set that will serve them well professionally.

RJ: What's one thing that you're most proud of about the CSH? What's one thing you'd change?

LZ: I'm proud of the quality of care that we deliver on a daily basis and the teamwork and mission focus that it takes to pull it all off. There [are fewer] turf battles than back in the U.S. because we have a common goal and we have to live and work with each other on a daily basis. What would I change? I worry about the effect of compassion fatigue that has been well documented in ICU literature back in the States, not only on current mission but [also] in our future dealings as healthcare providers. There is also the potential for skill degradation for very specialized professionals and the need for retraining.

Prior to serving in Bagdad, Zacher's most recent position was chief of the Department of Medicine at Brooke Army Medical Center in San Antonio, TX. She attended medical school at the University of South Dakota and completed her residency at William Beaumont Army Medical Center, El Paso, TX. She followed that up with a pulmonary/critical care fellowship at Madigan Army Medical Center, Tacoma, WA. Zacher says that her family has been very supportive of her deployment and it is a rare day that she doesn't receive a care package or letter.

As I plan to take some needed time off to be with my family this Christmas, I will be sure to pause and give thanks to the healthcare professionals who sacrifice much to lend their special talents to those in need. Because people like Col. Lisa Zacher are the real physician leaders.

Rick Johnson is a senior editor with HealthLeaders Media. He can be reached at
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