The dilemma of caring for wounded Iraqis

Iraqis get the same initial treatment as U.S. and coalition forces, but not the follow-up care


BAGHDAD, IRAQ — BAGHDAD, Iraq-- --The young soldier would die, a fate ensured by the bullet that entered his right eye and shredded his brain. But unlike many other patients on the beds and gurneys of the U.S. Army's main combat hospital, this one would die quickly, without any heroic attempts to open his skull or take over his vital functions with machinery, without the chance to remain alive until his family or friends could gather.

If the doctors thought he had a chance of survival, they might have treated him differently. But the soldier's medical care was not determined solely by his injury, but also by his nationality. He was Iraqi.

The evolving nature of combat in Iraq - the persisting violence and the increasing responsibility heaped on Iraqi army and police forces - is creating a logistical and ethical tightrope for the American medical centers in Iraq, which exist to treat injured American service members but are seeing large numbers of Iraqi patients brought to their doors.

Military doctors and nurses try to remain blind to the nationality of each patient. But they cannot ignore the conditions on the ground, including the huge disparity in follow-up care available to American and Iraqi patients.

Americans, for instance, can expect prompt evacuation by helicopter and military jet, multiple surgeries in four or more hospitals, and a long and comprehensive rehabilitation, regardless of the cost. Iraqis get the same initial treatment in the U.S. military's emergency rooms and operating rooms but might next face a late-night handoff to Baghdad's overworked and under-equipped civilian hospitals. With injuries such as severe burns and head wounds, which require long, resource-heavy recoveries, death can mark the difference between the two groups.

American doctors say the system pushes the boundaries of medical ethics by making some of the most complicated, high-risk treatments available to only the American patients. For instance, with aggressive treatment the wounded Iraqi soldier might have lived for six months, albeit unconscious and on a respirator, and died near his home and family. Instead he would die in an empty side room of the American combat hospital in Baghdad.

It is a consequence of wartime medicine that American medical teams throughout Iraq say they find troubling and sometimes heartbreaking, particularly given the growing number of Iraqi patients with severe injuries being treated in the U.S. military's hospitals.

"If we were really going to treat them exactly the same, we'd fly every Iraqi casualty back to the United States," said David R. Steinbruner, an emergency room doctor at the hospital. "But we can't do that. It's really difficult, some of the decisions you have to make."

While Steinbruner spoke, a 13-year-old Iraqi girl named Hadeel was resting on a bed behind him, as doctors tried to diagnose what was apparently renal failure. A team of Marines had arrived at her house west of Baghdad a few days earlier conducting a census, and her father asked them if they could help his daughter. She was the fifth of his nine children to suffer the same symptoms. The other four died.

The doctors promised to do what they could but knew that Hadeel's prospects were dim if she required dialysis or some other expensive, long-term treatment. Her father, who goes by the single name Hamadi, understood the limitations but said he had nowhere else to turn, despite the danger inherent in seeking help from the Americans.

"The American medical care is the only thing that can help her," he said, still looking off-balance from his ride in a Marine Corps helicopter a few minutes earlier. "This is not a matter of armies and nations, it is about my daughter's life. Of course I will trust them. I am grateful."

The hospitals in Iraq were once among the most capable in the Middle East, but years of economic sanctions followed by three years of war have erased that distinction. The Medical City complex in Baghdad, a full-service teaching hospital that serves as the city's primary civilian health clinic, is badly under-equipped and frequently a target of attacks, American doctors who have been there say. Many of the well-trained Iraqi doctors and nurses available when the war began have since been scared off or even assassinated.

Realizing this, American military officials make all of the U.S. medical facilities in Iraq - and helicopter and ambulance services - available to Iraqi soldiers, civilians or anyone else, even insurgents, injured within sight of American forces. Military medicine has approached combat care the same way in all the modern wars - treating soldiers, civilians and the enemy the same.

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