The results were obtained from evaluating 952 pages of the memories of healthcare providers in the Iran-Iraq war published in several books. These memories were collected in interviews of 101 healthcare employees who had taken care of the war wounded during the Iran-Iraq war. Themes and sub-themes derived from the data are shown in
Table 1. Themes and Sub-Themes Emerged from Data
Theme Sub-theme Promoting personal and professional empowerment Enhancement of the experience Proficiency and efficiency Training/Learning Training before entering the front Learning when caring of the wounded Discover the dormant forces in the human Evolution over time Compliance with laws and regulations Observance to discipline and obey the commander Medical team as field troops Holistic care Unusual Conditions Poor health conditions High workload The high volume of casualties Severity of injuries Action Observance to hygiene High speed operation Establishment of multiple treatment centers Triage Transmission and evacuation of the wounded Caring and treatment Holistic support Under control conditions Expression of good traits Self confidence Mobility/ability Diligence Loyalty Precision and focus Courage Creativity Wisdom Interpersonal relationships Interpersonal relations of staff Cooperation among staff Morality Cordiality Spiritual influence Relationship Therapy Sublimation of spirit The loss of materialist dependence in the front Escape from ordinary life A feeling of inner satisfaction Sublimation of spirit 4.1. Promoting Personal and Professional Empowerment
4.1.1. Enhancement of the Experience
At the beginning of the war, the majority of healthcare providers had no experience of dealing with the crisis, leading to many problems. However, over time, the troops and healthcare staff gained many experiences, leading to a better organized and more coherent planning that in turn improved the quality of triage, evacuation, transfer and assistance to the wounded, facilitated and speeded up treatment and care of them and subsequently reduced the number of martyrs and injuries.
“At first, doctors treated the wounded in very small tents or bunkers on the front lines that naturally many injuries were martyred because of the lack of skilled doctors and medical equipment. But over time, Iran’s frontline has with the strongest emergency and field hospitals in the world wars.” P
Healthcare workers sometimes used the experiences of indigenous people such as removing the sticky mud from the body of the wounded with water pressure, building the wood heater and the desert bathroom with style of rural people to solve their problems.
“The villagers had heaters operating with wood. We brought two barrels from the camp. We cut them by the bayonet and made something like heater of villagers. The heater actually worked great!” P
65 4.1.2. Proficiency and Efficiency
Some of the healthcare providers, including physicians, nurses, paramedics, and aid workers who went to the front had high proficiency and efficiency in the treatment and caring of the injuries. Indeed, war added to their proficiency and performance skills.
“We had become proficient in identifying the types of bombs so that we recognize them from their color. Is that nerve or mustard or cyanide bomb?” P
65 4.1.3. Training/Learning
The war had benefits despite the hardships and problems. The informants said that the front had become a center of education for all. One of the necessities of attending in the front was passing courses regarding such as chemical bombs, personal protection, decontamination, the types of guns and how to work with them, and how to use life vests. These training courses were very useful for the informants. In contrast, some said that they did not train before attending the front. So, they faced challenges in the treatment and caring of the wounded and protection of themselves. The majority of the informants mentioned the educational aspect of the care of the wounded. They had received great skills in the field of triage and evacuation of the wounded, treatment measures, complex surgeries, and care of veterans with complex trauma. Some physicians noted that they learned a lot of skills from the proficient nurses, clinicians, and rescuers. On the contrary, the nurses, clinicians, and rescuers acquired knowledge and experience from physicians in many situations. In fact, medical team did not neglect training in the midst of the war. Later, faculty members and other professionals who had participated in the war used this unique experience to teach their students and colleagues at the universities and therapeutic settings. Also, the healthcare workers tried to acquire knowledge and skills in non-medical fields such as shooting, working with anti-aircraft, driving trucks, buses, and tanks in their spare time. The informants emphasized that the war was a factor to explore the dormant forces in human.
“Participation in the war gives power to human to test his ability in difficult and critical situations and discover the dormant forces in him by overcoming unwanted fear.” P
Generally, most of them recognized the war as an informative and constructive factor.
4.1.4. Evolution Over Time
The findings suggest that the medical and nursing professions evolved with the acquisition of knowledge, skills, and experience over time.
4.2. Compliance with Laws and Regulations
4.2.1. Observance of Discipline and Obeying the Commander
The informants mentioned that discipline and obedience to the commander are necessary so that if disregarded, they can lead to irreparable injuries and damages.
4.2.2. Medical Team as Field Troops
They reminisced about the medical team by calling them as field soldiers. They noted that combat clinic was sometimes very close to the front line and the medical team attended in high-risk areas to take care of the wounded. They were not sometimes in a constant place but were sent to various camps.
“In the Army, the guideline has mentioned that clinic tents can be setup in thirty kilometers battlefield, whereas in the wartime emergency tents were setup ten kilometers away from the main place of the operation and ambulance drivers were sometimes forced to to go ahead two or three kilometers in the front line to bring the wounded back to the emergency tent.” P
3 4.3. Holistic Care
4.3.1. Unusual Conditions
The medical team took care of the wounded in poor sanitary conditions, high workload, and high volume of casualties with extensive trauma.
“Most rural people had infectious diseases such as diarrhea and vomiting due to the use of contaminated water.” P
A nurse said:
“The hospitals and clinics in the city were full of the wounded and martyrs. Skilled staff and existing facilities would not be enough for that tragedy.” P
A doctor mentioned about the high workload in the hospital at the time of enemy’s chemical attack:
“No one would sleep until the next morning. Handling of 1,500 chemically wounded patients had exhausted all. Most staff of hospital did not go to their homes and stayed in the hospital for 17 days.” P
Another informant quoted:
“A critically injured male was brought to the emergency line. The young man had been directly hit shrapnel in his face. His facial muscles hanged and didn’t have the lower jaw. The wound was so deep that technicians were moaning when looking at him and they did not dare to dress his wounds.” P
One rescuer said:
“Unfortunately, we were faced with a tragic scene. All 15 people were pulled from the rubble piece by piece and all were martyred. Cut limbs, crushed and bruised bodies and faces were not recognizable. We found that there were 14 heads of the martyrs, but the pieced body of a three year old girl was headless.” P
25 4.3.2. Actions
The main actions of the medical team included observance to hygiene, high speediness, triage, transferring and evacuating the wounded, caring and treatment, holistic care of the injured, and keeping conditions under control. Establishment of the post of relief, emergency centers, field hospitals, and hospice has been mentioned in the data. An informant said that high speediness in doing procedures is necessary.
“Here (in front) mobility and speediness are of great importance for success.” P
A physician said:
“The injury of the wounded was worse than all (a wounded in the back of the pickup). It was very difficult to prioritize injuries in that situation. I was alone; I did not know which of the wounded must be handled first.” P
A nurse had memorized chemical attack by Iraq in Halabja and deployment of Iranian reinforcements in a pig shed as a second station (Bane) care and treatment of the wounded.
“At first, we gave compotes to chemical injuries, dressed them with sterile cloths, instilled eye drops, sprayed inhaler, superficially dressed their blisters to not be burst and transmit the infection. Then, they were immediately transferred to the Station No. 3 (behind Bane). Medical staff sent the wounded to Bakhtaran after treatment.” P
A doctor mentioned about the Iraqi chemical attack in the Valfajr 8 operation and the care and treatment of the chemically injured in Imam Hussein hospital (Jurjani).
“Chemically wounded patients were regularly admitted. The basement and the upper corridors of the hospital were full of injured patients. We started fluid therapy for them. Nurses sniped ruptured blisters on the body’ wounded then other doctors and I washed them with disinfectants and use the ointment after drying. Finally, we gave them antibiotics. Some of the wounded had severe dyspnea. Even they had a blister in their lungs and had to use oxygen tent.” P
A nurse aide noticed numerous martyrs and lack of enough space in springhouses.
“Springhouses were full of the corpses. Even there wasn’t enough space for the family of Mrs. Dehghan (one of the nurses that all members of her family were killed). Evening soldiers prepared a place for corpses. Some ice slices were put around them to prevent the spread of bad smell and a person stood sentinel to keep the bodies away from animals.” P
17 4.4. Expression of Good Traits
The critical condition of the war caused more expression of good traits such as self-confidence, mobility/ability, diligence, loyalty, precision and concentration, courage, creativity, and wisdom in healthcare providers. An informant said about the creativity of medical staff:
“We frequently were out of enough collars (to fix the neck of persons affected by explosion wave). So, we decided to make them with styrofoams of military equipment that were better than plastic collars and worked very well.” P
66 4.5. Interpersonal Relationships
4.5.1. Interpersonal Relations of Staff
This sub-theme included cooperation between staff as well as morality, cordiality, and spiritual influence. A supervisor of a military hospital stated:
“We (hospital staff) were very warm and intimate. We helped each other and were like a coherent family.” P
Interpersonal relations of staff sometimes were unsuitable and resulted in challenges. An informant noted unsuitable cooperation of local staff from one of the border cities with dispatched staff that caused difficulties for the dispatched team from Tehran.
“Local medical staff stayed in the city after vacating the hospitals. They didn’t cooperate with us and deferred the preparation of operation room and equipment that we needed.” P
Another significant dimension was high spirits of most injured patients despite the severe inflicted injuries that surprised medical team and reinforced their spirits. In contrast, there were people who had a strong urge to return to their homes; they negatively affected other soldiers as well as medical team.
4.5.2. Relationship Therapy
One of the important roles of the healthcare workers, especially nurses, was psychological support of injuries and their families. This role became more difficult, especially when the wounded needed more complex treatments and surgeries or when they were involved in complications leading to serious changes in lifestyle of the wounded, such as limb amputation. One of the difficult situations that employees faced was informing the families of martyrs or injured warriors and psychological support of them. Sometimes the situation was so stressful for the medical team that they could not appropriately react. However, they tried to use their previous experiences and wisdom to manage such situations.
4.6. Sublimation of Spirit
This theme included the loss of materialist dependence in the front, escaping from ordinary life, feeling of inner satisfaction, and sublimation of spirit. Entrance to the spiritual world of the front line led to waking up the mettle of medical team and internal changes.
“All dependencies would be lost. Work, office, car, home, wife, and children lost their meaning.” P
A nurse wrote about keeping away from normal life by going to the front and her feelings at the time of the end of the war:
“It was hard to believe, but we were going to start a normal life again; something that we had escaped from. We had come here to find ourselves. We were closer than ever to death and martyrdom. But, now we had to go back.” P
One doctor wrote about his inner satisfaction:
“I was tired, but I feel good because I had helped the poor.” P
Another informant quoted about uplifting their spirit and flip awakening:
“A flip in the life wakes us up. This is where the sense of responsibility for the war veterans shows its true value and we felt our responsibility. This situation teaches sacrifice and devotion to me and people like me, and warns us that we have not done too much important, if we are joining an amputated hand.” P