The medical rules of engagement
Stars and Stripes May 20, 2008
JISR DIYALA, Iraq — Puss oozes from the gaping hole drilled behind her right ear.
A tube intended to drain excess fluid around the brain protrudes into a ridge that runs down the side of the skull to her abdomen. The scarred and malnourished 7-month-old looks like the victim of a back alley surgical hack job.
Marian, who comes from a village south of Baghdad, is running out of time.
"This is not good at all," Maj. Felix Oduwa mutters to himself as he conducts his examination.
For Army doctors, who spend a portion of their time doing medical outreach, such cases are agonizing. Oduwa, a doctor serving with the 2nd Brigade Combat Team, 1st Armored Division, knows what this child needs. He just doesn’t know whether he can deliver it.
To send an Iraqi to a U.S. military hospital, rules of eligibility dictate that life, limb or eyesight must be at immediate risk of being lost. But determining immediate danger isn’t an exact science. There are gray areas, and it’s not yet clear if Marian meets the standard.
"We are put in a difficult position sometimes. As a doctor you’re trained to help people and relieve suffering. But we are in a war zone and the rules are different," Oduwa said. "It’s not something I like at all."
Oduwa first learned about Marian a week ago. The baby’s father, out of money and options at Iraqi hospitals, made the trip to Jisr Diyala in the hopes of getting help from the Army.
Abdul Kadum Hamdi first tried to get help at private Iraqi hospitals, but they always wanted money upfront, he said. In one case, they even wanted the family to provide the medication as well. Hamdi had neither. The government hospitals, meanwhile, never offered much more than an IV drip to help with dehydration.
"I go to the hospital, but the doctor didn’t help. He says she needs this and this and this but that he can’t do it," Hamdi said.
Hamdi suspected the Americans could do more. Armed with pictures and X-rays of his daughter, he made the drive from a neighboring village to Jisr Diyala to find out. He left his daughter’s medical information with soldiers from Task Force 1-35 Armor, hoping it would get to the right person.
The pictures ended up in the hands of Oduwa, the unit’s surgeon. At first, Oduwa thought the deformity on Marian’s skull could be a tumor, which wouldn’t be classified as an immediate emergency. Nonetheless, Oduwa’s curiosity was piqued.
On Friday, the doctor got his first look at the girl.
During the exam he asked the usual questions. He learned that the child is breast-fed but refuses to eat. The child is all bones and too weak to raise the pitch of her constant cry to a scream.
The doctor gives a blunt assessment.
"Your baby is very sick. The shunt needs to come out," Oduwa told the parents. "She’s malnourished and dehydrated. She needs to be taken to a hospital for a long time to save her life. This is a matter of life and death."
The doctor was telling the parents something they already seemed to know. The question was whether anything could be done about it.
Oduwa walked out the door to phone his headquarters. He placed a call to the brigade surgeon at Forward Operating Base Hammer to make his pitch.
"We need to get some help for her. I can’t just send her home," Oduwa said over the phone. "She’s the sickest child I’ve seen in a long time. If you’re going to do anything for anybody, it’s this little girl."
But it’s not a simple matter. Can the case be called an immediate life-threatening emergency? Does it fit into the medical rules of engagement? Marian’s been in this condition for weeks, if not months. If she’s stable, shouldn’t she go to an Iraqi hospital?
After the phone conversation, Oduwa isn’t too confident about the prospects.
"That girl is going to die if she doesn’t get help," he said after hanging up the phone.
Oduwa tells the parents that he’s trying to get their daughter admitted to a military hospital, but there’s also a good chance they will have to visit an Iraqi hospital instead.
Hamdi and his wife, who uses a bottle cap to drop water into Marian’s mouth, simply nod. The difference between the two hospitals is the difference between a death sentence and a chance at survival, Oduwa later reflects.
Then the call from headquarters comes. Capt. Joseph May, the 2 BCT surgeon, reports they’ve got the go-ahead to evacuate Marian. Ultimately, questions about life and death must be answered by doctors in the field, not from headquarters, May said.
When Oduwa hears the news, his grimaced face relaxes.
"Thank you. Thank you," he says.
"It’s tough for a doctor to see somebody and say, ‘Oops, there’s nothing I can do for you,’ " he tells May.
Then he goes to tell Marian’s parents.