The United States Army perioperative nurses face unique patient care situations during overseas deployments. In this report, the experiences at the U.S. Army's 28 th Combat Support Hospital in Iraq are described. The lessons learned from these situations can assist in patient safety in future operations. The challenges to the nursing staff of performing "housekeeping" tasks while simultaneously accomplishing a number of other patient care tasks are reviewed. The surgical suite structural requirements for the operating room (OR) and for central materiel service (CMS), and the adaptation of the workflow capabilities through CMS to ensure the best possible sterile products are discussed. Cleaning becomes very difficult in deployed environments because of the mass casualty episodes as well as the relentless wind and sand. The effects of fatigue, sleep deprivation, and stress threaten maintenance of standards and attention to detail. Steam sterilization and glutaraldehyde soaking are useful as sterilization methods when adapted to this harsh environment. With this environment, it was necessary to extend the length of sterilization times, adapt pressure bags to rinse lumens, and realign the work flow to ensure better cleaning and sterilization practices. Cultures of the OR and CMS demonstrated the efficacy of our efforts. Room air exchanges, temperatures, water quality, and other structural requirements were measured on a routine basis and problems were aggressively addressed. The work and traffic flow practices were designed specifically to provide an aseptic environment and functional equipment. Staff safety and well being were given priority in order to maintain standards.

The continued evolution of military munitions and armor on the battlefield, as well as the insurgent use of improvised explosive devices, has led to embedded fragment wounds containing metal and metal mixtures whose long-term toxicologic and carcinogenic properties are not as yet known. Advances in medical care have greatly increased the survival from these types of injuries. Standard surgical guidelines suggest leaving embedded fragments in place, thus individuals may carry these retained metal fragments for the rest of their lives. Nursing professionals will be at the forefront in caring for these wounded individuals, both immediately after the trauma and during the healing and rehabilitation process. Therefore, an understanding of the potential health effects of embedded metal fragment wounds is essential. This review will explore the history of embedded fragment wounds, current research in the field, and Department of Defense and Department of Veterans Affairs guidelines for the identification and long-term monitoring of individuals with embedded fragments.

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Infections, troublesome in even optimal health care environments, can be a source of serious and persistent concern for local populations and health care workers during a disaster, and in austere environments such as those found in Iraq and Afghanistan. For these scenarios, it is vital to have standard infection control practices in place and to have them used consistently. Only then will healthcare workers be able to contain the potential spread of disease and improve conditions for those affected.

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