When looking at the history of countries, it is seen that there have been many wars and conflicts due to political or social reasons. The idea of assigning medical personnel at wars goes back to the Battle of Solferino, which took place in the 19th century. Reference Bebiş and Özdemir1 It is known that emergency health services were carried out by soldiers in World War 1. While military health services had been executed by military units in Turkey until 2016, due to the closure of Military Medical Academy after the July 15 coup attempt and the following transfer of these units to the Ministry of Health, they have been obliged to purchase goods and services for all types of health care transactions. Reference Çetintaş and Akyön2 Since the Syrian civil war began in 2011, Turkey, as a neighboring country, has been very affected by this situation. Besides the negative conditions, such as malnutrition and lack of sufficient water for cleaning, due to the war in their own countries, Syrian refugees suffer from health problems because of the psychological effects of the war as well. They carry these health problems to the regions they move to. Reference Çevik3,Reference Miles, Huberman, Huberman and Huberman4 In this study, the problems experienced by the emergency medical specialists (EMS) who are assigned by the Ministry of Health along the borderlines due to the situation in our country, the methods of overcoming these problems, and the effects of this system on the physicians are discussed.
Materials and Methods
The case study design is used as a qualitative research method in this research. Eleven EMS who had a border duty between 2018 and 2019 are interviewed.
A sample is a sufficiently large cluster considered to best represent a universe when it cannot be measured entirely. Sample selection differs in qualitative and quantitative research traditions. When it comes to qualitative research methods, the number of people included in a sample is not significant. It may be the whole universe or just 1 person. Reference Yıldırım and Şimşek5 In such cases, the non-probability sampling method is used. The type of sample varies according to the subject determined in the non-probability sampling. In line with the research question of this study, typical case sampling (TCS) was used. In TCS, the point is to find a sample that most typically describes the event in the universe. In this study, a sample of clusters is selected from physicians working in the border regions. The number of such physicians varies dynamically, depending on the process. No official figures have been released up to now.
A semi-structured interview form is used as a data collection tool. The preliminary interviews and pilot applications are examined by an expert, and the questions are finalized thereafter. Some feedback of the expert are taken into consideration by the researcher. Within the scope of the interviews, code names are used for the participants. Verbal and written consents are obtained from them ahead of the interviews.
The descriptive index tables belonging to the pilot application of the interview are created, and the reliability value is calculated with the help of the expert. The reliability of the research is calculated by using a reference. The reliability is found to be P = 84.09%. Reference Miles, Huberman, Huberman and Huberman4 As determined above, P = 70%, the research is taken as reliable.
The thematic analysis is made when coding data, finding themes, arranging themes and codes, and defining and interpreting the findings. Reference Miles, Huberman, Huberman and Huberman4 Within the scope of the analysis, 2 themes and 7 subthemes are obtained.
Results
The research data are adapted to the written text, and then a content analysis is conducted. Two themes and 7 subthemes appeared in line with the subproblems of the study.
Theme 1: Problems of Border EMS Working at Border Points
Subproblems, subthemes, and codes of the first theme are presented in Table 1.
Table 1: Problems Experienced by Emergency Medicine Specialists Working at Border Points (Theme 1)
Difficulties Before Border Mission
In the content analysis of this subtheme, conducted as part of the research, the problems experienced by the EMS before the duty process are addressed. It is found that financial uncertainty is the leading problem. At the beginning of the duty process, the physicians have not been paid to cover their travel and accommodation costs. They have been informed that the written documents would be kept during the duty and that payments would be made at the end of it. The point to take into consideration here is not the physicians’ insistence on financial matters but the problem of their personal rights not being met.
“Nothing is clear in terms of financial issues. It is not obvious wherefrom the payments will be made, how much will be made, even if it will be made or not.” (Physician – İlke)
One of the biggest problems faced is that the duty details of the physicians working voluntarily and compulsorily have not been given, the living spaces have not been described, and the expectations have not been met after then.
“I was informed about my border duty just 10 days before. The head of clinic gave me a ring when I was on call at the hospital. I didn’t receive any official letter. No one had clear knowledge.” (Physician – Ali)
Difficulties and Environmental Conditions Faced During a Border Mission
The most important problem, according to the research data, is poor environmental conditions, in particular, tents used to accommodate and fulfill the duty.
“Especially, the tents that we serve and rest in during guard days are in itself a great weakness. They are not safe.” (Physician – Barış)
One of the biggest weaknesses in terms of first aid tents is that medical supplies are not sufficient and cannot meet the demand. The identification of these deficiencies is done by the physicians, but remedying them is a subject of hierarchy and procedures.
“There is no equipment to make a medical diagnosis and provide treatment in the field tent where I am working. The deficiencies expressed are not reported and remedied immediately. The main reason behind that is we do not have a clear duty description and an addressee.” (Physician – Barış)
Female physicians are also assigned border duty. The problems experienced and stated by them predominantly weigh on sexism and hygiene. Another thing is local people’s views about the physicians and the other officials. Sociodemographic characteristics are likely to have an impact on anxiety levels. In the general population, anxiety is usually more prevalent in females than in males. Reference McEvoy, Grove and Slade6 Likewise, it has been reported that female physicians have higher anxiety levels than male physicians. In addition to the constraints imposed on all physicians, female physicians are also exposed to specific stressors related to discrimination, lack of role model and support, role stress, and overload. In the academic field, women are promoted more slowly, paid less, benefit from fewer resources, and suffer from a number of micro-inequalities. While the frequency of moderate–severe anxiety was 26.6% in female physicians, it was 12.6% in males. Despite all difficulties, female physicians are usually satisfied with their career and cope with stressors owing to their personal coping techniques. Reference Dutheil, Aubert and Pereira7
Places where the physicians and the other medical professionals fulfill their duties are located very close to the borderline. It is very unlikely for them to adapt to a duty that begins without knowing the dynamics and characteristics of the environment and without preparing themselves for this process. Reference Jahn8
“During a mortar attack on the military post where I was serving in, I heard the sound of the mortar shell and then lay down on the ground to take my own precautions. Nevertheless, 4 shrapnel pieces glanced off my body.” (Physician – Tolga)
Cold weather conditions and lack of appropriate solutions are other major problems physicians have expressed. Damaged heaters, old tents with holes, or ripped ones increase these problems.
“Weather conditions are harsh. A different geography. As soon as we arrive to the city, without even getting used to it, we begin our duty.” (Physician – İlke)
Unsafe transportation routes increase the stress of these physicians. They are scared of being attacked on their way out: “Every day, we reach the military post after our own heart. We have no idea whether these routes are safe or not. There is no medical staff wearing a combat uniform. No one knows if there are sufficient uniforms or not.” (Physician – Ali)
One of the most important elements for people in such regions to feel safe is shelter. According to the information obtained, the shelters built there are not suitable for crowded groups. Moreover, areas used normally as canteens are transformed into shelters by closing their windows. Dr Ali reported his observations in the following:
“Although the shelters are above the ground, they do not have enough ventilation and lighting when they are filled with people. There is no safe medical intervention area in case of attacks. Soldiers’ dining and resting places are transformed into shelters by placing sandbags in front of their windows.”
As their cell phones have generally no service, the physicians cannot communicate with their families and relatives sufficiently. This makes the environment more difficult for them.
“I had no opportunity to make a constant contact with my family, my child, and my friends as my phone had no signal along the borderline.” (Physician – Sezer)
Some problems may occur between the physicians and the military personnel due to the fact that they belong to different professional groups and that there is no clear duty description and no defined hierarchy.
“Unfortunately, the most distressed situation I have experienced with our soldiers is the problem of who will first search the body. They claim that it is the health care professional’s duty to undress and search the body.” (Physician – Ahmet)
Environmental conditions, whether working in a tent or in a hospital, are not suitable for medical diagnosis and treatment, protection of relatives, and prevention of violence.
Professional Difficulties on a Border Mission
The difficulties experienced by the physicians on this duty are the basis of this subproblem. Participants express sense of duty and responsibilities. The lack of a duty description and an explanation on which issues they would take initiative have caused some difficulties. Reference Jahn8
The physicians have had negative thoughts during their duties as they experienced a different process compared to their routine work. This has caused a feeling of noncompetence in terms of their professions. It is asserted that battlefield medicine should be performed by a different medical field and a unit with different equipments.
“I have never felt medically incompetent but very ignorant. I thought if only we could have gone through a war training (medical and/or security, etc.) or built a more professional unit for this kind of work.” (Physician – Cem)
During the war period, there are differences in terms of cases when the operations are executed and suspended. While injuries and more serious cases occur as the operations are actively continuing, normal polyclinic cases with complaints, such as upper respiratory tract infection and low back pain, are predominant during non-operation times. It is stated that the necessary conditions have not been sufficient for the physicians to make a medical diagnosis and treatment during this period.
The variety of cases in the border region may differ from previous ones that are well known in theory and in practice. Related literature and an exchange of ideas are needed at such times. One of the participants emphasized on the variety of cases, in the following.
“It was challenging to deal with pediatric cases that I do not encounter frequently in the hospital and congenital diseases that are not extensive in our country.” (Physician – Ahmet)
Theme 2: Overcoming Methods and Suggestions of Emergency Medicine Specialists Against the Problems Experienced
Subproblems, subthemes, and codes of the second theme are presented in Table 2.
Table 2: Suggestions and Methods for Overcoming the Problems Experienced by Emergency Medicine Specialists Working at Border Points (Theme 2)
Situations to Overcome
In some situations, the physicians have refrained from getting stuck in procedures, formal processes, and hierarchy. The methods of preceding ones who had many problems during their duty to overcome these problems would be a guide for newcomers. It cannot be said that every problem encountered in this process has been resolved.
One of the major problems that occurred during border duty is related to drugs. They have been provided by the physicians’ own efforts. The process of supplying desired medicines may take longer than necessary when left to the system. Some participants, such as Dr Barış, emphasized with codes and anecdotes that they had tried to solve their drug supply problem by themselves: “Depending on the frequency of the cases encountered, I and my teammates had gathered the medicines provided by our own means in the field tent, and had given them to the soldiers in need.”
What physicians need most is the assistance of their colleagues who are working or had worked in the region. This is about consulting and sharing information on possible solutions of the relevant situations. In this regard, Dr Gizem stressed that receiving assistance from her colleague had made her feel more comfortable: “I had a friend from the National Medical Coordination Team (NMCT). I knew that I could always consult him. Knowing that you are not alone makes you feel strong.”
As it would be a serious waste of time to anticipate positive results from official interventions against the backdrop of every difficult physical condition, the physicians have stated that they had used effective communication while overcoming such problems. This communication medium is important not only for the solution of problems, but also for the improvement of the psychological status of the soldiers who have been working under these difficult conditions for months.
At the beginning of their duties, most of the physicians have created lists to determine what materials are available for their use. In addition to this, Dr Ali stated that he had detected the blood groups and the chronic diseases of the soldiers who perform their duties in the same military post to be practical in case of a possible attack: “For many of the deficiencies, we provided opportunities in light of the literature. I created a chart that comprises the blood groups and chronic diseases of the soldiers. This would be a risk, but I have to take initiative at life-threatening times.”
It is very important to deploy well-trained people against every possible situation in the region. Problem solving capacity is higher among the personnel who have received such trainings and have been familiar to border region cases. Dr Ali had voluntarily provided trainings to the assigned medical personnel to overcome this problem: “I trained other medical personnel what we could use in armored vehicles. Many of them didn’t have such training.”
Recommendations for Newcomer Physicians to the Borderline
The participant physicians who had worked in the border region have made general and personal recommendations for newcomers. Among these recommendations, Dr Gizem put forward of keeping basic first aid supplies accessible. She also recommended writing down their experiences and reading books to abstain from the environment: “They should carry materials such as needle and thread, basic drugs, pocket-knife, plaster, aluminum thermal blanket on their back or waist packs.”
Dr İlke laid emphasis on making contact with the preceding physicians to get help and opinions. She stressed that effective communication could be a solution to the problem that occurs due to the lack of legal documents and sources: “They should communicate with the preceding physicians and meet the needs before arrival. Self-protection, authority, and responsibility instructions corresponding to the duty station should be received before the assignment because there are no legal documents including most of them.”
Dr Ali recommended giving basic life and first aid training to the soldiers in the same duty region: “They should absolutely give medical training to the soldiers in the duty station.”
Suggestions for Improving the System
In light of the findings, it is understood that most of the problems arise from the system. The participating physicians anticipate that training physicians on battlefield medicine, clearly explaining to them the environment, planning orientation trainings, organizing experience, and sharing meetings would increase the quality of the medical service and the security. The common suggestions of the participants are to plan these trainings under various topics.
“I believe that the medical personnel to be assigned should be first trained on basic military matters and then brought here.” (Physician – Barış)
Dr Barış suggested improving the tent conditions within the system and establishing well-equipped and secure medical centers affiliated to the regional outposts. According to him, improving the environmental conditions for medical diagnosis and treatment would positively affect the physicians assigned: “I think that being assigned in a medical center instead of a field tent affiliated to a military post would increase our effectiveness.”
The NMCT takes an active role within this system. Clarifying the realm of authority as to this unit and supporting its actions is also an important proposal to improve the system. To make the assignments more effective and have the NMCT consist of physicians well-equipped in accordance with the environment conditions, the physicians suggested that commissions be established at the Ministry of Health and that battlefield medicine minor programs be built within the universities.
“The NMCT should be transparent and institutionalized as soon as possible, and its realm of authority should be cleared. The NMCT’s authority and action capacity should not be left to the initiative of the local governments.
“Battlefield medicine should be built as a minor branch under the emergency medicine specialist program. It should be transformed into an honorable medical discipline with its personnel being rewarded for their efforts. Medical organizations in the field should be planned by the experts.” (Physician – Ali)
Impacts on Physicians Working at Border Points
The impacts of border duties on physicians during the assignment and before are discussed in this section as anecdotes and codes.
According to Physician Ali’s statements (after an explosion and an injury case, he had not been personally involved but had seen in his immediate environment), he began to question how he would react in such a situation. Having nightmares at nights due to the explosive noises he heard has had the most negative impact on him. Physician Ali emphasized that such a duty for his country brings peace and experience to him, despite all the difficulties:
“Working along with our soldiers in such a place gives both an experience and a peace of doing a duty for our country.
“My son, whom we don’t allow him to use a cell phone, has now become a child playing with it. I miss him and think that I am an incapable father.”
Feeling incapable is a situation that everyone experiences at some point in his or her life. But this feeling and the lack of self-confidence that comes with it, feeling incompetent and weak, and even embarrasment, might prevent the related person from maintaining his or her relationships, achieving success at school or at work, and feeling happy and peaceful. Not to be able to be around his child and his family, to meet his child’s needs when requiring basic care, with his wife’s assuming full responsibility, gave Dr Ali a feeling of incapableness as a father.
“I would wince even if a door crashes swiftly now. I am psychologically in this mood. I am constantly waiting if something drops from the sky. I still could not get through this process, and it had a negative impact on my social life after I had returned.” (Physician – İlke)
Physician Ahmet stated that he feels vocationally happy, thanks to his experiences gained. Besides this, having been tested by difficult conditions made him reach a more dynamic result: “Being able to perform my profession under these difficult conditions provided a personal satisfaction for me. Thanks to my experiences, I was able to return as a more vigorous and dynamic person.”
Despite some negative impacts, high levels of professional happiness and satisfaction are determined within the scope of this study supported by anecdotes and codes.
Conclusion
The assignment of physicians as EMS along the borderline and in the war zone is increasing due to the policies of the Ministry of Health. Systematic problems arise from the fact that the system isn’t managed from a single center during the assignment process, that the physicians do not have a special experience in this field, and that there are various negations in terms of the environment conditions. The physicians assigned couldn’t generate individual solutions to the environmental and systemic problems due to the hierarchy and other reasons.
Changing the system in accordance with the outcomes, giving special trainings to the physicians assigned, providing academic education in battlefield medicine field, and executing appointments and assignments from one center are the main measures to be taken. Apart from these, the problems with respect to security, tents, and shelters need to be solved. While the border duty has many psychological, sociological, and emotional effects on the physicians, they state that professional satisfaction has been met, but personal rights have not been granted. In this process, the physicians need many solutions, such as mentoring and experience sharing meetings.
Conflict(s) of Interest
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this paper.
Ethical Standards
Informed consent was obtained from the participants.
