MOSUL’S MEDICS: REFLECTIONS OF WAR, FOUR YEARS ON

“The whole experience truly changed me… It gives me constant perspective of my small problems in this world.” – Katie Batrouney, frontline medic, Mosul, Iraq

 

Amid the chaos and intensity of the battle against ISIS in the Iraqi city of Mosul, a critically injured girl was rushed into a makeshift field clinic less than a kilometer behind the frontline. During her escape from ISIS-held territory, the child had suffered multiple gunshot wounds and many other injuries that put her on the very edge of survival.

Within seconds of arriving at the clinic, Katie Batrouney, a young paramedic from Australia, dressed the child’s wounds, stemming the bleeding to buy her some time to reach a hospital. As Katie carried the child out into the street in search of an ambulance, military vehicles screeched to a halt outside the clinic carrying more and more gravely injured civilians in need of emergency medical care, overwhelming the clinic’s few medics and limited resources.​

In that moment, I decided to set my camera aside and accompany Katie in the ambulance, hoping that I might be able to help in some way or at least offer my support. ​As the ambulance sped along the dusty, abandoned, war-torn streets of western Mosul, the child’s terror-filled screams began to weaken until she eventually stopped breathing. With no gurney or medical supplies inside the ambulance, Katie placed the bleeding child onto my lap and instructed me to hold her still while she inserted a needle into her chest, allowing air back into her collapsed lung.

As I held the child on my blood-soaked lap, her terrified eyes locked onto mine, I looked at Katie and thought to myself, how on Earth did we get here!?

In June and July 2017, during the final few weeks of the military offensive to oust Islamic State militants from the narrow and densely populated streets of Mosul’s Old City, I had an opportunity to accompany a team of international medics who I’d heard were working just behind the frontline. The medics were operating out of makeshift field clinics – what they referred to as trauma stabilization points, or TSPs – set up inside abandoned buildings, moving forward as Iraqi security forces reclaimed ISIS-held territory. As civilians escaped across the frontlines, often under fire from ISIS snipers and exposed to air strikes, those who were sick or injured were brought to the TSPs for emergency pre-hospital care.

Documenting the extraordinary lifesaving work of the medics, who are part of the international medical organization Global Response Management (GRM), was a defining period in my professional life, and undoubtedly one of the most moving and challenging experiences of my life. I was especially moved by the strength and fortitude of the female medics, who, for several weeks, I photographed and watched in awe while they worked tirelessly around the clock saving lives under extremely difficult and dangerous circumstances.

On July 10th, 2017, victory was declared over ISIS in the city of Mosul. Four years on, I reconnected with Katie Batrouney, Alex Potter and Kyirsty Unger – three of the remarkable female medics of GRM (who will forever be my heroines) – to ask about their motivations for volunteering in an active war zone, their reflections on the experience, and the impact it’s had on them since.

Katie Batrouney, a paramedic from Australia, carries a critically injured child to an ambulance after providing emergency medical care at a makeshift field clinic near the frontline during the battle against ISIS in the city of Mosul, June 21, 2017.

KATIE BATROUNEY, PARAMEDIC AND NURSE FROM AUSTRALIA

 

Can you tell me a bit about your background?

I grew up in Melbourne, Australia, and from a young age I wanted to participate in humanitarian aid. My first experiences with aid work were when I was 17 and I went on a school trip to Bangladesh. After that,  I knew I would be suited to a career in the medical field and had my heart set on Paramedics.

I’ve now been an Advance Life Support Paramedic for Ambulance Victoria for over 6 years and recently completed my Nursing degree. I’m also working as a Nurse at a Supervised Injecting room that focuses on harm reduction and provides safe spaces for people who use drugs.

I have had the privilege to support people in crisis in Australia and overseas. I find my heart to be cemented in my international disaster relief and aid work. It’s where I believe I can make the most difference and where the support is lacking for these communities in crisis.

When did you travel to Iraq and what motivated you to volunteer as a frontline medic?

 

I traveled to Iraq on my 26th birthday on the 3rd of June 2017. My partner, who also is a medical aid worker, had worked on the front line in Iraq a few months prior and had seen the same need for trained staff to answer the call.

I believe that it’s unacceptable to be in a privileged position with my kind of training and means and not lend a hand. It is simply sheer luck that I am a person who has landed in one of the world’s safest countries and I believe that every individual deserves the same health care that I enjoy.

Civilians flee as the fighting continued to retake the remaining pocket of ISIS-held territory in the Old City of Mosul, June 21, 2017.

You were working extremely close to the frontline – what were the main dangers you faced?

 

Our work brought us very close to the front line, which presented us with some inherent dangers. We were particularly worried that our makeshift medical centre would be discovered by ISIS and bombed. Being shot was also a concern; at any one time you would hear gun shots and the sounds of explosions.

Being a female in a war zone holds some unique dangers for personal safety. Women are often targeted and kidnapped so we had to be incredibly vigilant with our surroundings.

 

What are some of your reflections on that period? I remember being incredibly moved and inspired by how calm and composed you were all the time – how did you cope working in such an intense environment?  

 

The whole experience truly changed me. I felt a lot of clarity when it came to my own privilege and perspective. The work was exhausting and emotionally draining, but I truly thrive on the ability to move to action when it’s needed. Although the environment is intense, it’s also very empowering that there is work to be done and you are able to provide the care that those people require.

 

A critically malnourished two-month-old baby is examined by frontline paramedic Katie Batrouney at a makeshift field clinic on the edge of Mosul's Old City, June 21, 2017.

Two of the cases I remember most clearly are the extremely malnourished baby who you examined and the little girl with the gunshot wounds. Can you share your recollection of those two cases?

 

The malnourished baby was quite moving for me also; I found myself with the time to pause with this infant and reflect on the life they had had up until this point.

The girl with the multiple gun shout wounds had an eviscerated bowel and a gunshot wound to her chest that had pierced completely through. She was extremely unwell. I was able to dress her abdomen with specially designed combat dressing and place chest seals on the front and back of her chest. I then put an IV cannula in and gave her pain relief. The girl was becoming increasingly short of breath as the bullet had pierced her lung. She was showing signs of a tension pneumothorax, which can be temporarily relived with a needle decompression. A needle decompression involves piercing the chest between the ribs with a specially designed needle to relieve the built-up pressure in the lungs. It can be a lifesaving procedure; however, it is only temporary and the child needed to get into surgery as soon as possible.

I then escorted the patient to the closest hospital in the Ambulance while holding her on my lap as there was nowhere else to place her. During the Ambulance ride she began to re-tension, which is when I asked you to hold her still while I inserted another needle into her chest. The little girl made it to hospital, and I handed over to the surgeon who hoped to be able to operate on her soon.

Unfortunately, we don’t know if she survived because we had to get back to our Trauma Stabilisation Point as there was an ever-growing number of casualties to be treated.

After surviving months without enough food and water, Mosul resident Mohammed cried with relief when he was brought to a field clinic in western Mosul. In an extremely weak state, Mohammed had to be carried to the clinic after escaping across the frontline in the Old City of Mosul where the battle raged against ISIS, June 22, 2017.

Are there any other cases or memories that stand out from your time in Mosul?

 

While at the trauma stabilization point, I remember three women presenting to myself and another medic with their friend who had been shot. While we were dressing the wound, one of the girls said in wonderful English that she is an English teacher and that they had been held captive by ISIS for three years. They all began clapping and singing. I asked why they were singing, and the teacher replied that it is all of their birthdays today. I mused that it was amazing that it was all of their birthdays on the same day, and the teacher held my hands and said it is their birthday today because this is the day they are free; this is their new birthday.

I’ll tell you there weren’t many times that I cried while I was in Iraq, but this was one of them.

I remember that you had tried to return to Iraq after the Mosul offensive came to an end – what motivated you to go back? 

 

I knew that the offensive had come to an end which meant a lot of the other major medical providers where leaving. Although the offensive had ended, the fighting had not, and then more than ever the people of Iraq needed emergency medical care. The day I was leaving to go back to Iraq, they announced that the border would be closed for an unknown period of time. Myself and a few team members decided to wait in Turkey in hopes that the borders would re-open. Unfortunately they didn’t, so we were unable to return.

Australian paramedic Katie Batrouney treats an injured child at a trauma stabilisation point a kilometre from the frontline as the fighting continues to liberate the remaining pocket of ISIS-held territory in Mosul's Old City in June 2017.

How did you feel about your experience after you left, and what are you doing now?

Now, due to this global pandemic, we are all restricted from travel, which puts a dampener on any international aid plans. I am very lucky to be in Australia and working as a Paramedic and a Nurse for my local community.

I felt truly humbled by my experience in Iraq – it gives me constant perspective of my small problems in this world.

Combat medics prepare to enter the narrow streets of Mosul's Old City during a mission to find and treat injured civilians fleeing the remaining area of ISIS controlled territory, July 3, 2017.
Injured and sick civilians are treated at a makeshift field clinic set up inside an abandoned store on the edge of Mosul's Old City, July 4, 2017.

ALEX POTTER, REGISTERED NURSE, EMT AND FOUNDING MEMBER OF GLOBAL RESPONSE MANAGEMENT, FROM THE USA

 

Can you tell me a bit about your background?

I’m originally from Minnesota, but since graduating from college I’ve bounced around a bunch. I went to school for nursing but had always loved writing and photographing, even small stories for local agriculture publications when I was young. Throughout high school and college, I followed the coverage of Iraq and Afghanistan closely, and was really drawn in by the photos of something so different from where I grew up, and the idea that one could chronicle history in real time.

I remember pouring over the work of Lindsey Addario, Ami Vitale, Moises Saman, and Ron Haviv, but thinking this journalism path was just so unpredictable and unattainable. Long story short, I graduated, peaced out from Minnesota, and started working in the Middle East, gradually building my visual voice and learning to be a storyteller along the way. I spent most of my time between 2012-2018 in the Middle East, bouncing back to work short per diem nursing contracts.

Alex Potter, a registered nurse form the USA and frontline medic with Global Response management, treats children at a makeshift field clinic on the edge of Mosul's Old City as the battle to oust ISIS intensifies, July 2017.

When did you first travel to Iraq and what motivated you to go there?

 

The first time I went and stayed for a significant period of time was 2016. While the battle for Mosul was just kicking off, I was pursuing a story of refugee couples that had been split up in the previous year’s journey into Germany. But when I saw and heard from friends that there were few frontline medical providers, I figured I could put my skills to work in a more meaningful way – there were many colleagues who’d covered Iraq for years, so I sought an opportunity to work in the trauma sector.

 

How did you end up working with Global Response Management?

 

I heard about a young and motivated group of medics treating civilians on the frontline, so I messaged their country director, Pete Reed. I went into the field with that organization the next week, thinking I’d stay for a couple weeks, but the need was great, so I was dedicated to stay till the end of the battle. Pete and I formed GRM in early 2017 in response to the need for more structure in an organization, the ability to obtain funding, and reach more people with better supplies.

A teenager receives treatment for a severely infected head wound at a makeshift field clinic set up inside an abandoned store on the edge of Mosul's Old City, July 2, 2017. Without access to proper medical care while trapped in the Old City, many civilians arrived at the field clinic in need of emergency treatment for old wounds that had become infected.

How did you combine your work as a photojournalist and a medic in Iraq, and how long did you stay in the country?  

 

The photos I took in Mosul were initially for me – just a way to process what was going on around me, and to give something for my hands to do when we weren’t treating patients. I tried to keep my journalism work very separate from the medic work.

I was there from November 2016 to April 2018 – the extent of the Mosul offensive, the aftermath, and a few months pursuing another story at the end.

A child receives emergency treatment for head trauma and other injuries at a makeshift field clinic set up inside an abandoned store on the edge of Mosul's Old City on July 2, 2017.

You were working extremely close to the frontline – what were the main dangers you faced?  

 

To be honest, it felt very secure to me most of the time – except the last month or so in the Old City. Where we set up our medical points, the buildings had been cleared twice at least by EOD (Bomb Disposal teams), the majority of our volunteers were former military, and I had worked in overt and insidious risk environments before, so I knew we all had good heads on our shoulders. We also had a good working relationship with ISOF (Iraqi Special Operations Forces), and they were very protective of us as well.

 

There were a couple times our team had to pull back to a safer location because of a specific threat, but it happened quickly and efficiently, and we were able to re-engage soon after. I was more nervous for colleagues going to the literal frontline – the very kinetic environment there on a regular basis.

An elderly woman is treated for heat exhaustion and other injuries at a makeshift field clinic behind the frontline in the battle against ISIS in Mosul, Iraq, in July 2017.

 

What are some of your reflections on that period?

 

I feel like I’ve always been a person of action – something needs to be done, so I do it. Throughout Mosul it was just continuously going through that same loop daily on the micro level, and on a weekly or monthly on the macro level. In healthcare, especially as a first responder, you have to stay calm for the sake of your patients and the sanity of your team, and I’ve honestly always thrived in intense situations – I don’t do well during the downtime.

 

I definitely had my own moments of private freak out, but not when patients were around. It was a really intense time though – my entire value set was being challenged, as well as my feeling toward conflict and intervention, alongside the trauma of civilians, particularly children who were very wounded and their first stop was in our door. As a team we tried to rotate everyone back to Erbil every week or every other week to decompress – that was absolutely necessary to prevent burnout, and even with that, because Pete and I and a few others were there the whole time, we were still very burnt out.

Are there any cases or memories that stand out from your time in Mosul? Any lasting personal connections that you made? 

 

There are many – especially of particular patients, but those are pretty jarring, so I won’t really mention them here. The good memories however ironically, also abound. Driving into or out of the city at dusk, listening to music along the way, family style meals with the team and the Iraqis, sitting on the roof of our medical points at night watching the offensive under the stars.

 

The conflict was horrendous, but there were many moments that made you appreciate life even more. I’ve made many personal connections but the main one is Pete, as we started dating there and are still together 4+ years later.

How did you feel about your experience after you left? What are you doing now?

 

After I left, I needed to reconnect with myself, get outside and [do something] cathartic. I do that through the outdoors and physical challenges, so for the next two years I split my time between nursing and working as a Wildland Firefighter in Idaho, which was extremely healing. Because of logistics and some personal career goals, I haven’t been back overseas since mid-2018, but I’m definitely ready to get back to photographing communities I really care about.

 

Mosul absolutely had a lasting impact on me – I’d covered conflict before, but never been so intimately involved with the carnage it imparts on individuals. For a long time, I was very numb and distrusting of others and myself.

 

I don’t want to say I’ve come full circle, as I now have a bit of a darker view of the world, but I don’t sit in that place of darkness anymore.

Kyirsty Unger, an American nurse and volunteer frontline medic, treats an injured man at a makeshift field clinic on the edge of Mosul's Old City, June 27, 2017.

KYIRSTY UNGER, NURSE PRACTITIONER FROM THE USA

 

Can you tell me a bit about your background?

I live and work in the United States. I am currently a family nurse practitioner in Portland, Oregon, but I have a background in emergency and critical care nursing. I’ve worked in adult and pediatric emergency department, trauma center, and a burn critical care unit. Prior to this experience, I have had several experiences working and volunteering overseas in austere environments, which led me to look into disaster medicine and seek out training under that umbrella.

 

When did you travel to Iraq and what motivated you to volunteer as a frontline medic? 

I traveled to Iraq mid-June 2017. I had been involved with an organization called Global Outreach Doctors who referred me to GRM. They were seeking nurses with trauma and burn experience. When I read what the environment was like, I thought about all my training and disaster experience and felt it only made sense to put it into practice.

I thought, ‘if volunteering on a frontline wasn’t for me, who was it for?’ This realization was a strong force that pulled me to this assignment. I think it takes a certain type of person to put themselves out of a place of comfort into an environment of severe uncertainty. My personal life had led me to a place where uncertainty and discomfort felt normalized and I felt as though I would have been resilient enough to handle the experiences and danger. With that, I felt like if I could do this, I could be of use and make it out alive and spiritually sound then I should go. In a weird way, I felt called to it.

Kyirsty Unger, an American nurse and volunteer medic, treats an injured man at a trauma stabilisation point on the edge of Mosul's Old City on July 2, 2017. Days before victory over ISIS in Mosul was declared, civilians continued to emerge from the remaining pocket of ISIS-held territory with many showing signs of critical malnutrition after surviving months trapped in the Old City without enough food, water and fuel. Volunteer medics worked around the clock to provide pre-hospital care to fleeing civilians and injured soldiers.

How long did you stay in Mosul? 

I was in Mosul for about a month. I traveled back and forth between the frontline area to Erbil so there were moments of rest within that time. My friends and I also tried to go back a few months later but were unable to get into the country due to the politics at that time.

 

You were working extremely close to the frontline – what were the main dangers you faced?  

The most incredible thing that I learned on this trip was the idea of ‘relative danger’. Prior to going to Mosul, I had plenty of discussions with my veteran friends and those who served in the Middle East. I researched IEDs [improvised explosive devices] and had reviewed some survival/worst-case scenario trainings. However, when I got there, I remember driving into the Old City, holding my breath waiting for bombs to drop or guns to fire at me, but it was never like that.

The danger surrounding me was insidious, but I rarely felt directly unsafe. Gunshots and airstrikes were blocks away. Strategically placed roadside bombs were detected and detonated by specialists. Stray bullets flew above my head. I think about it a lot. At home in Portland, in the United States, I would feel unsafe if a bomb went off across the country in Boston. However, in Mosul, the violence was close but never directly impacted me, and for that I was lucky.

Honestly, we were just well protected by the circumstances we were in. There is always an opportunity to be killed but I felt safe as ever. After the first three days, it all felt normal and by the time I left I wanted to be closer to that direct danger so I could be of more use and help more people. It was an incredible arc of acceptance.

What are some of your reflections on that period of time? What was the experience like for you? I remember being so moved and inspired by how calm and composed you and the other medics were all the time – how did you cope working in such an intense environment?  

 

I feel as though you could ask me this question every day and I could have a different answer. I wish I had kept a journal and had asked myself this directly after I returned home versus now.

In hindsight, I see my experience as incredibly personally informative. I learned so much about myself, the world, the military, and human capacity for strength and perseverance. While I was there, I felt enthralled to know I was actually doing something that was helpful. I think in health care, the systematic issues are confining and it’s easy to feel disconnected from the reasons and motivations one originally seeks in these types of positions. However, this was visceral. It was hard work as well as heartbreaking, exciting, and frustrating, while moving all at once. It made it hard to feel normal. It was hard to go back and hear people complain about their problems that seemed so abstract by comparison. At the time, being there didn’t register as stressful. The stress of my position was only hard when I returned home, and at times I feel like I’m still chasing the feeling that I really have something to offer.

Medics from Global Response Management treat injured civilians at a trauma stabilisation point on the outskirts of Mosul's Old City, July 4, 2017.

Are there any cases or memories that stand out from your time in Mosul? Any lasting personal connections that you made? 

I think what I remember the most are the days where there were much less volunteers. There was a day that there were only three of us with GRM at a checkpoint. There was an airstrike that hit a building with multiple families inside. On this day we had an MCI (mass casualty incident) with around 70 patients at once. Two of the medics who I knew had my back were driving a baby to a hospital and not on scene. I remember patient after patient, human after human, piling up in a little cement room. Chaos and an overwhelming amount of burn victims surrounded me. We didn’t have enough in our crew to really do anything helpful and the triage processes quickly got out of hand. I remember having a moment where it felt like time stopped and I realized that more people than I could count were going to die this day and they didn’t need to. If we were anywhere else in the world, if there were more people to help, if we had more supplies then they wouldn’t.

At that point, it felt hard to breathe and I felt like I couldn’t move. But then I did. I turned and started walking, pulling two children out of a tank who’s burnt skin stuck to the hot metal of the vehicle. I held them and gave them pain medication. I looked around and just treated the people I could until the ones who were strong enough could clear out of the space.

I think I blacked out and came-to as I was telling some Iraqi soldiers to black tag (leave to die) three older women. I identified a large number of people who could benefit from the hospital. I took a breath. I found more to do and eventually the moment passed. I think a lot about whether or not my being there actually helped anyone. I like to think it did. However, every time I think about why it matters to me to be good at my job I come back to that moment. If I was a better leader, if I had more skill, if we had more resources, then maybe that day could of turned out differently.

As a closing thought, that whole memory would have hit me differently had I felt supported by my team of other healthcare workers. It makes me think about being in a US hospital and all the times where things come together and work well. When the medics returned, I was able to breathe a sigh of relief. I knew in that moment, even if we were overwhelmed again, I had the support I could rely on to carry and share that experience with. I felt deeply connected to the people I met and worked with in Mosul. We collectively shared an experience most will never know in their lifetimes; we also had a lot of fun and incredible memories in spite of the circumstances. They will always be family to me.

An Iraqi soldier prays next to the body of a baby outside a makeshift field clinic on the edge of Mosul's Old City, June 22, 2017.
An Iraqi soldier walks along a street in Mosul's devastated Old City as Iraq's Prime Minister Haider al-Abadi declared victory against the Islamic State in Mosul on July 9, 2017. After nine months of intense fighting between Iraqi forces and the Islamic State, victory was achieved at a heavy cost to Mosul's residents, leaving behind a city in ruins as a result of a prolonged campaign of aerial bombardment and shell fire. According to an Associated Press investigation, the battle claimed the lives of an estimated 9,000 to 11,000 civilians, with thousands more injured and displaced.