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    M. Margaret Knudson, MD


    December 4-18, 2006

    SVS Program Objectives

    Overview

    The two weeks that I spent at LRMC are among the most rewarding of my entire surgical career and I strongly encourage others to take advantage of this unique opportunity. If you do, you will find yourself surrounded by excellent, dedicated physicians, nurses, pharmacists, respiratory therapists, transport teams, dieticians, social support personnel and others who focus on one thing only: providing outstanding care to these critically injured soldiers. It is a system unlike any that most academic surgeons ever experience and it will change your life in ways that cannot be adequately described in words.

    Highlights and Lessons Learned

    1) The soldiers coming out of theater have unique constellations of injuries, often blast, burn and blunt trauma all in the same patient typically injured by an IED. The critical care of these types of patients is incredibly intense and requires strict attention to every detail. Having the burn protocols and the support of the burn team from BAMC is helpful, but the ICU care in Landstuhl really determines if the patient will live or die. Renal dysfunction is common in these patients, due to the myoglobin loads, and the accompanying respiratory problems often require unique modes of ventilatory support, both in transit and in the ICU. Careful attention to escharotomies and/or fasciotomies is important, and all wounds and lines coming from "down range" are considered dirty. Patients are swabbed for organisms, all wounds are debrided and cleaned in the operating room shortly after arrival, and all lines are changed. The use of the new Silverlon dressing materials has greatly facilitated the wound care; these dressings are easily applied and fixed in place and can remain for several days as long as they are kept moist.

    2) ICU rounds were also a unique experience. Daily rounds included the surgeons, pulmonologists, an infectious disease physician, a pharmacist, a dietician, a PI nurse, social and psychosocial staff, as well as ICU nurses. Every aspect of the care of each patient is thoroughly discussed. Nutritional support and infection control are aggressively (and appropriately) pursued. It is challenging to pick up these patients "mid stream", without first-hand knowledge of their initial presentation/resuscitation and even their operations (sometimes 2 prior to arrival at Landstuhl: one at an FST unit and one in Balad or Baghdad).

    3) Another challenge is the need to consider all the changes that can occur during the next phase of the patients' care: the long transport via the CCATT teams to the US (CONUS). Expected changes in flight include elevation in ICP, increased tissue swelling in all compartments (extremity, pulmonary, abdominal) , the difficulty in caring for open wounds in flight, the battle to prevent hypothermia, and the real risk of developing venous thrombosis(see below). Any potential medication (including blood) must accompany the patient during transport, which may be as long as 12 hours. The CCATT teams that transport these patients are incredibly well trained. The highlight of my trip was to see the "flight line" at Ramstein Air Base as patients were unloaded and loaded on to the C-17 transport planes. This is a well orchestrated and extremely professional process and I was grateful for the opportunity to view it first hand.

    4) The VTC conference has been mentioned by others before me. I had the opportunity to present one of my patients, who had originally undergone a damage control operation by Mark Boywer at Balad, I participated in his second operation and was relieved to hear that he did well thereafter at WRMC! This method of information sharing and patient follow-up provides an insight into the challenges at each level of care and serves as an excellent example of a system wide performance evaluation.

    5) The operating room staff (nurse, techs and anesthesiologists) were extremely pleasant to work with and were always ready to provide rooms for the needed second operations. Twice we had to call in extra teams, who came in promptly and without complaints.

    Objectives

    In addition to participating in all phases of patient care during my two weeks, I focused on two other main issues: trauma center verification and trauma/critical care research.

    Trauma Center Verification

    LRMC is working to assure that all the criteria necessary to meet Level II ACS standards are in place. This requires a commitment by the Hospital Commander (currently Colonel Bryan Gamble, a plastic surgeon) and can be solidified by language written into the mission of the European Regional Medical Command. Many organizational steps have already been accomplished, such as developing a trauma registry, hiring an extremely experienced and talented trauma program manager (Kathy Martin) and other support staff for the program, organizing multi-disciplinary trauma review committees (in house) and the trauma systems committee mentioned above. However, there are some unique challenges that still need to be addressed:

    • Information systems: gathering the necessary data from the forward hospitals and the CSH (including X-rays, operation reports etc) is extremely difficult, despite the computerized Joint Patient Tracking System. The data is often spotty and key factors are sometimes omitted, requiring phone calls and/or emails to the providers in Iraq or Afghanistan. Additionally, getting access to this information was difficult, especially for those of us who are not in the military, and thus were not allowed on these computers. Sending radiology files on CDs with the patients would be of great assistance and would prevent unnecessary duplication of studies.
    • Interventional and vascular radiology does not exist currently at LRMC and this deficiency should be addressed. The existing CT scanner is old and slow, although there are plans to replace it with a multi-slice state-of-the-art scanner.
    • The physicians in the ICU are embroiled in routine paper work which could easily be completed by nurse practitioners. Addition of NPs would also help to assure compliance with practice guidelines, as the nursing staff in the ICU have a high rate of turnover as their deployment tours end.
    • The "prehospital phase" and the "initial evaluation/resuscitation phase" of trauma care is currently provided primarily down range. A thorough description of these phases will need to be included for the ACS site visitors. The experience gained by the core surgeons who are planning time in Balad (Warren Dorlac in Jan-Feb and Ray Fang in March-April) should facilitate this process.
    • Addition of physical and occupational services in the ICU should be encouraged, as some of these patients stay longer than the more typical 48 hours and could greatly benefit from early institution of rehabilitation services (especially those with head injuries and amputations).
    • The plans for the hospital during periods of de-escalation should be thoroughly in place. These plans might include a skeleton experienced trauma crew that could be exported to other places of need during the next conflict; provision of on-going disaster training for other regions; participation as a trauma center within the existing German trauma system; or a stronger focus on prevention and/or community outreach as some potential solutions to this rather unique dilemma.

    Trauma Research

    There is a wealth of data in this system and many opportunities for scientific investigation. Many of the core surgeons and pulmonologists are working with the Nova-lung, a device used to rescue patients in respiratory distress who have failed all other methods of support. They are developing the indications for use and protocols for initiation of this therapy. Other areas that are ripe for study are the use of the wound vac during transport and the development of compartment syndromes during prolonged fights. Measurement of bladder pressures and use of the NIRS to evaluate extremities should be considered. I brought a portable ultrasound machine with me and we used it almost daily in the ICU. Several studies using ultrasound could be initiated.

    One particular problem is the development of DVT/PE in these young soldiers. Their risk factors seem to be the high amputation rate coupled with the prolonged immobilization during flights. During my two weeks, we had one patient with DVT and one with PE who were found to have these complications develop after arrival at WRMC. Both had been receiving prophylaxis and had undergone surveillance scanning prior to transport to CONUS. This suggests that the long transport contributes significantly to this potentially life-threatening problem. Ray Fang and I have already developed a VTE study protocol that we hope to get funded and initiated within the next few months and which will, by necessity, have to include both Bethesda and WRMC. Because the support for research at LRMC is limited, I have offered the administrative and biostatical services of the San Francisco Injury Center to assist in getting this study underway.

    Conclusions

    During my time at Landstuhl, I had the opportunity to work with the following outstanding physicians, with whom I interacted daily both professionally and socially. I am deeply indebted to them for making my time there so rewarding:

    • Warren Dorlac
    • Pete Marco
    • Valerie Pruitt
    • Bruce Bennett
    • George Smith
    • Vic Davis
    • Ken Graff
    • Ray Fang
    • Gina Dorlac
    • Steve Silvey
    • Steve Flaherty

    This is a unique time in trauma surgery. While our very existence as a specialty has been challenged by some, this is also an opportune time to re-define ourselves. The SVS program has initiated the process of providing civilian surgeons an opportunity to work closely with our military colleagues outside of the U.S. in a challenging, stimulating, and rewarding environment. We should be looking for ways to expand this effort, perhaps by including our trauma fellows and surgical residents in the process. Our profession as a whole and trauma surgery in particular, stands to benefit from this program, as do the injured patients that we collectively care for. I am grateful to Bill Schwab and Wayne Meredith for supporting this program and to Jay Johannigman and John Holcomb who worked so hard to get it initiated and who graciously offered me the opportunity to participate.