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    John B. Fortune, MD, FACS

    January 20-February 10, 2007

    SVS Program Objectives


    The Senior Visiting Surgeon program at Landstuhl Regional Medical Center (LRMC) provides a unique opportunity to expose experienced civilian trauma surgeons to the successful work and accomplishments of the staff of LRMC as they provide an essential component of combat trauma care to the injured soldiers and civilian contractors of Operation Iraqi Freedom and Operation Enduring Freedom. For me, this was an "eye opening" experiences that I will remember as one of the hallmarks of my career. The level of care, compassion, and communication at LRMC are among the best that exists in any trauma center.

    Care in theater

    As noted in previous SVS reports, LRMC is a component of the continuum of care for injured warriors that begins in theater (combat zone) with the resuscitation and initial management by Forward Surgical Teams (FST) followed by transfer to one of the Combat Support Hospitals (CSH or "cash") and eventually to the air base at Balad for transfer out. At the CSH, definitive diagnosis and care is provided with the availability of rather sophisticated radiology equipment (a 16-slice CT scanner) and experienced trauma nurses, general surgeons and other surgical specialists. The injured soldiers are rapidly transferred from theater on board C-17's from Balad or Baghdad under the care of a Critical Care Air Transport Team (CCATT) that provides sophisticated monitoring and ventilator support during the 5-6 hour flight to LRMC. Care in theater is outstanding with heavy reliance on the principles of damage control (abdomen, orthopedic, and neurosurgical) and rapid resuscitation with early administration of blood products. By the time the soldiers reach LRMC, most are remarkably stable in spite of devastating injuries.


    I anticipated that this medical center would be entirely dedicated to the management of the combat casualties. On the contrary, LRMC is an efficient multi-specialty general hospital that serves as the regional tertiary medical center for active duty personnel, dependents, and retirees serving or residing in a huge landmass comprising Europe, western Asia, and northwestern Africa. Like any general hospital, it provides a full gambit of services ranging from pediatrics to obstetrics to psychiatry. The outpatient clinics and emergency department are also an essential component of the hospital that provides care to servicemen and their families in the region. The medical center is operationally managed by the Army but is a true model of collaboration that enjoys contributions from all branches of the service (Army 50%, Air Force 25%, and Navy 25%).

    My experience was primarily associated with the trauma and surgical critical care service which provided care to the most seriously injured soldiers from downrange. Several hours prior to arrival, the trauma team would be notified of the patient's condition and previously delivered medical care by way of the web-based Joint Patient Tracking Application (JPTA). Radiographs were transferred digitally by satellite. Upon patient arrival with the CCATT team, the nurses went to work by connecting monitoring lines, bathing the patients, sorting out the dressings, and obtaining lab work and surveillance cultures for aceneitobacter. The immediate trauma surgical care was exactly as we would expect to see at most sophisticated and efficient trauma centers. Complete exams were performed, radiographs and tests were reviewed, and consultants were called. The major difference was the unavailability of complete medical records documenting the excellent work that was done in theater. Often the records had to be reconstructed from the computer entries on JPTA, the limited progress and nursing notes, the brief x-ray interpretations, and the anesthesia records. Documentation of orthopedic procedures was often written on the dressings! This is clearly understandable due to all of the medical and surgical priorities of the surgeons and nurses downrange.

    Rounds were conducted daily at which time the patient's condition was discussed and care plans developed. Collegiality and collaboration was a common theme among nurses, surgeons, respiratory therapists, dietitians, pharmacists and consultants. The primary operative procedure performed at LRMC was a wash-out of an extremity or abdomen, and the most common bedside procedure was a bronchoscopy (supported by extremely affable and helpful respiratory therapists). From admission forward, the overriding goal was to provide transitional (and sometimes definitive) care in order to facilitate the next phase of treatment which involved a transfer to the military hospitals in the continental United States (CONUS). The home-bound transport missions with the CCATT teams were scheduled for Tuesday, Friday, and Sunday, and the manifests were usually determined during rounds on the day prior. Attention was always directed toward the special needs of the critically ill patients during flight with the understanding that these were usually 9-12 hours in length in a noisy C-17 with limited critical care resources. The fact that this could be done was remarkable!

    So where does LRMC fit into this model of combat trauma care provided over long distances? From my observations, an "intermediate trauma care facility" (in terms of time and location) like LRMC is important for the following reasons:

    1. LMRC provides continuity of care in a less hazardous, more controlled environment. While I did not personally experience the provision of trauma care downrange, I was told that it is performed in an environment of organized chaos with patients arriving almost continuously and without warning. Additionally, I was told that for every coalition soldier or contractor that is evacuated out of theater, there are 9 or 10 Iraqi nationals receiving the same level and quality of care. While the result of trauma care in theater is outstanding, the continual surge of new patients must impair the ability to provide long term critical care to the wounded. Additionally, the need for new open beds must always be a pressing issue in order to provide space for the new admissions. Having "programmed throughput" for the more stable coalition soldier is essential to the CSH's ability to provide resuscitative management to the new patients.
    2. LMRC provides follow-up for "damage control" procedure". Damage control for orthopedic, abdominal, and neurosurgical injuries has become a common and life-saving approach to the massive injuries associated with blast mechanisms. Knowing that the patients will be transferred to a care center that is capable of providing the secondary treatment for damage control procedures allows this approach to be used more freely, confidently and effectively. The rapid transfer to an intermediate care facility is essential for the repetition of wash-outs or definitive care/closure outside the CSH facility. Knowing that surgeons of LRMC are waiting to provide secondary care of the damage control protocols certainly improves ultimate outcome.
    3. LMRC provides a thorough "tertiary survey" of the injured patients. In my short experience, very few injuries and diagnoses were initially missed during the evaluation downrange. On the other hand, full surveys with liberal use of radiological scanning did define some injuries that were not apparent due to the life-threatening nature of the other injuries. Treatment for these could be established in a timely fashion.
    4. LRMC develops a definitive medical record. The surgeons at LRMC were extremely compulsive with documentation and each patient that returned to CONUS had a comprehensive admission note and discharge summary. In many cases, this involved deciphering and reconciling the records from theater, but by the time of discharge a definitive understanding of the injuries and anticipated needs could be communicated to the physicians at Walter Reed or Bethesda or BAMC. The weekly trauma teleconference between the downrange facilities, Landstuhl, and the CONUS hospitals allowed concurrent discussion of patients who had come through LRMC and provided immediate feedback for process improvement. It was clear to me that this should be a component of every regional trauma system.
    5. LRMC establishes medical contact with the family. Every day on rounds, special efforts were devoted to update the status of family notification and communication. In most case, the soldier's primary unit took the responsibility of initially notifying the soldier's families, but the physicians at LRMC provided primary medical contact and ongoing updates. What a relief it must have been for families to get the information on the injuries and follow-up from the physician who actually was providing the care to their wounded family member.

    Since this model is working so well in the military paradigm, one wonders whether a variation should be considered in the civilian response to disasters. It is easy to speculate that a terrorist activity resulting in a huge explosion ("dirty" or otherwise) might partially incapacitate the health care resources in the immediately available facilities. In this scenario, successful patient management would then lie in the appropriate triage and transfer to "disaster destination hospitals" based on the LRMC model. The key elements of this type of plan would lie in the mobilization of a sufficiently sized and medically adequate transport system and the availability of receiving hospitals to provide the services described above. Perhaps this is a model that may eventually transition to the civilian sector as we continue to refine our plans for disaster response.

    Lessons Learned

    Throughout human history, surgical advances are often made during times of conflict. Operation Iraqi and Enduring Freedom will be no different. If I may be so bold as to predict the trauma advances that this conflict will produce:

    1. Continuity of care over long distances. This is discussed above and may be eventually translated into the civilian practice. The implementation of the CCATT concept has been lifesaving for many of our wounded warriors.
    2. Early use of blood products in trauma resuscitation. Immediate blood product administration for patients with active bleeding seems to be the rule for downrange resuscitation. Often, this was associated with appropriate but limited crystalloid administration. Early reports and publications are showing the benefits of this resuscitative approach including the use of fresh whole blood. Anecdotally, I saw one patient with massive lower extremity injuries who arrived at the FST in profound shock (near-PEA) and received over 25 units of blood and over 10 units of FFP along with platelets as part of the initial resuscitation; only 9 liters of crystalloid was given. About 30 hours after wounding, she was in LRMC speaking to her family on the phone ... minimal edema and no pulmonary dysfunction! Imagine that!
    3. Damage control. This is liberally used for not only abdominal injuries but also for orthopedic and neurosurgical injuries. Damage control allows for early physiological stabilization of catastrophically injured patients without necessarily providing definitive repair of injuries. In a system that allows for timely follow-up and definitive surgical interventions, there is very little ground lost with a delay in the definitive treatment. In fact, the required repeat wash-outs (especially for abdominal and orthopedic injuries) may actually remove or dilute the accumulating cytokines in the wounds. Perhaps this approach to less catastrophic wounds may be more common in the future.


    Accomplishments and recommendations

    As a longtime advocate of guidelines for trauma care, I spent much of my time working with the very capable support staff to help refine the meaningful and useful guidelines that were already in place at LRMC (primarily through the previous work of Dr. Warren Dorlac). With the help of the trauma surgeons, neurosurgeons, infectious disease specialists, pharmacists, and dietitians, we were able to develop some templates for the following guideliness:

    • SICU management of brain injury
    • Nutritional support for the trauma patient
    • Clearance of the cervical spine
    • Presumptive antibiotic use
    • Clearance of the thoracic and lumbar spine
    • Admission guidelines
    • Transfer criteria for CCATT
    • Communication with CCATT

    I have only two recommendations that were made to senior leadership. The first involved the observation that the admitting surgeons were overwhelmed with paperwork which could be reduced by the development of better computer-based medical records. Perhaps, the unit should consider rapid turnaround dictation/transcription until user friendly EMR's become available. The second is the restriction of the ICU physician staff to experienced intensivists. Everyone assigned to the unit was an excellent surgeon but many of the reservists came from backgrounds that did not provide much exposure to critical care. I believe this change is being considered but an early implementation might improve continuity, communication, and efficiency.

    For Senior Visiting Surgeons who are planning to visit LRMC in the future, I would suggest that you pick a specific project on which you would like to help. The clinical aspects of care at LRMC are very well covered by excellent and experienced staff who, in many cases, have seen more of these type of injuries than you. In my opinion, the benefit of the SVS, lies in the ability to educate, provide vision, and help mature an already very clinically capable organization.

    Some thank you's: Everyone with whom I came in contact was affable, warm, and welcoming. All of the physicians and staff did their best to make me feel part of the team and welcomed me into their practice and even into their homes. Special thanks goes to Ray Fang who was the host for this experience. I would also like to thank Ken Dempsey, the process improvement coordinator, who provided me with an orientation to the base, the region, and to military tradition. I will never forget the interesting walks through "small town" Germany and the hospitality of his family on weekends. More thanks to Kathie Martin who is doing a yeoman's job in preparing LRMC for an ACS trauma center verification visit in June ... and to Julie Pruitt who helped organize our guideline templates and was the administrative host for the trip. And, of course, thanks to all of the LRMC physicians and surgeons and physicians who are devoting their careers to helping our wounded warriors.

    If anyone has any questions about the SVS, I would be happy to answer e-mails. I can be contacted at fortunej@upstate.edu.