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    Kimball I. Maull MD, FACS


    December 18, 2006 – January 14, 2007

    Overview

    Landstuhl Regional Medical Center (LRMAC is the largest hospital outside the United States which is owned and operated by the US government. It serves many roles including that of primary care provider to the 55,000 military personnel and their families who reside in the immediate vicinity of the hospital. It also provides specialty care to the >500,000 military personnel, active duty and retired, and their families who reside in the European theatre. LRMC has a busy emergency department and provides ambulatory services in family practice, internal medicine, psychiatry, pediatrics, and dermatology. Surgical services include general surgery, plastic surgery, orthopedics, neurosurgery, urology, and otolaryngology. The obstetrical service averages three births per day and consultative services include radiology with computed tomography and MRI, nuclear medicine, addiction medicine, and neonatal intensive care. The hospital is fully JCAHO accredited. LRMC operates 142 beds but can open and staff over 350 beds in a crisis.

    It is in the context of being a busy general hospital that LRMC's role as a very special trauma center must be viewed. For example, there is a daily operating schedule which includes elective general surgery as well as major operations in the surgical specialties. In other words, the surgeons are not limited to operating on trauma but have elective general surgical patients to maintain their skills. There are two operating rooms which remain available for priority trauma operations. During my four week tour of duty, I had the privilege to work with a number of dedicated surgeons and other physicians, including 3 residents and a critical care fellow, as well as an enthusiastic support staff. I participated in the care, including operative care, of 32 acutely injured patients.

    LRMC is designed as a series of 14 interconnected two-story pods with a central corridor and a main building which contains the emergency department, critical care units, operating theatres, etc. The facility is modern, clean, and, during weekdays, the halls are bustling with an admixture of people in military uniforms, scrub garb, and street clothes. An occasional overhead page in German is a rare reminder that one is not in the USA. Conveniences within the medical center include a post office, bank, fast food, and travel agency, among others. It is a very supportive environment for fulfilling the hospital's multi-dimensional mission.

    As one enters LRMC, the logo clearly defines "selfless sacrifice" as the principle focus of the institution. This beneficent attitude is almost palpable, and examples of putting the patient first occurred on a daily basis while I was on assignment at the hospital. "Never give up" justly describes the approach to even the most desperate and clinically challenging injured patients. On more than one occasion, I helped or observed a seemingly hopeless situation only to discover via video-conference the next week that the patient was not only alive but off the ventilator. Aggressive surgical therapy is routine and, "if in doubt, wash it out" clearly makes a difference.

    This difference plays out "down range" or "in theatre" as the lingo refers to trauma care in the combat zone. I was continually impressed with the quality and extent of operative intervention - operation and re-operation - which was performed before the patient arrives at LRMC. Typically, a wounded serviceman or woman would be treated on site by a medic, evacuated to a Forward Surgical Team (FST) where life and/or limb saving operation could be performed. The wounded patient would then go the the Combat Surgical Hospital (CSH) for additional surgical intervention, if necessary, and lastly to the evacuation point(Balad in Iraq and Bagram in Afghanistan) for flight to LRMC, or for additional care prior to evacuation. The typical patient arrives 24-36 hours post injury via Critical Care Air Transport Team (CCATT) which includes a physician, nurse and respiratory therapist.

    A Trauma Clearinghouse

    According to all accounts, the transmission of clinical information from point of injury to LRMC is vastly improved compared to earlier methods. Although labor intensive, the availability of clinical data on each expected arrival, often including images of CT scans performed in theatre, is clearly an advantage. Further, the hospital course at LRMC is added to the database and all of the data follow the patient up the line to the next treatment facility. Compared to the routine data which accompanies an injured civilian stateside, this is an exceptional system, especially considering the environment in which data is generated. Nonetheless, the philosophy at LRMC is to re-do everything, from re-assessment of the patient, to re-placement of vascular access, arterial and venous, to re-washout of open wounds, to re-explore and re-close abdominal wounds, if appropriate. One cannot argue with the results: the goal is the safe transport of the injured back to CONUS (continental US) and LRMC's track record is nearly error-free. In this regard, LRMC serves as the clearinghouse for all casualties from Operation Iraqi Freedom (OIF) and from Operation Enduring Freedom (OEF). Any seriously injured patient who cannot be returned to duty within 30 days is evacuated back to CONUS. Military personnel injured in Europe or who find their way to LRMC because of medical illness may also be air evacuated. Typically, Walter Reed Army Medical Center (WRAMC) is the destination point for army casualties and those with major amputations; National Naval Medical Center (NNMC) is the destination for navy and marine casualties and all cranially injured by penetrating missiles; Brook Army Medical Center (BAMC) receives all burn patients and those whose home base is west of the Mississippi River. Wilford Hall preferentially receives air force casualties. CCATT rarely transports to destinations other than those listed above, whereas air evacuation of less severely injured may travel to a wider destination list.

    "Experience-based Medicine"

    One of the most remarkable insights I gained during my four week assignment was an appreciation for the clinical protocols and how they evolved from practical experience. I have always been skeptical of "cookbook medicine" because it tends to discourage independent thinking, but it is clear that much of the genesis of the trauma protocols came from just that. For example, the leading cause of secondary mortality early in the conflict was from venous thrombosis and pulmonary embolism. An aggressive anticoagulation protocol was instituted. With the exception of intracranial injury, almost no one showed up without prophylactic fractionated heparin already implemented, including patients with "damage control" packed livers, pelvic wounds with massive transfusion, patients least likely to be heparinized early in civilian practice. I became a believer when bleeding complications failed to materialize. Because the severely wounded are sedated for the eight hour flight from theatre to LRMC and, in turn, for the twelve hour flight to CONUS, the need for prophylaxis is extreme and has paid off by not recording a single death from thromboembolism since the protocols have been instituted. In addition, venacaval filters are commonly used in the spinal cord injured patients, and all patients with a femoral venous line at any time receive venous doppler studies to detect femoral venous clot. Two positive studies were found during my stay: one received a filter plus prophylaxis and the other patient was fully anticoagulated.

    There are protocols for most everything and the majority are based on experience or a combination of experience and current clinical thinking. Antibiotics are used sparingly and only on specific indication, depending on the injury. Acinetobactor is a common and vicious bug. All incoming patients from theatre are skin swabbed for culture when they arrive and again when they depart. This is a work-in-progress but should yield some idea about where the contamination is acquired, what happens while the patients are confined at LRMC, and if therapy at LRMC is beneficial. I had occasion to participate in the care of a soldier injured by an IED who developed an aggressive acinetobactor infection which required daily washouts and debridements, and delayed his evacuation to CONUS for nine days. Preventing ventilator-associated pneumonia (VAP) is another rigorously practiced protocol using a scoring system for determining the need for antibiotic therapy. Preventive measures are vigorously used in all patients who are ventilator dependent, including an early weaning protocol with extubation goals that pre-empt evacuation. This is based on the "experience" that it is safer to delay the patient's transfer and have the patient extubated than to transport a ventilated patient, delay extubation and risk VAP. I witnessed several examples of this and became convinced of the wisdom of these decisions. Other protocols, to mention a few, include a very tight glucose control protocol, optimizing the blood sugar between 90-110; electrolyte replacement - automatically replacing potassium, phosphate and magnesium when certain thresholds are reached; immediate enteral nutrition - if not at operation then by endoscopically placed transpyloric jejunal feeding tube; and the use of a multidisciplinary checklist to facilitate complete daily patient reviews for rounds in the critical care unit.

    Rounds in the ICU are typical for a high quality trauma program. All the players are there: surgeons, critical care docs, nurses, respiratory therapist, pharmacist, nutritionist, chaplain as well as any "learners" like fellows, residents and medical students. In short order, it became clear that we are all learners and, protocols or not, a tremendous amount of discussion was generated by and for these critically injured and critically needy patients.

    Critical Care Air Transport Teams

    This was another area of practice which I found enlightening and impressive. Three times a week, flights to CONUS had LRMC critically injured patients as the priority for transport. The teams often made rounds with the ICU service the day before, just to get up to speed with patients scheduled for transport the next day. On the morning of transport, they arrived with their 60 plus pounds of equipment, transferred the patients to the evacuation stretchers and observed them in the ICU for 45 minutes before transporting them to the flight line and situating each patient in the belly of the C-5 jet transport planes. This is as close to an exact science as you can get in transporting widely different patients to different destinations under difficult conditions. The level of pride and professionalism among this group stands out. The physicians, usually critical care or ED physicians, together with the critical care nurses and respiratory therapists, are highly skilled and organized with clear commitment to rendering the best possible care to their patients.

    Performance Improvement

    Notwithstanding the dedication of the personnel and availability of technical resources, there is always room for improvement, and the staff are the first to recognize the need to stay at the top of their game. The preparation for Level II trauma center verification is a tangible emphasis in this direction, but weekly morbidity/mortality conferences have long been in place and are used for the benefit of patient and clinician alike. A recent addition, which strikes me as a "best practice" model, is the weekly Video Trauma Teleconference (VTC) and the monthly Continuum of Care Systemwide VTC. The VTC includes all echelons involved in the care of the injured patient from the FST to the CSH, from Bagram and Balad, with follow-up from WRAMC, BAMC and NNMC. LRMC coordinates this exercise but the patient is tracked from the first point of intervention to the patient's current location where his/her status is recounted. Problems, including errors in diagnosis or management during the care of the patient along the way, are discussed. More importantly, this unique communication setup provides meaningful feedback to reinforce the clinicians' efforts. I immediately fell in with how empowering this was to those who toiled tirelessly to save life and limb. The monthly VTC includes a much broader group of players and considers system issues such as pain control, equipment updates, burn treatment during transport, and progress reports on programs already in the pipeline.

    Final Thoughts

    I highly recommend this program to civilian trauma surgeons as a meaningful and professionally rewarding experience. You will learn far more than you teach and, in the process, gain an appreciation for the fine work being done by our military counterparts. As a parent, if I had a son or daughter in OIF or OEF and if they became a battlefield casualty, I would be relieved to know the commitment, dedication and priority that our military places on each and every injured armed forces member. At LRMC and up and down the line, selfless sacrifice continues every day.