Historically, there have been major advances in the management of the injured resulting from experiences gained in the military campaigns since the birth of this nation. Our current war initiatives, Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), will be no exception. Although the combat engagement continues in both Iraq and Afghanistan, a defining chapter has already been written with regard to "lessons learned". In the opinion of this consultant, there have been five major advances:
1) introduction of a more elaborate system based combat evacuation process
2) defined indications for tourniquet utilization in the field, with evidence-based support
3) the establishment of comprehensive critical care management, including involvement of the Air Force CCATT
4) the initiation of full spectrum analyses of trauma/critical management from "downrange" to Landstuhl and CONUS (especially video trauma teleconference)
5) the establishment of video teleconferences for system assessment
The Landstuhl Experience
As previous senior consultants have underscored, the Landstuhl experience is truly unique opportunity for both the civilian specialist and our military colleagues. This consultant will not describe what has been adequately covered in previous reports regarding the patient management process and the established monitoring/treatment protocols. However, it should be noted that the overall decline in the patient census, especially active duty military, is likely to continue. The focus of the senior visiting surgeon program (SVSP) needs to change in order to maximize the potential of this collaborative effort (see Critical Analysis). A possible area for improvement is the fact that morning ICU rounds are almost always work rounds. While addressing the service demands of an extremely busy service is of the highest priority, fostering a culture of scholarly exchange should also be a priority, particularly when multidisciplinary rounds are being conducted and when there are trainees involved. There are few occasions when intellectual discourse cannot be achieved. Team leaders should take advantage of teaching opportunities, particularly when students/residents/fellows are an integral part of the team.
The highlight of the visit was a first-hand look at a state-of -the-art evaluation process. Every aspect of patient care is critically reviewed, including management "downrange", at Landstuhl, and CONUS (continental United States). Perhaps, the most impressive features of this evaluation process are the weekly video/audio teleconferences in which management issues are fully discussed by the physicians/surgeons and key personnel at each level of care. The "downrange" participants are audio-connected while Landstuhl and CONUS facilities have audio and visual capabilities. Equally impressive is the monthly video teleconferences on issues regarding the system. There are also daily performance improvement rounds led by Colonel Flaherty with the expert support of staff, especially Mrs. Kathy Martin. In addition to this being an outstanding evaluation system, substantive management changes have been made as a result of the process, with the establishment of practice guidelines and protocols.
This civilian and military collaboration should continue. However, with the precipitous decline in overall clinical activity, the goals/objectives of the program need to be redefined if SVSP is to remain viable. While there is always a cyclical and seasonal component to hospital census, the downward trend in patient admissions is now well established. Therefore, the inherent value (including cost benefit) of having clinically active senior consultants assigned for two weeks (or one-month) blocks must be reassessed in order to ensure that this is a value-added experience for both the visiting surgeon and the host institution. I do feel that this can be achieved by redesigning the program, perhaps with greater involvement in the performance improvement process throughout all the echelons of clinical management. This would require specific assignments and tasks expectations. This and other programmatic changes will be imperative if this initiative is going to be sustained.
With optimal collaboration, there are two areas that are fertile for return on investment (ROI):
a) enhanced research productivity and
b) the development of a unique trauma center verification process for the military medical centers involved in the care of the injured.
enhanced research productivity
With a now mature military trauma registry, an advanced performance improvement evaluation process (under the strong leadership of Colonel Flaherty and Mrs. Kathy Martin) is the ultimate in patient continuity (note: weekly video conferences with all participants from "downrange" to CONUS and monthly video teleconferences on system issues), There is no reason, with adequate staffing for research projects/publications to be less than robust. The military does have the necessary research infrastructure and funding; however, the consultants involved in Senior Visiting Surgeon Program could provide additional expertise in bringing investigative projects to fruition and findings to a broader audience.
trauma center verification
Using the current ACS Committee on Trauma verification process as a template, the various military hospitals that participate in the management of the injured can participate in a verification or designation process that would be pivotal in ensuring optimal trauma/critical care management throughout the military network. With preparedness being so vital, particularly during protracted periods of peace, such a verification/designation process, done every three years, would be essential in this effort. A membership consortium consisting of the military, Committee on Trauma (ACS) and the American Association for the Surgery of Trauma could provide the appropriate oversight and essentially be the verification/designation body. There would likely have to be special recognition for the unique features of certain centers. For example, the role of Landstuhl Regional Medical Center is so key in the transition management of the injured in the military theater that a special Level I category should be given to this type of facility.
I want to specifically acknowledge the following individuals for the special support provided me during my visit to Germany:
- Col Stephen F. Flaherty, MC, USA
- Mrs. Sandy Pruitt (and staff colleagues)
- Mrs. Kathy Martin (and staff colleagues)
- Sandra Wamek MD, MAJ, MC
- Chris Bombeck
- Raymond Fang, MD, Lt Col, USAF, MC, FS
- Valerie Pruitt, MD
Special thanks are directed to Mrs. Sandy Pruitt for orchestrating the many aspects of my visit, including travel arrangement, lodging, etc.