A review of the reports of the previous participants in this program, which are posted on the AAST website, would be helpful to understand the location, mission, and procedures and protocols for the surgical care of casualties of the Global War on Terrorism (GWOT) from Afghanistan (OEF) and Iraq (OIF), as carried out at Landstuhl Regional Medical Center (LRMC) in Germany. I will try to avoid repetition of many of the points in these prior reports as much as possible, though some aspects of this experience that have been common to all of us are worth emphasizing.
It should be noted that other surgical specialty organizations have developed similar visiting surgeon programs to LRMC that were modeled on that of the AAST/ACSCOT, including the Orthopedic Trauma Association and the Society of Vascular Surgeons, leading to an orthopedic trauma surgeon and vascular surgeon also visiting here during my tenure. This demonstrates the educational value of these visits.
All of the senior trauma surgeon participants in this program came to LRMC with their own unique backgrounds and expertise in the management of injured patients. It should be noted that this report comes from my perspective as a clinically active and fairly busy trauma surgeon in the U.S., and as a former US Navy surgeon who was deployed on several overseas missions while on active duty, and who was called up from the active reserves in 1991 to deploy to Saudi Arabia with the 2nd Medical Battalion of the 2nd Marine Division from Camp LeJeune in the First Gulf War. I served in combat zones with the US Marines on two of these missions. Despite this background, I was surprised and impressed with the level of devastating injuries of the combat casualties evacuated to LRMC. I was highly impressed with the exceptional competence, professionalism, compassion, and phenomenally unswerving commitment to the welfare of each and every casualty that I observed, without exception, among the physicians, nurses, CCAT evacuation teams, and ancillary professionals who are all involved in the care of these casualties. This commitment extends from the OEF and OIF battlefields and forward medical facilities, thru their stay at LRMC, to the main definitive care military medical facilities in the U.S that constitute the final casualty destinations, at Walter Reed Army Medical Center (WRAMC), the National Naval Medical Center at Bethesda (NNMC), and Brooke Army Medical Center in San Antonio (BAMC).
Although this program was designed to serve as a two-way educational experience for both the civilian trauma surgeons and the military healthcare providers, my experience was heavily weighted to the former. I found essentially no deficiencies whatever in the clinical abilities, knowledge base, organizational skills, respect for colleagues and patients alike, or medical procedures and protocols among this motivated group of trauma and critical care professionals. Although I participated actively in daily rounds, patient care, teaching conferences, and surgical procedures, I really believe I got the best of the bargain from my visit. A great deal of work over the past few years has been directed at streamlining the surgical services at this facility to their present point of a very efficient operational system that I cannot at all criticize. It is a system that works in this specific setting, a setting and mission that have essential differences from U.S. hospitals and trauma centers. The best demonstration of how well it works is the recent designation of LRMC by the ACS as a Level II trauma center.
Travel and Location
The military covers all travel and lodging costs, and provides the airline reservations into Frankfurt. A shuttle service is provided for travel to and from Frankfurt. Landstuhl is located about 90 miles southwest of Frankfurt, very close to the French border in the Rheinland-Pfalz province. It is a quiet village nestled in a small valley that is surrounded on three sides by sizable hills, and the LRMC hospital, first built in 1954, is at the top of one of those hills. Burg Nanstein is a 15th century castle that overlooks the entire area from atop another of these hills. Landstuhl was originally included in the Ramstein-Landstuhl U.S. air base when constructed in the aftermath of WWII, with Ramstein then becoming the largest and busiest NATO air base in Europe. This military air base is located just a few miles north of Landstuhl, and serves as the arrival and departure point for all incoming and outgoing American combat casualties and other medevac patients that funnel through LRMC from downrange, and to the U.S.
Car rentals and rail travel are convenient and easy to secure in Landstuhl or Ramstein, providing ready access to surrounding areas. Paris, Munich, Austria, Belgium, and Berlin are among the many places that can be reached in a matter of hours and visited for a few days. There are a variety of restaurants and sights in Landstuhl that are within walking distance of the hospital compound at the bottom of the hill on which it is located. This is a steep hill that apparently was labeled “cardiac hill” by Bill Schwab. However I didn’t find the climb so difficult Bill, I guess it’s just the difference in our ages? There are a number of extensive hiking and biking trails in the area. Prices are surprisingly low here, although Euros are required outside the American facilities. It is wise to have a supply of ready cash in Euros, as it is unusual for credit cards to be accepted by local merchants.
Preparation for this visit takes a few months, as we must be fully credentialed by the hospital as medical providers, have to secure a background check by the American Red Cross, and have BLS, ATLS, and ACLS certifications current. We are able to work here by being designated as Red Cross volunteers. This process was coordinated nicely through Julie Pruitt, who is the administrator for the Trauma service, and the credentialing personnel at the hospital were also very helpful. One of the general surgeons is designated as our liaison, who provides an orientation to the hospital and area, helps us obtain all necessary ID’s and food, and generally helps us ease into the routines and into the life here. Valerie Pruitt took on this role for me and was very generous and helpful with her time. Kathy Martin serves as the trauma program manager, among her many responsibilities, and was also very helpful and hospitable in acquainting me with the hospital, local area, and the structure of trauma services here.
A temporary military ID can be obtained from Ramstein, which makes access to the hospital and military facilities somewhat easier. I carried my passport wherever I went, as this is necessary to access the strict security at the hospital and at Ramstein. Without an ID, you must be accompanied by someone from the military to buy anything on base. The hospital cafeteria, coffee shop and Burger King do not require military identification. Lodging is provided at the Ramstein Inn just a short walk from the hospital. These are comfortable suites with a living room, private bath, bedroom and kitchenette, very quiet and convenient. There are US electrical outlets in the rooms, as well as a TV, DVD player, coffeemaker, refrigerator, stove and basic appliances. There is no wireless internet service here for non-military personnel, but basic access to the internet for e-mail is provided for us in the ICU call room. A cell phone is provided to us to be accessible to the hospital, which also allows us to access clinical personnel and areas.
LRMC is a large complex that serves active duty and reserve military, dependent, and retired military personnel throughout Europe, Africa, and the Middle East. It is a full service general hospital with outpatient clinics and elective surgery, and is the largest American hospital outside of the U.S. The trauma and critical care service is a part of the Department of Surgery, and is primarily charged with the evaluation and care of combat casualties from the GWOT. All general surgeons rotate for prescribed periods on this service, under the supervision of the trauma and critical care medical directors. The surgical and ICU nursing staffs consist of members from the Army, Navy and Air Force.
Col. Steve Flaherty (Army) is the current department Chair and Trauma Medical Director, CDR Bennett (Navy) is the Vice Chair of Surgery, and Lt Col Ray Fang (Air Force) is ICU director and the primary coordinator of the Senior Visiting Surgeon Program. The hospital commander is Col. Brian Lein (Army), who is also a general surgeon.
There are 5 echelons of care that casualties go through by the time they reach their definitive care facility back in the U.S. The first is the battalion aid station at the battlefield, consisting only of medics. The second echelon consists of both forward medical facilities with general medical officers , as well as the first surgical capability, for immediate resuscitation and life saving interventions to keep them alive long enough to make it further back (i.e. ligation of bleeding, shunting injured vessels, emergent laparotomy). The 3rd echelon is at the Combat Support Hospitals (CSH) at Balad and at Camp Victory in Baghdad, where full surgical capability is available for definitive management of vascular repairs, abdominal procedures, neurosurgical interventions, and initial attempts at extremity fracture stabilization and limb salvage, or immediate amputation. At least two patients I saw had been resuscitated from cardiac arrest from hemorrhagic shock 2 or 3 times before finally being stabilized at the CSH and arriving quite stable at LRMC. The effort and commitment to saving lives at the front lines very much impressed me, as clearly so many of these casualties would never have survived to reach medical care in previous wars, or even in many civilian sectors in the U.S. LRMC then represents the 4th echelon of care where patients are further stabilized and resuscitated as needed, and care is provided that is directed to simply allowing the safe transport to definitive care back in the U.S. as expeditiously as possible at the 5th and final echelon of care at Walter Reed, Bethesda and Brooke Army Medical Center in San Antonio.
The ICU at LRMC is a combined medical/surgical unit of about 12 rooms and is where, along with the operating rooms just across the hall, the visiting surgeon spends most time. There is also the opportunity to spend time on the surgical wards and clinics. Medical intensivists and pulmonologists are integral members of the surgical ICU coverage, taking inhouse night call and primary responsibility for patients, including the combat casualties, right along with the general surgeons. I was pleasantly surprised at how well these many disciplines worked together seamlessly in the care of casualties in this setting, something that is not very common in civilian American trauma centers.
There is a computer in the ICU call room that provides internet access for visiting civilians like ourselves, for e-mail. All other computers are secure and cannot be used without an ID and restricted pass codes. There is a hospital cafeteria with restricted hours of operation for all meals, and a small grocery store that requires military ID to use.
Clinical Routines and Procedures
Each morning begins with a brief review of Performance Improvement issues from the day and night before, with surgeons from the ward and ICU present. At this time the scheduled incoming patients from downrange in Iraq and Afghanistan for ICU and ward care are reviewed with a short summary of injuries. Each of the ICU surgeons then uses this patient information to access the Joint Patient Tracking network (JPTA) to obtain the complete information on each patient to prepare for their arrival later in the day. This is a computerized network that contains all information put in by surgeons downrange on nature of injuries and what care was rendered there, op reports, and all imaging studies. There is no formal medical record from downrange beyond this info. The formal medical record is begun in Landstuhl with this initial info, then added to as care is carried out at LRMC and also pushed into the JPTA for use by the care teams in the U.S. who will then be receiving these casualties uprange. Although this requires a huge amount of paperwork by the physicians at LRMC, it does provide a reliable system for information transfer and continuity of care. The weekly video conference between all units downrange, LRMC, and all receiving hospitals uprange, further enhances this continuity of care, as well as vetting PI issues for resolution.
The great majority of patients are victims of bomb (IED) blasts, accounting for hugely devastating injuries. I only saw two come through with gunshot wounds in my two week visit. Almost all have some level of extremity amputation and severe soft tissue wounds. Fairly definitive care has already been rendered downrange in the first three echelons of care, and most casualties therefore arrive fairly well stabilized. Most fractures have been washed out and ex-fixed, laparotomies have been done, many having open abdomens with wound vacs in place.
ICU rounds begin at 8am, led by the ICU director or his designee, and are truly multidisciplinary. All surgical patients are seen at this time. Rounds are quite comprehensive and educational. Patients were presented primarily by the rotating residents, with attending input, all issues are raised to discuss, and a fair amount of education also takes place. I found the give and take between the surgeons, residents and pulmonologists/medical intensivists very worthwhile. Other surgical specialists, infectious disease physicians, pharmacologists, and nutritionists rounded with us regularly. On every patient, plans for medevac were discussed as to timing and what things had to be accomplished to make it safe for the patient to fly; what wound care was needed, washouts, dressings, debridement, whether to extubate or leave on the vent, what meds had to go with the patient for transport, what special considerations should be relayed to the CCAT teams who will be caring for them in flight. Frequently the CCAT teams who would be transporting the patients would make rounds with us the day before the flights, and would also be present on the day of the planned flights to get the final checkout. Occasionally a patient developed problems shortly before flight and they had to be kept back, but often another patient was quickly substituted in their place, though this tends to be a logistical nightmare.
After rounds the clinical work begins with the patients—getting them to the OR, whatever bedside procedures or imaging studies are needed, and updating the medical record for the purpose of readying for transport. Incoming patients would also then be assessed and treated as needed upon their arrival, typically in late morning. Most procedures were done in the O.R. in view of how extensive and complex they typically were, and due to the fact that so many require the interdisciplinary teaming of many different specialists. There were very few procedures of the type we typically do for long term care, such as tracheostomies or closure of open abdomens, or PEGS, or definitive fixation of fractures stabilized by ex-fix, in view of the unique mission of this facility to serve primarily as a way station for the patients on their way back to the U.S. All efforts are geared to turning them over for travel in the shortest time, typically only one or two days, and therefore it is risky to add new procedures subject to complications in flight. Extubations had to be done several hours before any flight to be sure the patient would do OK. All patients who were intubated or NPO had nasojejunal feeding tubes placed endoscopically by the GI service at the bedside so as to assure placement beyond the Ligament of Treitz, as this is required by protocol to continue feeds in flight. There are rigid protocols in place for screening for DVT and placing on DVT prophylaxis and IVC filter placement, as thromboembolic complications are quite common. A rapid turnover of patients is necessary whenever possible to accommodate the constant influx of casualties from downrange, as well as to expedite their definitive care uprange.
Each Wednesday afternoon, the trauma M&M conference was held, followed by the video teleconference (VTC) with all units downrange and uprange participating. All patients from the preceding week were presented by each of the units by their treating physician, from how they presented and were treated downrange, to how they were handled at LRMC, to their ultimate F/U in the U.S. All PI issues were brought up and some resolution or plan for evaluation of these made. This was then followed by Surgery Grand Rounds where the visiting surgeon is expected to present a talk each week of tenure. It is best to present topics that have some relevance to the work being done there.
At least once on our visit we are allowed to accompany outgoing casualties to Ramstein airbase and observe the process of transport and loading of casualties onto the C-17 aircraft that will take them back home. Again, it is a huge logistical effort to accomplish this, and is done at least 3-4 times each week. CCAT (critical care air transport) teams accompany the casualties on these flights, with a surprising level of critical care capability for caring for them, including vent management, monitoring, suctioning, and the capability, though limited, for intubation and other invasive procedures if necessary. Each CCAT team consists of a critical care physician (surgeons, ER physicians, anesthesiologists fill this role among others), flight critical care nurse and respiratory therapist, all of whom must specially train for this role. Generally one team can take care of 4 patients, and if more patients go, more teams must be available. The patients are transported from LRMC to Ramstein on a specially equipped bus—it is only a few miles away. The flight back to the states typically stops at Andrews air force base in Washington, D.C. where most patients are shipped to Walter Reed or Bethesda. Some then go on to Brooke Army Medical Center in San Antonio, especially the severe burns. These flights also carry less seriously injured casualties who qualify basically as walking wounded and can –and must—be able to care for themselves, as there is little reserve in the event they get into trouble. These are termed AE (air-evac) patients. The entire mission and function of CCAT teams is to make these flights back and forth—over my two weeks in Germany, I frequently saw many of the same teams as they came and went over a few days, both to and from Iraq and to and from the U.S.
I was also privileged to visit the flight deck of the C-17and meet the pilots.
Thoughts and Observations
The protocols and procedures performed at LRMC work quite well for its specific unique setting and mission, because these have been honed down to a high level of efficiency by the clinical teams there over the years it has had this responsibility for combat casualty care. There is really very little, if anything, I could improve upon in their system. The PI and QA infrastructure is quite good and contributed to by all clinicians. The paperwork is quite burdensome, but they are moving to a full electronic medical record in the near future.
The greatest specialty need appears to be neurosurgical coverage. There is only one active duty neurosurgeon there, and while I was there two military reserve neurosurgeons were assigned there temporarily to give the former a break. As long as reservists are available this can work. The biggest neurosurgical need is for the care of spinal fractures, followed by head injuries. These fractures are extremely common from IED blasts, and are often at multiple levels, so much so that the spine is routinely scanned in all these victims. There is also one orthopedic spine surgeon there to help with this. Head injury of varying levels of severity is another common consequence of IED blasts, both from penetrating fragments as well as primary blast injury to the brain. How much work is done on these injuries at LRMC, in terms of fracture stabilization or definitive fixation, halo placement vs collar, craniotomy, intracranial pressure monitoring, etc depends on how stable the patient will be for flight. Much of the definitive care is deferred to the U.S. facilities when possible. Occasionally nearby German hospitals help with specialty care that is not available at LRMC.
There is no dedicated vascular or thoracic surgeon at LRMC, although they do not appear in as much need of those. Much of this work is performed by the general and trauma surgeons. Most definitive vascular repairs are done downrange where there are vascular surgeons. There is currently a program through the Society of Vascular Surgery to rotate civilian vascular surgeons to LRMC to help with their expertise, similar to this AAST/ACSCOT program. Interventional radiology is also limited with no capability for conventional angiography, although some imaging of this type can be done in the cardiac cath lab and some is referred to local hospitals when needed.
Burns can be quite severe in these casualties, a major consequence of IED blasts. Escharotomies and even fasciotomies are often done for extensive and circumferential burns, usually downrange and often being extended or done primarily at LRMC. I saw two thigh compartment syndromes with fasciotomies, which is common. The reason for fasciotomy for burns is the high incidence of compartment syndrome that was seen earlier in the war from burns in which only escharotomies were done, probably related to the primary blast effect on underlying muscle. Extremity injuries without burns also undergo fasciotomy liberally due to their complexity. There is always a high index of suspicion for compartment hypertension and compartment pressure measurements are common. For severe burns a burn management CCAT team from BAMC flies into LRMC to help with the management and to prepare the patient for the trip back with them.
The combat casualties have a very high level of thromboembolic complications, which has led to rigid protocols for aggressive screening, prophylaxis, and treatment. All high risk casualties are screened with U/S for DVT, including any patient who arrives with a femoral line. These lines are always changed out on arrival. In fact, a study is being developed with Peggy Knudson to begin screening all casualties. In my two weeks there, I saw three patients with a pulmonary embolus (two in the same patient as he developed a second PE while at LRMC), both diagnosed within hours of injury in Baghdad and already on full anticoagulation on arrival at LRMC. This early diagnosis is a tribute to the aggressiveness of their screening. IVC filters are placed liberally according to their developed criteria (i.e. spinal cord injuries, failure of, or contraindication to, anticoagulation, etc). Only some of the surgeons are capable of placing IVC filters, and they are done in the cardiac cath lab with the help of the cath lab and operating room personnel, through a protocol developed with the cardiologists. This obviously has worked for this system, but I wonder if a less logistically burdensome procedure could not be developed depending only on the surgeons placing them in the O.R., or even at the bedside, as the U/S and radiological technology to make this possible is available there. This would require only a little training and proctoring for any surgeon to accomplish, as bedside placement is clearly feasible.
Another interesting protocol at LRMC is the early and routine placement of nasojejunal feeding tubes in all patients incapable of taking a diet by mouth. These are all placed endoscopically by the GI service, to document positioning beyond the Ligament of Treitz, as this is required to continue feeding during flight. The GI service is obviously very responsive for this purpose and are a huge asset for this.
The team spirit and dedication of the trauma and critical care service at LRMC are remarkable. This would be a valuable educational experience for any surgeon, and particularly surgical residents, who currently do not rotate there. There is an effort underway to have surgical residents from military programs rotate there. It would be quite valuable to have civilian residents rotate there as well for the experience, although this would require quite a bit of preparation to accomplish. I recommend this experience highly.