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    R. Stephen Smith, MD, FACS


    Senior Visiting Surgeon Program

    R. Stephen Smith, MD, FACS

    April 28 through May 14, 2007
    Landstuhl Regional Medical Center Report

    Overview

    Landstuhl Regional Medical Center is a vital component in the system of care for servicemen and women who are injured or become ill in Afghanistan and Iraq.  This Army facility is the largest American hospital outside of the continental United States.  The hospital is uniquely designed.  It houses a number of outpatient activities in addition to providing inpatient services for active duty members and dependents.

    Senior Visiting Surgeon experience is one of the most meaningful events of my 25 years in surgery.  The professionalism and commitment to high quality care exhibited by the Tri-Service medical team at Landstuhl are truly exemplary.  The level of care, communication, and cooperation present at Landstuhl is a tremendous improvement over experiences in other recent conflicts.  The advances that have been made in the Department of Defense's approach to combat casualty care are light years ahead of my experiences during Operations Desert Shield and Desert Storm as an active duty member of the United States Navy Medical Corps.

    Highlights:

    • LRMC is an extremely busy trauma center. Essentially all injured patients admitted to LRMC are transported by the CCATT program from Afghanistan and Iraq. Due to this, injured soldiers, sailors, Marines, and airmen who arrive at Landstuhl have received initial treatment in Iraq or Afghanistan. Many have undergone one or more life-saving operations at these initial sites. The patients arriving at LRMC have severe and devastating injuries which most civilian trauma surgeons see only occasionally during busy careers. My two weeks at Landstuhl corresponded to the beginning of the most recent troop "surge" in Iraq. This resulted in an extremely busy clinical load. The vast majority of patients seen in the ICU were injured by improvised explosive devices (IED). I estimate that 80 to 85% of the critically injured patients for whom I had the privilege of caring were injured by these devices. Gunshot wounds were much less frequent, but were still a prominent mechanism of injury. Gunshot wounds were primarily secondary to sniper fire. The current generation of body armor worn by our troops is quite protective of the torso; therefore, wounds to the head and cervical region as well as extremities were prominent.

     

    • The level of care provided in the Intensive Care Unit at Landstuhl was second to none. The team at Landstuhl is truly multi-disciplinary and consists of trauma surgeons, critical care specialists, infectious disease specialists, and a variety of exceptionally capable ancillary personnel. The single neurosurgeon assigned to LRMC was extremely busy. Patients with severe intracranial injuries routinely were decompressed by craniotomy. This aggressive approach was the norm rather than the exception. Gastroenterologists also participated in the care of these critically injured patients by placing nasojejunal feeding tubes with endoscopic guidance within the first few hours of admission. The use of well designed clinical pathways and protocols improved the continuity of care at Landstuhl and could serve as a model for civilian trauma centers.

     

    • The anesthesiologists and operating room staff were quite capable and willing to go the extra mile in treating these patients. During my two weeks in Landstuhl, I participated in approximately 20 to 30 operative procedures at all times of the day and night. I was truly impressed by this hospital's ability to provide operative treatment for severely injured patients on an around-the-clock basis. Operating room personnel were not only quite skilled and knowledgeable, but were extremely pleasant and obviously committed to providing second-to-none care.

     

    • CCATT teams that provide transport of critically injured patients to and from downrange facilities are very well trained and capable. These teams of physicians, nurses, and respiratory therapists were responsible for the transport of severely injured, ventilator-dependent patients during flights of six to ten hours. The "mobile ICU" on the CCATT flights, including mechanical ventilation and invasive monitoring, was good although somewhat limited in scope. The support devices are actually attached to the litter on which the patients are transported. Most of the critically injured patients spent from 48 to 96 hours in the Intensive Care Unit at Landstuhl prior to transport. The goal in these patients was to stabilize and improve their status as quickly as possible to provide rapid, safe transport by CCATT as soon as possible.

     

    • Social Services and family support services at LRMC are fantastic. The families of injured servicemen and women were usually transported to Landstuhl within 24 hours of the arrival of their injured relative. The compassion shown to the injured service members and their families was truly impressive.

     

    • The VTC conference held weekly represents state-of-the-art, multicenter performance improvement. This conference provided audio and video links with downrange facilities in Iraq, Afghanistan, and at the major tertiary centers in the United States (Bethesda, Walter Reed, and Wilford Hall). This real-time discussion of patients through all echelons of care provided excellent and timely feedback to all involved providers. I witnessed multiple examples of performance improvement and loop closure during these weekly sessions. This system could serve as an excellent model for civilian trauma centers that receive significant numbers of their patients from outlying facilities.

     

    Trauma Center Verification

    During my visit to Landstuhl, the hospital was in the final stages of preparation for a visit from the American College of Surgeons, Committee on Trauma Verification Program.  To set the objective of Level II Trauma Center Verification was an extremely ambitious goal for this facility.  The efforts toward verification were lead by the commanding officer, Colonel Bryan Gamble, a plastic surgeon; Colonel Stephen Flarherty, Colonel Warren Dorlac, and an extremely capable and experienced trauma program manager, Kathy Martin, RN.  Seeking trauma center verification is further evidence of the commitment to providing quality trauma care.  This task was made even more difficult by the unique set of injured patients who are treated at LRMC.  The trauma service at LRMC was well on their way to Verification at the completion of my two week visit.  It was quite gratifying to work with the team in achieving this important goal.

     

    Senior Visiting Surgeon Activities

    The list of senor visiting surgeons scheduled for LRMC is quite impressive.  I felt extremely fortunate to have participated in this program.  My primary efforts during my time at Landstuhl included:

    1. Participating in bedside care of these patients. I participated in 20-30 operations. I made rounds daily in the ICU with the team for 13 days out of the two week visit.
    2. Providing a series of lectures, including a mini symposium on trauma ultrasound. This included not only clinical applications, but an overview of ultrasound physics and ultrasound instrumentation.
    3. Assisting in the Trauma Center Verification preparations.

     

    Recommendations 

    1. There is an abundance of opportunity for clinical research in multiple different specialty areas. The large number of severely injured patients represents a rare opportunity for cutting edge clinical research. I believe that resources should be provided by DOD to assemble a team to assist with research efforts that would include a Ph.D. research scientist, a statistician, and several research nurses. Some of the most important advances in the care of trauma patients over the next decade could potentially result from research activities conducted at Landstuhl.
    2. The staff at Landstuhl are extremely experienced, talented, and committed; but they were stretched quite thin. Additional surgeons and critical care specialists would be beneficial to the efforts there. In particular, additional neurosurgical assets should be assigned at LRMC. The single neurosurgeon assigned to LRMC was exceptionally busy. A second neurosurgeon should be added to the staff.
    3. I believe the interval of care at Landstuhl could be enhanced by a protocol emphasizing early tracheostomy for patients who will obviously require prolonged mechanical ventilation. The clinical load at Landstuhl was such that this could not always be accomplished in as timely a manner as would be optimal.
    4. One of the reasons for delayed transport from Landstuhl to CONUS facilities was the progression of respiratory failure. I believe that greater utilization of innovative modes of ventilation, such as ARPV, could be used to optimize the pulmonary status of patients prior to CCATT flights. Additionally, the transport ventilators are limited in capability and should be upgraded as soon as possible.
    5. Portable ultrasound systems should be placed on CCATT aircraft to enhance the ability to diagnose an in-flight pneumothorax. Auscultation of breath sounds with a stethoscope is essentially impossible in flight due to the background noise. US could also be used as an aid to line placement and for the traditional FAST exam.

     

    Final Thoughts

    The SVS program is a tremendous opportunity for civilian trauma surgeons to experience the devastating injuries that our military colleagues treat on a regular basis.  This program also provides for the introduction of new ideas by experienced civilian trauma surgeons into the already capable military system.  This is truly a win-win situation and should be continued and expanded.  My wonderful experience at LRMC was made possible by exceptional clinicians and fantastic hosts.  I wish to specifically recognize Colonel Stephen Flarherty, Colonel Warren Dorlac, Commander Bruce Bennet, Colonel Vic Davis, Lieutenant Colonel George Smith, Kathy Martin,RN,and Valerie Pruitt for their extraordinary efforts.