Standardizing war trauma surgery - 'Battlefield Docs' converge in Iraq

Published May 30, 2007
By Capt. Ken Hall
332nd Air Expeditionary Wing Public Affairs

BALAD AIR BASE, Iraq -- More than 40 "battlefield docs" -- surgeons and physician assistants from around Iraq -- converged at Balad's Air Force Theater Hospital May 21 to hone their already razor-sharp surgical skills at the Tri-Service Extremity War Surgery Symposium.

Battlefield medicine has greatly improved since the beginning of Operation Iraqi Freedom, more so since Desert Storm, and leaps and bounds beyond Vietnam and Korea. No longer does it look like the scenes portrayed in the TV series M.A.S.H., although Balad's hospital is reminiscent of the one staffed by "Hawkeye" and "Colonel Blake" in the sense it's still a maze of tents. Amazingly, though, survival rates for U.S. patients here have reached an amazing 98 percent -- unheard of in past wars -- and surgical procedures here rival any performed in trauma centers stateside.

"One of the ways we've been able to achieve that 98-percent survival rate was defining and perfecting a standardization of care that prevents, or at least reduces, unwarranted practice variations," said Col. Brian Masterson, the hospital's commander. He explained that while two doctors might treat a given wound differently based on their own unique experiences and training, there just plain has to be a standard way of treating wound 'X' with therapy 'X' to yield consistent, positive results.

That standardization has also improved 'throughput' capacity at the hospital. On several occasions in past months, the sheer number of casualties coming in within minutes might have shut down a trauma center back home. Not so at Balad. Where typical Level 1 trauma centers stateside might see 2,000 admissions a year ... the AFTH nets 8,000. So it is, too, with different types of trauma. Back home, only 30 percent of wounds are penetrating traumas compared to more than 90 percent in Iraq; and where high-velocity gunshot wounds are infrequent back home, here they are the norm. Finally, multiple-casualty events are rare at U.S. trauma centers, but are commonplace from today's battlefield.

"Our purpose with this symposium was to build a vision that all branches of service in the medical profession would embrace so we take optimal care of our men and women risking their lives every day," said Lt. Col. Craig Silverton of the 332nd Expeditionary Medical Group.

Symposium co-directors Col. Mark Richardson, also with the 332nd EMDG, and Colonel Silverton planned the day-long event to include interactive lectures and sessions in preoperative medical management as well as the treatment of Coalition Forces' vascular, soft-tissue and orthopedic wounds in order to better provide critical medical care in the theater of operations. Speakers with first-hand combat medical experience through past deployments shared lessons learned with one another and with new personnel recently deployed here. As a side benefit, the course provided eight hours of continuing education credits for deployed medical professionals in Iraq.

Echoing the hospital commander's sentiments on standardization, Colonel Silverton said, "We set up this symposium to build a 'standard of care for the theater.'" The colonel has a unique perspective of the care being provided in both combat theaters with a rotation at Landsthul Regional Medical Center, Germany, under his belt. He served there as the OIF/OEF orthopedic trauma surgeon in 2004, then deployed to Iraq with the first group of surgeons in the fall of 2004 when the Air Force took over Balad's theater hospital.

He said that since Balad became the [medical] 'hub' in Iraq, he's noticed a difference in the way war trauma surgery was carried out at various theater locations. Each surgeon had their own training and perspective on how best to handle a trauma patient.

"So it was my feeling a 'standard' could be initiated involving all three services, not just the Air Force, and we could form a consensus as to the best treatment for wartime casualties," he explained. Colonel Silverton also noted that what is unique about this environment is most casualties are related to IED's [improvised explosive devices] and EFP's [explosively-formed penetrators...a deadlier form of IED], and they're treated differently than typical high-velocity gunshot wounds seen with the AK-47 or the M-16.

"Debridement, or the removal of dead tissue, is crucial to preventing infection and for survival of the limb," he said. "Our first goal is to save the patient's life -- even if it requires amputation of one or both legs. Unfortunately, many times that is the case. Education is our main goal of this symposium, and if we can save just one life or one limb; it will have been worth our effort."

With the current generation of body armor and all its enhancements to better protect troops, the highest percentage of combat wounds in this war are to troops' extremities," said Lt. Col. Raymond Fang, co-director of the intensive care unit at the AFTH, "hence the focus of this symposium." He deployed from the 435th Medical Squadron at Landstuhl Regional Medical Center in Germany.

"Many people come here with vast trauma experience and expect it'll be just like back home, but this is totally different," said Colonel Fang. He has been caring for wounded Coalition Forces for the past three years at Landstuhl, but just a day or two removed from the level of care he is now seeing first hand at the AFTH. Combat medical care comes in stages from that given right on the battlefield by medics and corpsmen, to combat surgical hospitals throughout Iraq, to theater hospitals and then medevac to Landstuhl, and finally to definitive care at medical centers like Walter Reed and Bethesda in the national capitol region and Brooke and Wilford Hall in the San Antonio, Texas, area.

"The whole goal is that new personnel won't feel like they have to reinvent the wheel," said Colonel Fang. "Instead, they can draw and build upon past experiences so that from day one, they can provide the most up-to-date therapy available to wounded coalition forces."

What we do here is unique and different from medical/trauma care anywhere else in the Air Force ... all our common goal is to provide the best care possible to wounded heroes here in Iraq," said Colonel Fang. "We sometimes have to set aside our own pride and confidence in our learned way of doing things and do it the way it's been proven here on the battlefield through experience ... that's the benefit of capitalizing on the lessons learned here and creating standardized therapy."

"The care we're providing at the Air Force Theater Hospital is the best anywhere in the world," said Colonel Silverton. The hospital here has nearly every surgical sub-specialty covered, and with the most recent advancements in medical technology such as a 16-slice CT [computed tomography] scanner and hand-held blood analyzers at their disposal, the colonel said, "We have the ability to take an injured patient into the operating room within minutes being operated on by a highly skilled team of surgeons." That capability is critical because even though stateside most patients may require only one procedure and one surgeon, here at Balad, the vast majority of trauma patients require multiple procedures, and those procedures are most often performed by a team of surgeons all around the table at the same time.

As an Air Force Reservist, Colonel Silverton works in Detroit at Henry Ford Hospital, one of the main trauma centers in Michigan. "I would put our capability here in Iraq up against any major trauma system in the US," he said. "We are truly stellar in our ability to provide 'state of the art care' to our wounded service members."

USAF. (U.S. Air Force Graphic by Rosario "Charo" Gutierrez)