By Donna Miles
American Forces Press Service
WASHINGTON, Nov. 18, 2013 – Traveling around the combat
theater over the past four months, Army Lt. Col. (Dr.) James Geracci was on a
quest.
Like his contemporaries in military medicine, Geracci, a
family physician and operational medicine specialist, is thrilled about
advances over the past 12 years of conflict that have elevated casualty care to
a whole new level.
Every soldier, Marine, airman and sailor on the ground is
now trained as a medical first responder in basic lifesaving skills. Medical
evacuation response times have dropped dramatically, and the system now moves
casualties through progressive levels of care faster than ever imagined
possible. Advanced lifesaving techniques are applied throughout the continuum
of trauma care, reducing blood loss, controlling brain swelling, salvaging
limbs and saving lives.
But the military trauma community sees its glass as half
empty rather than half full. Instead of celebrating the advances that enable 98
percent of U.S. combat casualties that reach an advanced treatment facility to
survive, they’re focused on improving the odds for those who don’t.
So as Geracci recently traveled around the combat theater,
he went directly to the front-line commanders and combat medics he and his
fellow medical professionals believe hold the key. All were familiar with new
reporting and documentation procedures that require them to document the care
they provide at the point of injury and as casualties are evacuated to
advanced-level care.
But what Geracci quickly realized hadn’t trickled down
through the chain of command was the “So what?” So he and his team took that
message directly to more than 1,400 medics assigned to small combat outposts
and forward operating bases across Afghanistan, as well as to their nonmedical commanders
and noncommissioned officers.
“We looked them in the eye and said, ‘This is why this is
important,’” Geracci said. “We tried to explain that although this is an
enterprise-level initiative, it has to start at the ground level. And as we
talked to them, it was amazing. A light bulb suddenly went on.”
Air Force Col. (Dr.) Mark Mavity, the U.S. Central Command
surgeon, calls that recognition one of the most significant new developments in
casualty care for troops in Afghanistan.
The Department of Defense Trauma Registry, established in
2005 as the Joint Theater Trauma Registry, offers detailed information about
every trauma patient treated at an advanced theater facility. It tracks
patients from the moment of arrival at the closest field hospital or other
facility, through each movement to more advanced levels of care, and ultimately
through rehabilitation.
The registry also includes autopsy results from every
casualty who died.
Eight years since its introduction, the registry has become
the world’s largest combat casualty care databank. By studying it, medical
professionals have been able to verify which treatments were the most
successful and which weren’t, and to flag areas where new or different
procedures or technologies might improve survival rates and patient outcomes.
“This gave us an opportunity to step back and understand the
population of patients that have moved through the continuum of care and to try
to derive information about the care they received and the outcomes associated
with that care,” said Air Force Col. (Dr.) Jeffrey Bailey, the Joint Trauma
System director. “By being able to analyze and evaluate our practices, we have
found points where we can make improvements that provide a survival advantage
or some other advantage to our casualties.”
Lessons learned through the registry have resulted in “best
evidence-based best practices,” he said, propelling many of the advances in
caring for casualties and preventing them in the first place.
The formal documentation of injury patterns, for example,
led to improvements in personal protective equipment ranging from protective
ballistic undergarments to ancillary plating that protects the groin, shoulders
and neck.
The registry also provided statistical evidence of the
importance of immediate intervention during the so-called “golden hour.” That
led then-Defense Secretary Robert M. Gates to institute a policy in 2009
reducing the timetable for medical evacuation to 60 minutes.
Data provided by the registry also validated the use of
tourniquets and led to new approaches to transfusions, resuscitation procedures
and hemorrhage control.
But trauma surgeons recognized a glaring weakness in the
registry. Because it was based on care delivered at treatment facilities, it
omitted critical information about the care provided before the patient ever
got there. That “prehospital environment” was where most combat deaths
occurred. “So that is where we saw the greatest opportunity to make
improvements,” Bailey said.
“Some people call helicopter evacuation the ‘golden hour,’
but others have described what happens on the ground as the ‘platinum 10
minutes,’” he said. “It became clear that we needed to understand what was
going on on the ground during those platinum 10 minutes before the helicopter
showed up.”
That led to the stand-up of the Pre-Hospital Trauma Registry
initiative earlier this year.
Army Col. (Dr.) Russ Kotwal, a family and aerospace medicine
specialist assigned to the Joint Trauma System at Fort Sam Houston, Texas, was
a pioneer in championing this concept. Working for more than a decade with the
special operations community, much of it with the 75th Ranger Regiment, he
formulated a precursor to the militarywide prehospital registry in the late
1990s.
“I saw a huge gap,” he said, lacking any documentation of
patient care at the initial point of injury and on evacuation platforms.
But getting those who provided that initial care to take
time out to annotate exactly what they were doing was no easy task, he
acknowledged. “A lot of people find it more exciting to provide the care than
to actually document the care,” Kotwal said. “Some don’t understand the big
picture and how crucial it is to capture what you are doing for historical
purposes, but also for performance improvement.”
So Kotwal made it his personal mission to change that. “I
convinced the line command that if everybody has the potential to be a casualty
on the battlefield, especially in a line unit, everybody has the potential to
also be a first responder,” he said. “And if you don’t capture that information
about what you are doing, that data, it is hard to effect performance
improvement in that realm.”
Knowing that the success of his effort would depend on the
first responders, Kotwal made the documentation process as simple and
straightforward as possible. He and his senior medics changed an outdated field
medical card that was standard at the time to one that focused solely on
tactical combat casualty care.
Every 75th Ranger Regiment member was issued a card as part
of their basic equipment, and required to keep it in a standardized location on
their uniform. That way, first responders knew exactly where to look for the
card if they had to report the care they provided a comrade.
“They filled it out as they provided care if they could,”
Kotwal said. Sometimes they were overwhelmed with providing care or the
evacuation process was so quick that they couldn’t immediately get to it, he
said. “But they did it at the first opportunity,” he added.
As a double-check to ensure the reporting wasn’t overlooked,
Kotwal also got the requirement integrated into the after-action review
process. “This is something line guys do very well. Every time they come off a
mission, they go directly into an AAR and do reports based on the mission so
they can assess it and make improvements,” he said.
“The medical community didn’t do it at that level,” Kotwal
said. “So we instituted a [medical] AAR that had to be done within 72 hours
after a mission.”
Through this process, the 75th Ranger Regiment developed a
rudimentary pre-hospital trauma registry, refined it over time and expanded
across the special operations community, Kotwal reported.
Kotwal later joined the Joint Trauma System team to expand
this concept to conventional forces.
Geracci, a former division surgeon in Afghanistan, said he,
too, was “excited about the advancements taking place in facilities-based
care,” many attributable to the Joint Trauma System and its trauma registry.
“But I was also frustrated that we hadn’t been able to apply
the same degree of rigor in the prehospital environment,” he said. “I saw this
as a blind spot in the JTS process. So my goal was to help [the military
medical community] go after that blind spot.”
Geracci said he “jumped” at the chance to be one of the
Centcom Joint Theater Trauma System’s first pre-hospital directors in the
combat theater to address the gap.
“We’re building on the work already proven for about a
decade on the special operations side and taking those exact same principles
and importing them into the [combat] theater,” he said.
Just months after the Pre-Hospital Trauma Registry was
introduced, Geracci said, he’s already seeing its rewards. We have already seen
tangible benefits from putting that in place,” he said. “This is proving to be
an incredibly valuable tool.”
He credited combat medics and their commanders on the ground
who are putting that tool to work as they complete casualty-care cards and
AARs.
“They are the reason we have seen success in such a short
period of time,” Geracci said. “They understand that this information, and the
data they produce, provides better care not only for their comrades, but for
anyone who passes through the different levels in the continuum of care.”
Posts
No comments:
Post a Comment