Trauma Chief Cites Sweeping Changes in Critical Care

By Elaine Sanchez

Brooke Army Medical Center

JOINT BASE SAN ANTONIO-FORT SAM HOUSTON, Texas, Aug. 23, 2012 – From battlefield innovations to revamped health care systems, the military has radically transformed its trauma care over the past decade, a trauma expert here said.

These advances have led not only to the nation’s highest combat survivability rate in history, but also to countless saved civilian lives, said Air Force Lt. Col. (Dr.) Jeremy Cannon, the chief of trauma and acute care surgery at San Antonio Military Medical Center, which houses the Defense Department’s only stateside Level 1 trauma center.

Cannon summed up many of these sweeping improvements to military and civilian critical care in the August edition of the “Surgical Clinics of North America.” Serving as guest editor, the doctor called on a number of his military and civilian health care colleagues to contribute articles on recent advances, while offering insights from his experiences during three deployments in the past six years.

One of the most significant trauma care advances, he noted in the journal, was the introduction of regionalized trauma care, which involves a network of trauma centers in the same region working in coordination to save lives.

South Texas offers a perfect example of a smooth-running regional system, he noted. A network of area hospitals, including SAMMC, accepts trauma cases from smaller hospitals that may not be equipped to handle severe injuries. All work together to ensure patients receive optimal care, Cannon wrote.

The military adopted this civilian-based concept in combat, he added, implementing care that ranges from point-of-injury treatment to extensive surgery. By doing so, he explained, the military was able to take this concept downrange, “tweak it,” and feed it back to the nation with improvements.

Cannon also noted the introduction and growing popularity of “damage-control” surgery. This approach involves surgeons focusing on the most life-threatening wounds first, followed by other surgeries as time and the patient’s strength allow. Prior to this concept, he said, surgeons typically would “fix everything and close,” then adopt a “wait and see” approach. While this may be fine for some patients, the doctor said, it became evident, particularly with catastrophic combat casualties, that a multi-phased approach would better benefit some patients.

Wound management also has seen significant changes, Cannon said, noting the impact of vacuum-assisted dressings, a temporary closure that protects the organs while monitoring fluid output. These dressings, which allow stabilization of the wound, have eliminated the need to change gauze dressings several times a day, increasing patient comfort and enabling nurses to focus on other, more pressing aspects of care.

“It’s had an invaluable benefit to a tremendous number of patients,” he said.

Cannon also noted the major advances in en-route critical care, or taking a soldier from the point of wounding to definitive care. He attributes successes to a combination of long-range transport by critical care teams and advanced critical care therapies for “early acute organ failure.”

Additionally, cutting-edge technology has transformed the care provided in intensive care units, Cannon said, citing ultrasound equipment as an example. Bedside ultrasound imaging has “greatly enhanced the ICU toolkit for diagnosis, monitoring and interventional procedural guidance,” he said. These monitors, he explained, have become less invasive and better at pinpointing vital information.

Cannon points out these examples and many more in the journal, while also looking to even broader changes in the years ahead. The Joint Theater Trauma System, for example, will provide the framework for identifying future potential critical care needs. Through this system, doctors enter combat casualty data rapidly into the JTT Registry, which they can later mine for information regarding diagnoses and survival rates. Put simply, this information can be used to make better decisions regarding future care.

Cannon said he set out to chronicle lessons learned and to create a reference point for future generations to explain “why we do what we do.”

“It was an honor to be asked to do an update of such an important topic,” he said. “I hope it can serve as a benchmark for today’s trauma care.”

New burn care center fully operational in San Antonio

SAN ANTONIO, Texas -- The U.S. Army Institute of Surgical Research began a new era in burn and combat casualty trauma care when the staff moved its patients into the burn intensive care unit recently.

They performed the first surgical procedure May 25, in one of two operating rooms of the new burn center in the San Antonio Military Medical Center, or SAMMC, consolidated tower at Joint Base San Antonio - Fort Sam Houston.

The completion of the move comes several weeks after the initial move of the burn rehabilitation center, the outpatient clinic, the administrative section, and the clinical studies branch.

"The new burn center challenges us to use all that we have learned during the war and improve care for the benefit of all future burn patients admitted to our center," said Col. Evan Rez, Burn Center director.

Renz said the move marks a monumental milestone for the only Department of Defense burn center.

"The long anticipated occupation of the new burn center highlights the organization's enduring commitment to combat casualty care and research," he said.

As the only burn center for the DOD for more than 50 years, it has been providing specialized care for casualties with severe burns, inhalation injury, and complex soft-tissue trauma, or BICU, sustained in combat or accidents.

In addition, it serves as the regional burn center for South Central Texas, providing care for hundreds of civilian emergency patients each year.

"Our role as a regional burn center is twofold," said burn center Chief Nurse Lt. Col. Louis Stout.

Stout said the first is to provide a critical service. The second is the necessity to remain clinically proficient in times of peace so that we can assume our mission rapidly in times of conflict.

"These are perishable skills that are not easily, or quickly, mastered and must be maintained" she said.

The center is located on the fourth floor of the new seven-story tower at SAMMC and is approximately 40 percent larger in size than the previous unit.

Some of the new features include two operating rooms with cameras installed in the surgical lights to transmit live videos of surgical procedures to monitors in the operating rooms and nurses' stations, and a conference room for educational purposes for medical students and staff.

The new facility also combines two eight-bed burn intensive care units into one 16-bed unit where each BICU room utilizes a 360-degree design in which most of the vital equipment is attached to a ceiling-mounted boom, allowing the patient's bed to rotate completely around the room.

"The successful transition to the new burn center has validated the integral value of a multidisciplinary approach to patient care," said clinical nurse Maj. Trinity Peak, BICU officer-in-charge.

It also reaffirmed staff that they have the skills and knowledge to accomplish their mission anywhere and at anytime, he said, while never losing sight of the the patient."

Since 2003, the burn center has cared for approximately 1,000 wounded warriors evacuated from Iraq and Afghanistan and 2,500 civilian patients from the South Central Texas region. The Burn Center employs approximately 300 staff members with multiple critical burn care skills from the Army, civil service, and contractors.

The United States Army Surgical Research is a subordinate command of the U.S. Army Medical Research and Materiel Command.

The mission to "optimize combat casualty care" is accomplished by conducting science and clinical research in the fields of damage control resuscitation, homeostasis, engineering, and tissue regeneration affecting combat casualties, including burns.