Trauma treatment is often a surgeon’s race with death. The Navy must upgrade its capability for high-intensity trauma surgery now, in order to save its warriors in the future.
The U.S. Navy deploys worldwide, but getting there—wherever there is—is not half as hard as staying there, especially once the shooting starts. Keeping the equipment functioning seems to get adequate attention in today’s Navy, but apparently the medical support necessary to keep the warriors themselves in combat may be lacking.
Two decades ago, the National Research Council identified traumatic wounds as the “neglected disease of modern society.” Two active-duty Navy surgeons writing the July 1987 Proceedings stated that “a general proficiency in the skills required for high-intensity trauma surgery does not exist in Navy medicine at this time.
There are ways to resolve these deficiencies. The Committee on Trauma of the American College of Surgeons reports that “to be considered well qualified for caring for the injured, surgeons must be regularly involved with injured patients.” Navy physicians are not. Navy surgeons need the same opportunities for rigorous training and sustained hands-on experience in order to develop and maintain the skills required for successful trauma surgery.
The Importance of Surgical Care: Trauma is a disease that must be treated surgically and, therefore, the sooner that surgical judgment and skills are brought to the severely injured, the better the results will be. The talents and skills of a broadly trained general surgeon are needed to ensure the early resuscitation of casualties, to evaluate the extent of injuries, and to establish priorities in both diagnostic studies and therapeutic interventions, particularly for patients suffering from multiple injuries. Availability of competent staff, assiduous training, and high-quality performance levels measure the surgical team's commitment to trauma care.
While the well-trained general surgeon provides needed operative skills for patients with wounds to the abdomen, chest, soft tissues, and blood vessels, he still relies heavily on neurosurgical, orthopedic, and other surgical consultants to evaluate and treat injuries that fall within their areas of expertise. Orthopedic surgeons, for example, are clearly essential to care for most trauma patients. Not only will the majority of major and minor trauma victims require orthopedic evaluation and treatment, but the ever-increasing use of surgical fixation—stabilization of fractures—will ensure that the skills of orthopedic surgeons will always be in high demand. The naval officer billet code (NOBC) system does not indicate that the Navy realizes it requires doctors with special skills to treat the very specialized injuries caused in combat. Under field combat conditions, even an experienced civilian surgeon may make costly mistakes when treating traumatic injuries. In the combat setting, many accepted surgical procedures and techniques that work will in civilian practice may further jeopardize the patient's changes for survival.
Military medical journals and the news media, for example, highlighted the Argentine military physicians’ gross mismanagement of war wounds during the Falklands Conflict, resulting in many cases of gas gangrene among wounded Argentine soldiers. Conversely, the British military, with much experience in combat-type wounds, emanating from their Northern Ireland operations, had few, if any, such cases. During a ten-year period between the mid-1960s and 1970s, 27 cases of noncombat-related gas gangrene also were seen in Miami, Florida (including ten cases associated with a single aircraft crash)—as many as were seen during the entire U. S. military experience in Vietnam. The civilian physicians who handled the cases in Miami reportedly managed the wounds in much the same manner as the Argentines. Unfortunately, civilian physicians such as those in Miami or the inexperienced U.S. military physicians, will be staffing military hospitals and surgical support groups during any major conflagrations in the future.
Specialized training programs for combat injuries are needed. Assessing medical preparedness for war by merely matching available general surgeon and orthopedic surgeon NOBCs against billet requirements is unrealistic. An institutional commitment to trauma training should extend beyond the limits of a personnel function. The principal question is whether the Navy is ready to make the commitments necessary to improve combat trauma readiness, recognizing that the fate of the injured largely depends on the quality of surgical care provided.
Significant data from civilian experience suggest that death from trauma has a tri-modal distribution:
The first peak of deaths occurs within seconds or minutes of injury. About 50-60% of civilian trauma victims who die do so before reaching a hospital. These deaths primarily result from lacerations of the brain, brain stem upper spinal cord, heart, aorta, or other large blood vessels. Few of these patients could be saved, although in some large urban areas, with rapid transport, some have survived.
The next peak of deaths is within two hours of the time of injury and can be attributed to bleeding in and around the brain, penetrating wounds of the chest cavity with internal bleeding, a ruptured spleen, lacerations of the liver, fractured thigh bones, or multiple injuries that cause significant blood loss. If medical evacuation assets are operative, and trauma professionals are available promptly, these patients usually can be saved. Delay in diagnosis, delay in surgical intervention, and unfocused care generally are responsible for otherwise preventable deaths from trauma. This category of patients, whose numbers are significant, and whose wounds resemble those of the most seriously wounded in combat who survive transport to a surgical facility, benefit most from readily available trauma care.
The third peak occurs days or weeks after injury and is most often the result of generalized infection and multiple organ failure.
Trauma's Impact: A Case History: Several months ago, one of my scheduled urological surgical procedures was suddenly “bumped” from the surgical schedule. All available operating room resources were diverted to support a trauma case being brought into the operating room. A young Navy petty officer had just been shot. As I watched the surgical team attack the large hole in the rear of his main abdominal artery (aorta), I saw blood pouring out of the tubes that drained his wounded chest. I observed the anesthesiologists while they pumped nearly 70 units of blood into his veins in an attempt to help the patient overcome his shock. I was astounded at the technical expertise and extensive resource commitment required to manage this patient.
During the ensuing several weeks, the specialized resources of many intensive-care teams were employed in his care. Even so, he slowly started failing in his battle with generalized infection, lung failure, and liver and kidney failure. I was reminded of the profusion of articles on this very subject that appeared in the surgery and trauma journals during the Vietnam War years. This young man’s medical problems were identical to those that afflicted many wounded servicemen in Southeast Asia. This young Navy man died, succumbing to the same group of seemingly insoluble problems described by military surgeons several decades ago.
Despite all of our modem efforts and resource commitments, we obviously still have not overcome the problems that plague critically injured patients. This should be a major military concern. The uniformed services have a vested interest in this problem, and should take the lead in trauma care research.
The Search for a Solution: Too many of the Navy’s surgeons are doing hernia operations while the complicated problems, requiring sophisticated anesthesia, are being sent to civilian hospitals! How are the surgeons and anesthesiologists getting the training to prepare them for managing wartime injuries?
The Trauma Committee of the American College of Surgeons concluded that “adequate” experience in trauma for one general surgeon consists of treating 50 severe and urgent cases per year. However, the approval status of surgical training programs in some military medical facilities is in jeopardy because they are hard to staff adequately, and, frankly, there are too few patients requiring trauma attention.
One solution frequently presented is to create a program of field medical training for medics. But it is too easy to overestimate the net benefit of transporting surgeons to a “model” deployable medical facility in the desert. Surgeons certainly warrant a brief orientation to a deployable medical facility, and the opportunity both to “feel” the environment and view the equipment that they might use in the future.
Realistically, however, viewing a group of volunteer moulaged “patients” provides only spectacular imagery for those who are medically uninitiated and unsophisticated. Surgeons, however, will not learn the delicate judgment needed to manage complex wounds, complicated by shock, blood loss, and dehydration, in that setting. Similarly, the anesthesiologist also requires realistic hands-on experience anesthetizing patients suffering from severe shock and fluid loss.
Other areas of medical preparation need emphasis as well. In the Falklands Conflict, the British discovered that modem combat at sea produced large numbers of burn injuries. Nearly 34% of all Royal Navy injuries at sea were bums. The potential transfer of casualties, including bum victims, from seaborne units to fleet hospitals also should be anticipated. U. S. fleet hospitals in World War II received many casualties from ships engaged in the invasion of Okinawa. Provisions must be made in the fleet hospital program to train doctors for high-priority burn treatment. Burn management protocols must be developed for these facilities. Similarly, qualified physicians with previous combat experience must guide other physicians in* the standard treatment of other types of combat injuries traditionally handled by such facilities.
We must be motivated to recruit trauma experts into our organization, whether active duty or reserve, and use their expertise for our general benefit. Frankly, if the Navy continues to distinguish between active-duty and reserve assets, it never will benefit properly from the talents of nonactive-duty trauma specialists. It is hardly worth attempting to recruit these skilled professionals if these doctors would be wasting their time on “routine” reserve duties, instead of working in their specialties.
Providing optimal care of the trauma patients requires a commitment. For the Navy, it means providing capable and trained personnel who will be immediately available to trauma victims. It also implies, in peacetime, the use of sophisticated equipment and services that frequently are expensive to purchase and maintain. Trauma cases must enjoy priority access to sophisticated laboratory and radiologic facilities, operating suites, and intensive care units. In the civilian specialized trauma centers, a concentration of expert surgeons and physicians allows for a rational therapeutic approach that gives the patient a better chance of surviving. This also provides an opportunity to train trauma surgeons, research new treatment methods, and study mechanisms of infection after injury.
Those responsible for apportioning budgetary assets should make funding available to support Navy-wide high- quality trauma management and training. The extreme costs involved in attempting to duplicate or supercede those trauma care facilities that exist in the civilian sector most likely will require alternative options for the achievement of sufficient state-of-the-art trauma care and training opportunities within the Navy system.
While it is encouraging that the Navy’s new Surgeon General has broad experience and exceedingly credible qualifications, a Blue Ribbon Panel of trauma specialists and trauma educators needs to be convened to study Navy trauma treatment and training needs. The panelists should make recommendations for consideration by both the Secretary and the Surgeon General of the Navy. The panelists should visit medical facilities on board amphibious assault ships, carriers, and the hospital ships, as well as ground forces medical and hospital company facilities, and fleet hospitals. They also should visit Navy teaching hospitals and non-teaching hospital surgical facilities. They need to meet with Navy personnel, and evaluate Navy trauma needs from both patient service and training perspectives. In addition, they need to identify how and where Navy personnel can obtain the required training.
For example, it would appear that most trauma in this country is not being managed in military hospitals, but in civilian facilities. In addition, on must recognize that the "blunt" automotive trauma seen by many high visibility “trauma centers” is virtually a “different disease" from the class of “penetrating” injuries encountered in wartime. Primarily, the inner-city hospitals handle the. largestconcentration of penetrating injuries which are closest to those seen in wartime.
Recently, a Department of Defense (DoD) Commission sent questionnaires to civilian surgical training program directors, querying their interest in potential DoD funding of some physician residency training positions in "critical specialties.' Presumably, resident physicians who received military funding would be required to serve active-duty tours after completing their training.
A small number of Navy doctors and nurses presently are being sent to civilian trauma centers, such as Charity Hospital in New Orleans, Louisiana, for training. However, one month of exposure is not adequate training for a military surgeon and does not represent a commitment by the Navy to improve care.
Another option might be considered, however. Members of the orthopedic faculty at my own institution are being consumed by the significant time and physical demands of their trauma service obligations. DoD could consider funding faculty positions in trauma surgery for qualified military surgeons.
On a temporary loan basis, the military surgeons could staff the trauma service of various medical school faculties. While augmenting their own trauma experiences, they could assist and train younger surgeons still learning trauma fundamentals. Perhaps even young military surgical trainees might be afforded the opportunity to rotate through these civilian services. In essence, such a military trauma faculty could be the Navy's "cadre in training," while simultaneously providing no-cost faculty support to medical schools' trauma centers.
When blood is spilled again on the decks, as it inevitably will be during future conflict, let us hope that Navy surgeons will be in a position to respond, both effectively and skillfully. The time for taking action is now.
Captain Smith is professor of surgery (urology) at the Medical College of Georgia, Augusta, Georgia, where he is also a medical school liaison officer for the Navy Recruiting Command. He received his medical degree from the University of Maryland School of Medicine, Baltimore, and was an intern and resident in surgery at the New York Hospital- Comell Medical Center. After a residency in urology at the Columbia- Presbyterian Medical Center in New York City, he was a fellow in urological cancer surgery at Memorial-Sloan Kettering Cancer Center in New York. Captain Smith entered the Navy in 1965 and served as a surgeon on board the USS Randolph (CVS-15), followed by a tour on the surgical service of the U. S. Naval Hospital. Memphis, Tennessee. He served as commanding officer of Naval Reserve Medical Contingency Response Unit 507 in Charleston and as senior medical officer on the staff of Naval Reserve Readiness Command Region Seven in Charleston, South Carolina. He currently is assigned to the Uniformed Services University of the Health Sciences in Bethesda, Maryland, in the departments of Surgery and Military Medicine. He is a previous Proceedings author.
Doctors Should Train for the Fight
“You fight like you train” is a military dictum. If this dicturn also applies to the Naval Reserve’s medical department, then I expect that we are not training for a tough fight.
My ten years of Naval Reserve experience tell me that instead of preparing for a fight, reserve doctors have been training to perform physical examinations on healthy people and “mobilizing” mountains of paperwork to justify their existence. Annual physical examinations are designed to monitor the fitness levels of military personnel, but medical departments’ limited equipment, space, and supplies render most exams superficial at best. Having performed thousands of these physical exams, I can testify that rarely is anything discovered that requires further medical attention or disqualifies someone from the naval service.
The large number of required physical examinations and the fact that these exams take precedence over almost everything else allow very little scheduled training for the reserve medical departments. An entire weekend may be needed for a reservist to complete all the tests or a physical exam. The medical departments suffer, drilling reservists may lose up to one-twelfth of their annual training time, and units lose the reservists’ services because of these physicals.
After mobilization, the reserve doctors will be asked to provide medical support for forces operating in a hostile environment. They will be called upon to treat large numbers of serious casualties, on short notice, with limited support personnel and supplies. Medical personnel will have to prevent disease from spreading, monitor food and water supplies, and supervise field sanitation and vector control. They will need to rapidly establish lines of communication and chains of evacuation and resupply.
Consequently, the demands that routine physical examinations make on reserve medical doctors must be reduced. Physical exams could be performed only at enlistment and reenlistment. They also should be more comprehensive than they are now. Physicals could be repeated for special personnel categories—those unable to perform tasks or complete the physical fitness test, those who do not meet the body fat norms, or those being considered for promotion.
Reducing the numbers of routine and unnecessary exams would allow more time for training reserve medical personnel. Reserve medical departments need training to support operational activities in the field and on board ship, to be familiar with their gaining commands, and to care for combat casualties (e.g., advanced trauma life support).
If these changes are made, reserve medical personnel, who will be relied upon heavily in a conflict, will not have to relearn the lessons of triage and wound management at the expense of their first casualties.
If we will fight like we train, we had best train for a fight.
Commander Michael S. Baker, Medical Corps, U. S. Naval Reserve, is the Chief of Surgery at Contra Costa County Hospital, Martinez, California. He recently was appointed to the Navy Committee for Trauma of the American College of Surgeons.