October 2004 Bulletin

Military medicine wages its own war

U.S. military orthopaedists treat thousands of war-wounded; trauma research may be ‘silver-lining’

By Carolyn Rogers

The medical staff at Walter Reed Army Medical Center (WRAMC) in Washington, D.C., has treated nearly 3,500 U.S. service members injured in Iraq since the war began in March 2003. Above, Col. William C. Doukas, MD, chairman of the department of orthopaedics and rehabilitation at WRAMC stands in front of the medical center.

As U.S.-led forces continue to battle insurgents in Iraq, the military medical system is fighting its own war back home. For the past 19 months, military doctors, nurses and other caregivers have worked around the clock to treat thousands of wounded soldiers, many with devastating injuries rarely seen outside of a war zone.

The last report on military orthopaedists (June 2003 Bulletin) focused on the care injured soldiers were receiving on the battlefield and at Walter Reed Army Medical Center (WRAMC) and other stateside military hospitals. At the time, WRAMC had treated a total of 310 service members injured in Iraq, and the stream of incoming wounded had slowed to a trickle.

Fighting intensifies, casualties mount

But as the fighting in Iraq intensified, a dramatic surge in new cases nearly overwhelmed the military’s premier medical center. Orthopaedists at WRAMC, Brooke Army Medical Center (BAMC) in San Antonio and other military hospitals have remained heavily engaged in treating wounded soldiers.

“October and November of 2003 were exceptionally busy—a reflection of what was going on in theater,” says Col. William C. Doukas, MD, chairman of the department of orthopaedics and rehabilitation at Walter Reed.

WRAMC has treated 3,460 patients injured in Iraq since the war began in March 2003—including 798 battle casualties. Of those, 604 were treated as inpatients and 194 as outpatients. As of late September 2004, 42 soldiers remained at WRAMC as inpatients, most in Ward 57—the hospital’s busy orthopaedics wing.

Five other Army medical centers around the country also treat seriously wounded soldiers. BAMC has cared for 1,256 service members since the war began.

Although it is difficult to obtain accurate numbers from the Navy, at least another 1,000 service members—primarily marines—have been treated at National Naval Medical Center in Bethesda, Md. Soldiers with less severe injuries have been treated at dozens of smaller military hospitals and clinics around the country.

The evacuation chain

“Air evacuation time out of Iraq has been as fast as three to five days,” says Dr. Doukas. On average, the time from the point of injury on the battlefield to arrival at a stateside military hospital has been between seven and 10 days.

“This chain of care involves many individuals, ” he says. “We’ve received tremendous support in the field, from the medics on the battlefield, to the orthopaedic surgeons that are deployed forward, to the staff at Landstuhl [Regional Medical Center in Germany].”

Col. Mark R. Bagg, MD, chief of orthopaedics at BAMC and orthopaedic consultant to the Army Surgeon General, credits his colleagues on the frontlines for their work on the battlefield.

“The surgeons have done an excellent job at initial stabilization of devastating and complex injuries,” he says. “The successes we have had at BAMC are due in no small part to the excellence of initial care.”

In his role as orthopaedic surgery consultant to the Army Surgeon General, Dr. Bagg has traveled to Iraq twice—most recently in May 2004, when he spent a month inspecting all combat support hospitals and several of the forward surgical teams. He has special praise for the combat medics—the first link in the chain of care.

At Brooke Army Medical Center in San Antonio, Texas, orthopaedists Lt. Col. Roman A. Hayda, MD; Col. Mark R. Bagg, MD; and Lt. Col. James R. Ficke, MD, consult on a case.

“The level of expertise of the combat medic is unbelievable,” he says. “They go into a place where people have been injured as a result of enemy fire and put themselves in harm’s way to bring those injured soldiers back. If the medics weren’t out there putting on the tourniquets and doing the lifesaving procedures that are needed for these extremity wounds, we wouldn’t be seeing these patients. They would exsanguinate and die.”

Five echelons of care

After treatment by a combat medic, wounded soldiers typically advance through five separate echelons of care, Dr. Bagg explains—three in Iraq, one in Germany and one stateside.

“The first echelon is a battalion aid station where an E.R. doctor provides resuscitative care or advanced trauma life support,” he says.

The second involves a forward surgical team working in a forward resuscitative surgical system (FRSS)—a highly mobile, rapidly deployable trauma surgical unit. The FRSS enables the forward surgical team to perform lifesaving surgical interventions for those whose injuries are too severe to survive transport to the combat support hospital (CSH).

The CSH—the third echelon of care—is a high-volume, full-service, theater-deployed mobile hospital.

“Most of the initial care is handled at the combat support hospital,” Dr. Bagg says. “Once the patient is stabilized, we try to get them out of the theater as rapidly as possible.”

The fourth echelon of care takes place at Landstuhl—the only Level IV fixed facility outside the United States offering definitive care for combat forces in Iraq and Afghanistan.

Most of the military’s wounded stay at Landstuhl for just a few days before returning to the U.S. for fifth-echelon care at a stateside military hospital such as Walter Reed. These hospitals are staffed and equipped to provide convalescent, restorative and state-of-art rehabilitative services in addition to definitive and specialized medical care.

Stateside military hospitals

“Where a wounded soldier lands stateside depends largely on his or her base of deployment or home of record, as well as the severity of wounds,” says Dr. Bagg. “Depending on the complexity of the injuries, we have to get them to a medical center that has capabilities and expertise to take care of those wounds.”

Soldiers with complex fractures, burns or wounds requiring plastic surgery are evacuated from Landstuhl to one of six Army medical centers: WRAMC; BAMC; Eisenhower Army Medical Center (Augusta, Ga.); William Beaumont Medical Center (El Paso, Texas); Madigan Army Medical Center (Tacoma, Wash.), and Tripler Army Medical Center (Honolulu).

“Soldiers from Fort Hood, Texas, would be treated at Fort Hood if the injuries are not complex, but they could also be sent to BAMC for treatment,” Dr. Bagg explains.

All patients who have injuries in association with a burn are sent to BAMC, the Defense Department’s only burn center. Most amputees go directly to Walter Reed, which has set up an amputee service. BAMC is a secondary site for amputee care.

“Devastating” orthopaedic injuries

Body armor and Kevlar helmets are saving lives on the battlefield, Dr. Bagg reports.

“We don’t have definitive numbers, but anecdotal evidence shows that that they’re working,” he says. “The fact that those 18- and 19-year-old soldiers are actually wearing the body armor in 100-plus degree heat tells you that it’s working!”

Yet, while these protections safeguard the torso and head, they leave other parts of the body exposed to bombs, rocket-propelled grenades and improvised explosive devices.

The result? About 65 percent of combat injuries are orthopaedic related, involving either the upper or lower extremities.

“Many of the injuries are fairly devastating in terms of severity,” Dr. Bagg says. “Most are very complex, open injuries involving a significant amount of not only bone, but also soft tissue loss, making for a much more complex wound.”

Shift in wound patterns

In the first year of the war, military doctors saw a large number of injuries caused by rifle or handgun fire. Now they’re seeing more explosive injuries with massive tissue destruction as well as long-term injuries and amputations.

In his role as consultant to the Army Surgeon General, Dr. Bagg says he tries to keep on top of some of the demographics of how soldiers are wounded. This spring, he noticed a slight shift in the distribution of wounds.

“Between March 19 and June 30 we saw a slight shift in wound distribution—with an increase in head, neck and upper extremity injuries,” he says. This reflects a change in the way the enemy deploys their weaponry.

“They’re setting the improvised explosive devices up in trees now, instead of on the ground, resulting in devastating head, neck and upper extremity injuries,” he says.

“We’ve worked hard”

Military doctors, nurses, therapists, and others around the country—and particularly those at Walter Reed—have been on a “war footing” for nearly 20 months now.

“We’ve worked very hard,” Dr. Doukas acknowledges. “But all of us—orthopaedists, physiatrists, nurses, therapists—feel it’s just a privilege to be part of the solders’ care, and that’s self motivating.”

Walter Reed—a 95-year-old institution that has treated presidents and senators—has been transformed by the largest wave of combat casualties since the Vietnam War.

An ambulance leaves Andrews Air Force Base in Maryland and heads for nearby Walter Reed Army Medical Center.

Doctors and nurses from the pediatric and psychiatric departments have been pulled into the busiest wards, such as Ward 57. Hospital staffers have worked 70- and 80-hour weeks only to return on their days off to bring pizza to the wounded soldiers or run errands for them. Staff bulletin boards throughout the hospital are covered with photos of the patient-heroes.

To manage the flood of wounded soldiers arriving almost every night from Landstuhl, WRAMC set up triage in their cast room. “All the casualties would come in to the cast room to be triaged by orthopaedists, general surgeons, and ENTs and neurosurgeons as needed,” says Dr. Doukas. “We’ve had as many as 20 casualties in the cast room at a time.”

“To facilitate the rehabilitation process, we hired prosthetists, additional physical therapists, occupational therapists and nursing support,” he says.

Fortunately, the medical center’s new amputee service—the Amputee Center of Excellence—was up and running just in time. Two years ago—shortly after the United States went to war in Afghanistan—Congress allocated $3 million to Walter Reed to establish the unit. Thus far, the center has treated 132 Operation Iraqi Freedom (OIF) amputees, and 16 service members who lost limbs in Afghanistan during Operation Enduring Freedom.

As of late September 2004, activity at Walter Reed had “throttled back” a bit, Dr. Doukas says. “We’re still getting casualties, just not as many.” But there has been no change in the severity of the wounds.

“We’re trying to keep folks on active duty if we can, or at least try to set them up for success in transitioning to private life,” says Dr. Doukas. “We have career counselors, psychologists, social workers and occupational therapists, as well as our physical medicine staff, which assumes care of amputees and multiple injured patients to be sure their rehabilitation stays on track.”

Unique situation creates research opportunities

“If anything good can come out of war, it’s the rapid medical advances and new surgical techniques that develop as a result of treating these major injuries,” Dr. Bagg says. The sheer volume of patients treated and the data that is being collected represents a tremendous opportunity for scientific research.

The Army is now seeking research funding to help quantify its results in treating trauma so that information can be used to develop new and improved treatment protocols.

Long-term outcome studies are needed for recent advancements in orthopaedic trauma care such as vacuum-assisted closure devices and antibiotic beads. Research is also needed on body armor, bone fragmentation during limb salvaging, transportable traction systems, hand injuries, spine trauma and infectious disease of bone and soft tissue.

Some of the major research protocols WRAMC is currently looking at include: treatment and outcomes of open periarticular elbow combat injuries; treatment and outcomes of upper extremity peripheral nerve injuries sustained in modern warfare; limb salvage and amputation of the upper extremity in OIF soldiers, and use of bone morphogenetic protein for open lower extremity fractures and segmental tibial fractures sustained in Iraq.

Future WRAMC studies include a comparison of microprocessor vs. mechanical hydraulic controlled knee joint; 3-D rapid prototyping application to prosthetic fitting; and incidence of deep venous thrombosis and pulmonary embolus in combat casualties undergoing rehabilitation.

The Army’s most renowned surgical research center—the U.S. Army Institute of Surgical Research (USAISR)—is conducting studies of antimicrobial beads, bone replacement, irrigation and debridement, antibiotic use, splints and casts, and soft tissue/bone repair.

AAOS supports military orthopaedists

Over the past two years, the Academy has strengthened its commitment to supporting orthopaedic surgeons serving in the military.

In May 2004, AAOS President Robert W. Bucholz, MD, and AAOS staff convened a conference call with a number of military orthopaedic leaders to determine how the Academy could best assist military orthopaedics in their mission. AAOS staff members followed up in late June with a visit to USAISR in San Antonio to discuss the military’s orthopaedic research needs in greater detail

Col. Mark R. Bagg, MD

A variety of projects are now underway, including an orthopaedic trauma research initiative being spearheaded by the AAOS Washington office. Dave Lovett and his staff have already had some legislative success in this area.

Success with DOD bill

With the help of Sen. Kit Bond (R-Mo.) and Rep. Todd Tiahrt (R-Kan.), the AAOS was recently able to secure orthopaedic research funding language in the 2005 fiscal year Department of Defense (DOD) Appropriations bill, which President Bush signed into law in August.

Orthopaedic extremity trauma research has been included on the list of 21 health research topics that will be funded under the DOD’s $50 million Peer Reviewed Medical Research Program (PRMRP).

The funds allocated for the PRMRP do not include a guarantee of funding for orthopaedic extremity trauma research. Rather, it is a competitive, open, peer-reviewed research proposal process that allows for orthopaedic researchers to compete for an unspecified portion of the $50 million. Grant applications are typically due in March of each year; the Academy will keep AAOS fellows apprised of deadlines.

The AAOS Washington staff is currently laying the groundwork for 2006, and plans to spend the next year advocating for funding for orthopaedic trauma research. The Bulletin will report on the various AAOS/Army activities as the projects progress and as more information becomes available.

Help out military docs: Accept Tricare

Civilian orthopaedists who’d like to help out their military counterparts during this difficult time can do so by accepting Tricare patients, Drs. Bagg and Doukas say. Tricare is the military’s HMO system for active duty and retired members of the uniformed services, their families and survivors.

“Accepting Tricare is the most tangible way private orthopaedists can help us out,” Dr. Doukas says.

“If we could get more people to be understanding and accepting of Tricare—as a patriotic duty—it would really help out,” echoes Dr. Bagg. “As military hospitals have gotten busier taking care of our primary mission—treating wounded soldiers—we’ve been forced to shunt some of our routine beneficiaries into the civilian market through the Tricare system.”

To makes matters worse, the deployment of military orthopaedic surgeons has left several military medical treatment facilities without the orthopaedic support they need. “The stopgap for this is the Tricare system,” Dr. Bagg says. “Unfortunately, most doctors don’t want to deal with it.”

As a result, many of the young families of deployed soldiers aren’t able to get quality health care.

“Tricare isn’t the best paying system,” Dr. Bagg admits. “But, frankly speaking, this is a system that we have to live with. We would really benefit from some understanding on this.”

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