Trauma Readiness Training for Military Deployment: A Comparison Between a U.S. Trauma Center and an Air Force Theater Hospital in Balad, Iraq

MILITARY MEDICINE, 176, 7:769, 2011 Trauma Readiness Training for Military Deployment: A Comparison Between a U.S. Trauma Center and an Air Force Theater Hospital in Balad, Iraq McCunn Maureen, MD * ; Lt Col Gregory B. York, USAF MC ; Jon Mark Hirshon, MD ; Donald H Jenkins, MD ; Thomas M. Scalea, MD ABSTRACT The U.S. Air Force created the Center for Sustainment of Trauma and Readiness Skills at the Shock Trauma Center (STC) where staffs rotate before deployment. We sought to investigate the value of this training. A retrospective review of prospectively collected data of patient volume, injury severity, mechanism of injury, operative cases, and massive transfusion data from September 2006 to August 2007 was obtained from the STC in Baltimore and the Air Force Theater Hospital (AFTH) in Balad. Severity of injury and massive transfusions were higher at the AFTH. Soft tissue wound care represented approximately 25% of AFTH cases; a soft tissue service performed 465 operative debridements for severe soft tissue infections at STC. The STC s high-volume of major soft tissue debridement cases may offer the closest approximation of high energy wound care. Training at selected U.S. trauma centers may prepare military staff to care for war injuries, particularly those who do not practice in high-volume Level 1 trauma centers. INTRODUCTION In 1998, a U.S. General Accounting Office report identified a critical lack of trauma training for military medical personnel to prepare them for conflict situations because many of these individuals primarily cared for healthy, active duty personnel and their dependent retirees. 1 This report recommended development of collaborative military and civilian training platforms at urban Level 1 trauma centers to gain necessary training. The Department of Defense (DOD) subsequently opened trauma training sites, including the Center for Sustainment of Trauma and Readiness Skills (C-STARS) of the United States Air Force (USAF) at the R Adams Cowley Shock Trauma Center (STC) of the University of Maryland, Baltimore, in 2000. This program trains physicians, nurses, and medical technicians. Graduates of this program are subsequently deployed. This study period includes deployment to Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). There are four areas in which progress is thought to have improved outcomes of patients injured in each successive conflict from World War I to the current OIF/OEF: wound care, control and correction of blood loss, prevention and treatment *Division of Trauma Anesthesiology and Surgical Critical Care, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201. Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201. Department of Emergency Medicine, Charles McMathias National Study Center for EMS, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201. Division of Trauma, Critical Care and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. of organ failure, and organization and delivery of surgical care.2 The value of predeployment training at civilian institutions has not been tested, but experience in each of the areas identified at a high-volume U.S. trauma center may improve outcome once USAF personnel are deployed. The C-STARS program is staffed by USAF active duty personnel on a 3-year rotational billet, working in conjunction with the faculty and staff at STC. USAF staff members are integrated into the multidisciplinary team approach care teams at STC, including surgery, anesthesiology, emergency medicine, nursing, intensive care, operating room (OR), and radiology. While civilian/military training collaborations have improved care not only in the field, but also in civilian trauma care, 3,4 a formal assessment of the training experience in comparison to the actual conflict experience has not been conducted. This study compares the volume, acuity, and types of injuries seen during the C-STARS rotation at the STC, Baltimore, Maryland, vs. the medical circumstance experienced by health care practitioners in an Air Force Theater Hospital (AFTH) in Balad, Iraq. MATERIALS AND METHODS Study Settings The R Adams Cowley STC at the University of Maryland in Baltimore is a 100-bed hospital designated as the primary adult resource center for trauma in the state of Maryland. The center, founded in the 1970s as the nation s first free-standing trauma hospital, serves a population base of 6 million people over the 32,000 km 2 of the state of Maryland. The Baltimore metropolitan area, where the center is located, has a population of approximately 2.5 million. Direct admissions from the scene of injury account for 83% of total admissions (approximately air 40%, ground 60%); the remaining patients are MILITARY MEDICINE, Vol. 176, July 2011 769

transferred to the STC after stabilization at an outlying hospital. The STC facilities are presented in Table I. The AFTH in Balad, Iraq, is a multispecialty combat hospital originally housed in 25+ tents and now located in a hardened facility. Hospital capacity currently includes 30+ ward beds, 20 intensive care unit (ICU) beds, 12 Emergency Department beds, and outpatient clinics for subspecialty appointments. Hospital support includes a full contingent of logistics, pharmacy, and radiologic capabilities. The hospital is a Level I trauma center with 24-hour coverage by trauma surgeons and a host of surgical subspecialties predominately staffed by Air Force personnel. The hardened facility provides four ORs, each with the space to have two concurrent separate procedures per room. The majority of all patients arrive at the hospital via helicopters. The hospital also features a contingency aeromedical staging facility responsible for the movement of coalition patients out of the Iraqi theater ( Fig. 1 ). Data Summation administrative data on the volume of patients, mechanism of injury and injury pattern, OR cases, injury severity, and massive transfusion requirement were obtained from the two clinical sites from September 2006 through August 2007. Data from the AFTH were collected prospectively. Because of the austere conditions of the deployed setting, the injury pattern and massive transfusion data were only available for the 4-month timeframe of May to August 2007. All data were collected by one author (GBY) before initiation of the Joint Theater Trauma Systems database being established. The theater hospital collects data on all injuries discovered during a workup on patients whether actual physical injury from shrapnel, crush injury like a fracture, blast injury like internal organ damage to decreased mental status seen in a lower Glasgow Coma Score score. There are no inclusion/exclusion criteria at the AFTH level as to what injuries are documented essentially all are documented. As such the data in the manuscript reflect the percentages of each body area sustaining injury divided by total injuries. One can expect that one patient may have contributed multiple pieces of information to this data set this is not uncommon in combat injuries. There was no set criteria to only log the most serious injured area per patient or to limit how many data points per patient were entered into the registry. There are many patients within this data set who may have contributed multiple injured areas (i.e., head, arms, and spine) The STC maintains a trauma registry that was queried using the above categories representing the same time periods. A retrospective review of the data collected from each institution was accomplished within each category. Institutional Review Board approval was obtained from the University of Maryland, Baltimore, and coordinated with the Joint Trauma Theater System. RESULTS The STC admitted 6,311 patients during the study period. Of these admissions, 81.5% sustained blunt injury, whereas FIGURE 1. Aerial photo of the AFTH in Balad, Iraq. TABLE I. Comparison of STC vs. Balad Combat Support Hospital Facilities Clinical Capabilities STC Balad Combat Surgical Hospital Admissions Access Rooftop Heliport for 3 Simultaneous Helicopters, Dedicated Ground Entrance for Ambulances Helipad for 4 Simultaneous Helicopters, Dedicated Ground Entrance for Ambulances Admission Area 13 Resuscitation/Stabilization Bays, Each With Capability for 12 Resuscitation/Stabilization Bays 2 Patients Simultaneously ORs 6 ORs 4 ORs (2 Patients per OR Capacity) Post-anesthesia Care Unit 9 Patient Care Areas +2 for Isolation With Negative Airflow 2 Patient Care Areas (Located in ICU) Radiology 2 Dedicated High-speed CT Scanners, X-ray, 1 STAT Scan, Angiography Suite 2 Dedicated High-speed CT Scanners, X-ray (Fixed and Portable) Critical Care 12 Bed Multitrauma, 12 Bed Neurotrauma, 12 Bed Select Trauma 20 Total (2 in Isolation) Intermediate Care Unit 12 Bed Multitrauma, 12 Bed Neurotrauma, 12 Bed Select Trauma None Ward Beds 18 Beds 30+ Beds Hyperbaric Chamber 23 Patient Multiplace Chamber, Accommodates Ventilated Patients None Laboratory 24-Hour Clinical STAT Lab 24-Hour Clinical STAT Lab Blood Bank Immediately Available 10 U prbs s, 4 U FFP Thawed, in Admitting Area Immediately Available Resources to the OR, ICU, or ER Support Services Respiratory Therapy, Physical Therapy, Occupational Therapy, Speech Therapy; Pain Management, Nutritional Services, Social Work, Pastoral Care Staff, Designated Patient Advocates and Substance Abuse Program Respiratory Therapy, Physical Therapy, Nutritional Services, Pain Management, Pastoral Care Staff 770 MILITARY MEDICINE, Vol. 176, July 2011

15.7% sustained penetrating injury. The remaining 2.8% included miscellaneous categories of injury such as burn, hanging, drowning, and toxic ingestion. The AFTH admitted 3,637 patients during the study period. Of these admissions, 34.5% were the result of gunshot wounds and 50.6% were the result of blast injury from improvised explosive devices (IED), mortars, or rocket-propelled grenades. The remaining 14.9% were miscellaneous injuries where blunt mechanisms predominated, such as motor vehicle collisions and falls. Figures 2 and 3 demonstrate admission data and mechanisms of injury throughout the study period on a monthly basis. Specific injury pattern at each institution during the study period was compared for the months of May to August 2007. Injury patterns were divided into head, chest, abdomen, back/ spine, and extremity. Overall, head and extremity injuries represented the top two dominant injury patterns at both institutions. Head injury ranked first at STC representing 48% of injuries, followed by extremity injury at 21%. Extremity injuries accounted for 40% of the injuries at the AFTH followed by head injury representing 30%. ( Fig. 4 ). OR cases are depicted in Figure 5 for both institutions and over the period totaled 6,560 with a monthly average of 547 at the AFTH. For the STC, the study period total was 5,567 with the monthly average being 464. Admission base deficit comparisons are depicted in Figure 6 for both hospitals. In general, the admission base deficit was higher at the AFTH than the STC. The admission base deficit is used as a surrogate for injury severity, as injury severity scores were not available for the AFTH during the study period. Massive transfusion data between institutions are reported in Figure 7. Data are reported only from the period of May August 2007 because of availability. No specific pattern of massive transfusion requirement was noted between institutions. Discharged alive at the civilian STC was following variable lengths of total hospital stay, whereas at the military AFTH, it reflects time to aeromedical evacuation to a U.S. military regional medical center within 24 hours FIGURE 2. Number of trauma admissions per month by institution for September 2006 to August 2007. FIGURE 4. Percent of injuries for each body type by institution for May to August 2007. FIGURE 3. (a) Percent of injuries occurring per mechanism at STC for September 2006-August 2007. (b) Percent of injuries occurring per mechanism at Balad hospital for September 2006 to August 2007. MILITARY MEDICINE, Vol. 176, July 2011 771

FIGURE 7. Number of patients receiving mass transfusion by institution within the first 24 hours. D/C Alive = discharged alive. DOI = died of infection. FIGURE 5. Number of OR cases per month by institution for September 2006 to August 2007. FIGURE 6. Percent of admissions with base deficit 6 by institution for September 2006 to August 2007. of admission. For this reason, ICU length of stays could not be compared. DISCUSSION A previous article compared patients treated at a Combat Support Hospital in Iraq and a U.S. Level I trauma center. 5 Although the centers treat significantly different patient populations, the operations performed and outcomes were similar. The civilian trauma center presented in that article admitted 1, 339 patients over an 11-month period compared to 6,311 patients admitted to the STC and 3,637 admitted to the AFTH over our 12-month study period. Because a higher volume of trauma patient admissions correlate with improved outcomes,6 8 the large-volume, high-acuity exposure and training obtained by the C-STARS rotators at STC would suggest an advanced level skill set before deployment. Training An original needs assessment occurred Air Force-wide after the Desert Storm era which led to the Congressional mandate which in the Air Force produced the C-STARS program which has a set curriculum based on what the Air Force has determined are needed skill sets for particular medical personnel to stay current to go to war. The skill sets required by each practitioner are individualized by occupation and specialty (e.g., nurse, critical care vs. emergency department vs. OR, and physician, surgical vs. non-surgical specialty). The specific tracks within the C-STARS program address each of these required skill sets during the rotation, so those graduating will have had a firehose dose of experience and skills to get them up to speed to go into a busy combat hospital, especially for those who have not spent the past few years of their predeployment time in a trauma heavy medical environment. No specific needs assessment is performed on an individual basis at the time of STC course start; a pretest is given to assess knowledge level followed by a rigorous academic refresher, with refresher topics determined by the DOD Trauma and Combat Casualty Care committee. The C-STARS program addresses the needs of those medical technicians, nurses, and physicians who are slated to deploy to combat medical operations. Separate curricula exist for medical technicians, nurses, and physician providers, each heavily weighted in a clinical experience. All medical technicians are Emergency Medical Technician -Basic certified technicians there are typically no paramedics. All the nurses have bachelor s degrees in nursing and are a mix of clinical, emergency, ICU, and OR nurses. The providers are typically a mix of physicians, physician assistants, and nurse practitioners predominantly representing nonsurgical fields (Family Practice, Emergency Medicine, Internal Medicine, 772 MILITARY MEDICINE, Vol. 176, July 2011

and Dermatology). Each curriculum is divided into time for administrative needs, didactics, skills training, and clinical experience. ( Table II ) Administrative time is used for inprocessing, taking pretests/posttests, and outprocessing. Didactics includes the needed academic hours to provide an intense refresher into the care of the injured patient. The topics are numerous and include examples, such as airway management, fluid resuscitation, various trauma modules to casualty combat care, and aeromedical evacuation. Each didactic module is tailored to the specific course recipients whether technician, nurse, or physician. Skills training is spent refreshing techniques in the cadaver lab, plus practicing the team approach to horizontal trauma resuscitation in the simulation lab. The bulk of each curriculum is found in the clinical hours spent by the course attendee. These include time spent in trauma resuscitations, working in the ICU and surgical ward, and skills gained by participating in OR cases ( Figs. 8 and 9 ). The C-STARS rotators are integrated into the Shock Trauma teams. Teams consist of a mix of technicians, nurses, and providers that would approximate the complement of a team in a trauma resuscitation scenario. Each team member is assigned a role that they would normally be expected to assume in a resuscitation scenario in a combat hospital. Unfortunately, because of the assignment process and who the Air Force is able to send to the course at any point in time/the scheduling of courses and availability of personnel in certain specialties, the team complement may be lacking in certain areas; it is here that C-STARS faculty on a 3-year rotational billet in Baltimore can fill in. The students in each course do not come to the course as fixed teams from their locations essentially the teams are created after the students arrive. These teams then have a number of simulation scenarios that they are put through at various times during the course. On a different and clinical note, the students are also assigned to specific clinical teams based on their specialty. They are mixed with other faculty, residents and, nurses from the STC. During their time in the course, they participate and are completely integrated as full members of the STC team to which they are assigned. FIGURE 8. FIGURE 9. C-STARS trauma resuscitation. C-STARS training in ICU. Training Sustainment This is an ongoing issue in the Air Force Medical Service as the majority of our medical institutions do not care for injured patients on any frequent basis. There are three major avenues to maintain what we call Clinical Currency in the TABLE II. C-STARS Curriculum at the RA Crowley STC (Instructional Hours) Technician Nurse Physician Administrative 2 3 8 Didactics 46 30 6.5 Skills 7 8 14 Clinical 120 80 175.5a, 315.5 b Total 175 121 204a, 344 b a Nonsurgeons. b Surgeons. care of the injured patient. First, there are two DOD Level 1 trauma centers and those assigned have a daily ability to maintain their skills through their normal routine. Second, we have established many Memorandums of Understanding (and are continuing to establish) with civilian trauma centers that allow our physicians/nurses/technicians to rotate through and receive regular experience in the care of the injured patient. Finally, we have three C-STARS platforms that provide this experience to those who do not have either of the first two options available. Clinical Care The importance of training lies not only in recognition of complex injury care principles but in learning the art of triage, which also requires a high-volume, high-acuity trauma training environment. The STC is the highest volume trauma MILITARY MEDICINE, Vol. 176, July 2011 773

center in the United States and frequently admits a comparable number of patients to those seen in the OIF literature (44 admissions/17 operative cases in 24 hours). 9 Overall, the injury patterns seen at the two institutions were similar with head and extremity injuries being most common. However, combat injuries may differ because of the mechanisms of injury. During the period of this study, both injury severity and number of wounds per casualty increased, compared to an earlier period in the OIF/OEF conflict. 10 Most casualties in earlier wars were caused by bullet wounds, but recent conflicts have been marked by an increase in explosive wounds caused by fragmenting antipersonnel weapons (i.e., rockets, artillery shells, and mines). The introduction of the IED has created injury patterns rarely seen before the current conflict. 11 These weapons create casualties with multiple fragmentation injuries in addition to blast injuries, burns, and inhalation injuries. Traumatic brain injury surely has received much more attention during the war as the long-lasting effects of mild and moderate traumatic brain injury from explosive injury are becoming more relevant as we return individuals to their stateside occupations (whether in the military or civilian world). There is much to be learned from these types of injuries, and this recent conflict has produced a large patient population from which data can be obtained. As for the time this data set was collected, the screening programs within active duty and Veterans Affairs systems were in initiation phases. They have grown rapidly with guidance from higher echelons in the federal government just within a few years of the time that this data was gathered. The fact remains that the most common injury in theater remains to the extremities, for two very basic reasons. One reason is that each blast injury is typically always accompanied by a penetrating component of some form of shrapnel whether it be intentionally placed metal objects or just dirt/ rock from the surrounding environment. The second reason is that this is the area of the body that is the least protected, even when compared to the head. Many Western civilian practitioners may not have a vast experience caring for these types of injuries. A recent description of injuries sustained following terrorist events revealed that injury severity score was considerably higher in secondary fragment victims, although critical mortality rates were higher in gunshot wound (GSW) victims. 12 More than 40% of secondary fragment victims were injured in three or more body regions as opposed to <10% in GSW victims. This study also showed a higher degree of head (33.7 vs. 16%, p < 0.005) and thorax injuries (38.5 vs. 23.5%, p < 0.005) in explosive mechanism vs. GSW. Injuries seen in conflict produce a pattern of injury that is not seen in routine surgical practice.13 Explosive injuries are also rarely seen at the STC, but the center treats high speed motor vehicle crashes with severe torso injury, fractures, and soft tissue injuries. In addition, the STC treats a large number of patients with significant skin, muscle, and bone infections admitted to the soft tissue service, who require massive resuscitation, frequent OR debridement and prolonged hospital management. The soft tissue admissions seen at STC are secondary to infection, as opposed to those in Balad that are as a result of IEDs or rocket-propelled grenades. The wounds at the AFTH are high-energy and produce a significant amount of devitalized tissue. These wounds are all contaminated with dirt, shrapnel, and other miscellaneous items from the environment, which predispose the wound to severe infection. 14 However, care of both of these types of patients is similar. The similarities of the two patient populations support the value of this exposure for C-STARS rotators. Knowledge of damage-control surgery techniques in the management of complex trauma patients is essential for the surgeon in the combat environment. While the original description of damage control referred to laparotomy for treatment of exsanguinating intra-abdominal hemorrhage secondary to GSW, 15 more recent concepts of damage control have emerged in civilian practice to include those applied to orthopaedics 16 and resuscitation. 17 Management of patients at the STC with multiple extremity fractures or those with the combination of extremity fractures and other life threatening injuries with physiologic instability can be treated with temporizing stabilization with splints or external fixation. Recent reports from the military show that these damage control resuscitation techniques can also be helpful to treat severe isolated extremity trauma. 18 Our Balad data demonstrates that extremity injuries account for the majority of wounds on the battlefield, and hemorrhage remains the leading cause of potentially preventable death. 19 Newer techniques of tissue salvage, vascular shunting, and concurrent intraoperative physiologic resuscitation developed in the combat field have been shown to be an effective alternative to amputation. 18 Future research and collaboration should better define these principles. 20 Clearly, acquiring knowledge in all forms of damage control techniques before deployment will be helpful. An understanding of rationale for transfusion is also necessary before providing care in war. At both the STC and in the military, red blood cells, plasma, and platelets are used early in the resuscitation of massively bleeding patients, soon after patient arrival. At the STC, uncross-matched blood is used for immediate life threatening hemorrhage until type-compatible or fully cross-matched blood is available. 21 The military use of massive transfusion protocols, recombinant factor VIIa, and fresh, whole blood has been associated with improved outcomes. 22 The STC has extensive experience with the use of recombinant factor VIIa 23,24 but does not have fresh, whole blood available, hence the effort at duplicating this practice through the use of component therapy that attempts to mimic this effect. Despite the differences in transfusion practices, it would seem that the experience gained at the STC with massive transfusion practice would be helpful after being deployed. 774 MILITARY MEDICINE, Vol. 176, July 2011

Limitations Unfortunately, a comparison of civilian and combat casualty statistics may be inherently flawed. 25 The U.S. DOD provides information from current and past conflicts, suggesting that battle mortality for U.S. forces has dropped from 30% in World War II to 24% in Vietnam, to less than 10% in the current conflict. It is difficult to know what effect training has on this statistic, separate from the appropriateness of field triage, initial care, optimal evacuation, and the current use of more advanced therapies. We are not able to make a comparison of consistent civilian teams vs. the team approach with guard/ reservists, as the student population of the C-STARS program in Baltimore is all active duty. The C-STARS program in St Louis is the platform for training Air Guard and USAF Reserve medical personnel. It is also not possible to compare prehospital care as civilian trauma-systems prehospital issues are not specifically experienced in an AFTH. During the Iraq war, all patients arrived at the Balad AFTH via helicopter from the battlefield. All prehospital care was provided by medics in the field who are typically assigned to an Army/Marine unit followed by medics assigned to the MEDEVAC transport that brought casualties to the hospital. The AFTH did not provide any prehospital care (e.g., did not go get patients in an ambulance unless there was an incident on base, which rarely occurred). The patients were unloaded from the helipad and brought directly into the hospital. A final criticism of this review is that there was no formal objective evaluation of the educational training experience. Earlier reports, however, suggest a perceived beneficial effect of intensive training shortly before deployment at a Level I trauma center by subjective assessment of surgeons. 9 USAF C-STARS physicians, nurses, and technicians were administered pretests and posttests that covered their curriculum at the STC, in addition to a posttraining survey. Posttest scores improved significantly and the surveys demonstrated a perceived ability of readiness for combat trauma. (C-STARS staff, STC, Baltimore, Maryland, unpublished data; personal communication). The next step may be to administer written and skills assessments before and after STC training and then again 6 months after training/deployment to ascertain the value of the C-STARS program. Limitations exist for accurate and appropriate evaluation techniques as to the impact of this training. SUMMARY The U.S. military has undertaken a congressionally mandated program of preparedness training for medical personnel in each of the Armed forces. Military healthcare providers train at one of several U.S. top-level trauma centers before deployment to a war zone. This training may have contributed to the decrease in war-related deaths in recent conflicts. Effective curricula development for the training of healthcare providers before deployment to conflict zones depends upon evaluation and assessment of current programs. Morbidity and mortality outcomes are difficult to compare because of the differences in wounding weapons and patterns, but value can be assessed by individuals appraisal of trauma readiness training undergone. A formal follow-up evaluation program during, and immediately following, deployment may delineate these issues. 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