LTC Clinton Murray, MD, Infectious Disease Fellowship Program Director at Brooke Army Medical Center in San Antonio, talked about the continuing challenge of fighting infections in combat casualty patients. Murray noted that in some types of combat injuries, infection rates can be 50 percent or higher, and he also noted that in the last four to five months, BAMC has seen more and more Afghanistan combatants with infection issues.

Murray discussed the significant role of nosocomial transmission in the spread of pathogens. He looked at several studies in France and with military hospitals showing the inter-hospital transmission of drug-resistant bacteria, and also noted that Canadian soldiers returning from Afghanistan are treated in civilian hospitals.

The impact of these pathogens includes more hospital days, more ICU days, more ventilator days, and more fatalities. Some of the pathogens, like acinetobacter, are more indicators of infection severity than cause of death; as Murray noted, “Patients will die with acinetobacter, rather than die of it.”

Yet for older and immunosuppressed patients, the presence of drug-resistant bacteria can place them at higher risk. Murray noted throughout the presentation that MRSA is a continual challenge that medical personnel have to wrestle with all the time. He encouraged the use of existing national and international infection control guidelines to help prevent the spread of pathogens, and discussed at least one case in which simple, common-sense measures have dramatically affected infection rates in ventilator patients.

In this session, Dr. Amy Coburn talked about the disaster plan developed for Houston in addressing ophthalmology issues. Her first question was why do we need an eye plan in a disaster –- she noted that it’s important because the eye is a particularly vulnerable part of the body, and because eye injuries adversely affect disaster response. The first step in determining a disaster response plan for an area is to assess its risk. The Houston region, for example, encompasses 10 counties and includes 5.5 million people, about 30 percent of whom are uninsured. Its jurisdiction includes Galveston, which experienced a recent natural disaster in Hurricane Ike.

The Houston plan applies to mass casualty incidents, including terrorist attacks, as well as natural disasters, such as Hurricane Katrina, which inspired the push for a disaster plan. It utilizes a number of existing entities, including hospitals and other eye-related organizations, and anticipates the various logistical and transportation challenges that could arise in such a situation.

This session featured LtCol James Keeney and COL James Ficke, debating the pros and cons of ORIF in combat zones, as well as on LTC Kevin Kirk and Maj Michael Charlton on Mangled Hind Foot/Pilon: Limb Salvage/Early Amputation, moderated by Drs. David Teague and Mark Richardson.

The first half of the session explored the question put forth at the start of Ficke’s presentation: “Would you fix your son’s or daughter’s talus in Iraq?” Keeney pointed to the complexity of support services and cleanliness of Balab Air Base in Iraq as an indication that theater hospital conditions are improving, and looked at the higher risks of infection related to delays in wound coverage. Ficke argued that combat conditions, infection risks, and requirements for accelerated fixation still make ORIF in the theater a riskier prospect. In certain types of ORIF cases, Ficke noted infection rates haven’t significantly improved from the Vietnam War era. Given that these patients have to be evacuated to higher-level care eventually, that ORIF should be reserved for those environments.

The second half of the session explored the question of limb salvage vs. early amputation in mangled hind foot and pilon injuries. Kirk advocates for limb salvage in most cases, except for life over limb and non-reconstructable soft tissue cases. Kirk cited SIP (sickness impact profile) scores showing no difference early amputation and limb salvage patients, and comparable return to work rates. Charlton advocated for early amputation, noting a number of studies showing increased numbers of hospitalizations ad higher infection rates for limb salvage patients, plus complications specifically related to the talus and the calcaneus. He also noted that late amputation in a limb salvage case is often seen as a failed treatment by the patient, whereas early amputation is not perceived the same way.

Military doctors–including Dr. Peter Rhee (recently separated), COL Lorne Blackbourne, COL Brian Eastridge and LtCol Todd Rasmussen–opened the Mass Casualty Innovations session with graphic depictions of injuries sustained by soldiers in Iraq and some live footage of far-forward medical operations there to illustrate some of the lessons learned from Operation Iraqi Freedom.

Dr. Rhee described his experience caring for hundreds of injured civilians and soldiers at a time during a suicide bombing attack. Among his recommendations were:
-Keep triage simple, using quick, seasoned judgement to separate the wounded into immediate, delayed, walking and expectant categories
-Initiate a “walking blood bank” in order to get fresh, whole blood into the severely injured
-Prepare three plan levels to deal with small, medium and large numbers of wounded

COL Eastridge talked about the difficulty of categorizing a patient as “expectant,” or too injured to save. That decision is frought with both professional and emotional angst, he said.

With the experience that has come with our military involvement in the Middle East, Eastridge noted that the U.S. now has significant knowledge of how to deal with mass casualty situations, and has been quick to adopt new strategies as they come to light. “The mortality rate compared to that in Vietnam is way down,” he said.

Innovations that have been put into practice in the last few years include the combat application tourniquet (CAT), a combat pill pack, and vascular shunts. Eastridge noted that, as evidence from field hospitals mounts, there is indication that more advanced vital signs may be better indicators of patients’ conditions, thus leading to more effective categorization and treatment and better outcomes.

On the civilian side, Dr. Dror Soffer of the Tel-Aviv Medical Center in Israel, discussed how terror activities in his country affect the operations of the trauma center. As terrorism spreads throughout the world, he warned U.S. doctors to be prepared to deal with such trauma. In particular, he said, terrorism results in:
-Young, unprotected civilians being wounded
-Patients having more than one major trauma
-Blast lung injuries
-Amputations
-Burns

Soffer stressed the need for joint efforts among law enforcement, national agencies, medical facilities, and others to effectively deal with the trauma that results from terrorist activities.

The National Trauma Institute’s 15th Annual Symposium began with a keynote address from LTG Eric B. Schoomaker, the U.S. Army Surgeon General, whose discussion included a review of the ongoing, innovative collaborations happening between civilian and military trauma care centers. Noting that it is neither ethical nor practical to carry out clinical trials in combat zones, Schoomaker discussed four consortia in which amazing breakthroughs are happening in trauma care as a result of civilian and military collaboration. These include:

* The Orthopedic Extremity Trauma Research Program, with a goal of returning injured soldiers to function, including the recent, remarkable case of a soldier who survived amputation of all four extremities;
* The Armed Forces Institute for Regenerative Medicine, doing what Schoomaker termed, “amazing, science fiction type work” in cranio-facial reconstruction, compartment syndrome, burn repair, healing without scarring, and limb and digit salvage and reconstruction;
* The Prospective Observational Multicenter Massive Transfusion Study; and
* The Burn Multi-Center Clinical Trials, investigating a correlation between the intensity of PT and OT sessions and recovery.

LTG Schoomaker emphasized that rather than relying on anecdotal evidence and engaging in passionate debate, what is most needed to move medicine forward is the dispassionate, sound evidence that comes from quality science. Quality care, he said, can only come from quality science.