“It’s a bad idea to stick things blindly into the airway and think good things are going to happen,” warned Dr. Jay Ellis of Tejas Anesthesia, as he directed participants in the correct placement and tracking of the optical stylet at Station 1. “These are motor skills. You need to do this several times a month in order to stay current.”

At Station 4, Dr. Thomas Grissom, an associate professor at the University of Maryland School of Medicine, talked a young medic through the process of using a video laryngoscope to open the airway, reminding him to keep it midline for best results. “The young guys [who are used to video games and other simulations] are better at this than the older guys are,” he said.

Pig tracheas were used at Stations 5 and 8 so that Dr. Kurt Grathwohl (Brooke Army Medical Center) and Dr. Joseph Brennan (Wilford Hall Medical Center) could realistically demonstrate different approaches to performing a cricothyroidotomy. Dr. Brennan urged participants to learn the technique by feel. “If there’s blood everywhere, you’re not going to be able to see anything, so really use that index finger so you know exactly where you are,” he said.

The room swirled with activity throughout the three-hour-long workshop, as participants rotated through the 12 demonstration stations and two bonus tables.

Dr. Strong pointed out that the majority of warriors exposed to traumatic events do not develop PTSD. He said a potential mechanism that explains vulnerability to PTSD is exposure to traumatic stress in early life. His research group is looking at several questions surrounding the effects of early stress on susceptibility to PTSD, as well as whether the “programming” that may be the result of early stress can be reversed.

In animal fear conditioning and extinction studies, Strong’s group found that prenatal stress programs adult sensitatization to fear and resistance to fear extinction, as indicated by chemical changes in the brain and automated measures of animal responses.

Following Dr. Strong’s presentation, Sheila Rausch, PhD, a clinical research psychologist with the VA Ann Arbor Healthcare System, reported on a study of a new PTSD treatment under review in a DoD primary care setting.

The treatment under study follows the Stepped Care Model, where, at lower levels, interventions such as self-help materials and web-based CBT and phone support are made available. Higher levels of care include primary care intervention (currently there are few, if any, specific PTSD programs at this level with a therapeutic component), specialty mental health care, and finally, inpatient programs.

The primary care PTSD treatment approach under study involves four to six 30-minute visits, a self-report assessment, education on the normal recovery curve and exposure-based treatments and discussion of primary and specialty care options. Participants advance though a workbook, answer emotional processing questions and complete homework. Preliminary data on the 15 participants who completed the study showed a signficant reduction in PTSD symptoms.

Despite the small study size, Rausch believes that primary care PTSD treatment can reduce PTSD and depression over four weeks, and it can be a critical component of a stepped care model of PTSD treatment.

COL Geoff Ling of the Defense Advanced Research Projects Agency (DARPA), talked about CPP (cerebral perfusion pressure) Management and whether it changes TBI outcomes. CPP is an indirect measure of CBF, it’s easy to obtain and there is a certain amount of science to back up the clinical practice. However, he said, it does not adequately reflect local perfusion, and it is not supported by Level 1 evidence.

Dr. Ling concluded that the current guidelines are pretty good–keeping the CPP range between 50 and 70–and result in the best outcomes.

Eileen Bulger, professor of surgery at the University of Washington, explored hypersomolar therapy and its effect on outcomes in TBI patients. Dr. Bulger said a 2001 Journal of Trauma article by Doyle et al is an excellent source of data on the potential advantages of hypertonic therapy. There is a lot of basic science and animal literature that says this therapy may be beneficial.

Based on Dr. Bulger’s review of the data, she said we still don’t know if ICP-guided therapy improves long-term neurologic outcome. We don’t know if mannitol or hypteroic saline is the best choice, among many other questions.

LtCol Vikhyat Bebarta, chief of medical toxicology at Wilford Hall Medical Center, shared data on progesterone treatment for moderate and severe TBI patients. He said that moderate and severe TBI is a major problem in the U.S., with 1 TBI case every 15 seconds. And in the current Middle East conflicts, TBI is the “signature wound;” yet, while we have improved armor to reduce penetrating injurings, very little has been done to improve TBI treatments. Medical treatments that have failed in big trials include steroids, mannitol, magnesium, albumin and hypertonic saline. Studies of hypothermia are inconclusive.

Dr. Bebarta said that progesterone, a sex steroid, rapidly enters the brain, has a history of safe use and great pre-clincical data. The outcomes of animal studies have shown that progesterone is beneficial for treatment of brain injury. Epidemiology support, however, is limited, but Dr. Bebarta said there is a study currently under way with promising initial results.

Dr. Guy Clifton, professor in the Department of Neurosurgery at the University of Texas Medical School at Houston, next took the podium to discuss the use of hypothermia in treatment of severe brain injury. Work that Dr. Clifton and others engaged in in the early 1990s showed that a few degrees of hypothermia worked as well as or better than any current drug therapy. However, a later study Clifton ran showed no difference between hypothermia and other therapies.

Practically, Dr. Clifton said what can be said about hypothermia at this point is that there is not much evidence that it is protective for patients with diffuse brain injury. However, three studies conducted in the Netherlands and in China show that hypothermia lowered ICP and had positive outcomes. Dr. Clifton believes there is Level I and II evidence to support that hypothermia impoves outcomes; but for neuroprotection, hypothermia worsens outcomes for patients with diffuse brain injury. More studies are needed to explore whether hypothermia improves outcomes for hemotoma.

The final presenter of the morning, Dr. Alex Valadka, chief of adult neurosciences at Seton Brain and Spine Institute, explored the use of cranioectomy. Dr. Valadka admitted that he’s one of very few neurosurgeons in the country who believes decompressive cranioectomies are overdone. The literature is not too helpful, he believes, and if we are creating vegetative survivors, is that really a preferred outcome? “This is not a benign treatment,” Dr. Valadka said. “Recognize that it is not free from complications and I believe there are more problems with it than a lot of other neurosurgeons do.”

Slabaugh recognized that the evidence is sparse–accute repair is supported but not proven to be the best option. He stressed that each patient needs to be assessed individually.

LtCol Warren Kadrmas, orthopedic consultant to the USAF Surgeon General, argued for delayed reconstruction. He pointed out that acute injuries occur in more highly active individuals, such as professional athletes, and that such people may report lower levels of pain than those in the general population, skewing some measures of success of acute repair.

The advantages of delayed reconstruction include avoiding compartment syndrome, achieving return of neurologic function, and needing only a single surgery. Kadrmas said it’s universally accepted that reconstruction of ligaments is better than repair, but something in between–sub-acute reconstruction (within 6-12 weeks)–may be best.

The sepsis bundle includes the resuscitation bundle, which is administered in the first six hours, and the management bundle, which should be administered in the first 24 hours. This bundle is more controversial and includes recommendations such as low dose steroids for septic shock, activated protein C and antibiotic therapy. Croce explored whether sepsis bundles save lives, and his conclusion was: yes and no. The initial resuscitation bundle is critical to a good outcome, he allowed, but the management bundle has questionable utility.

Dr. Seth Lotterman, an emergency physician at Baptist Health System in San Antonio, said that checklists make it harder to do something wrong and easier to do things right. The improved communication enabled by checklists puts everyone on the same playing field.

Lotterman pointed out that medical errors occur at higher rates in emergency contexts.

There are many reasons to perform humanitarian treatments, but there may also be many reasons not to perform, Boston said. There’s no data to support whether or not performing such surgeries results in positive outcomes–for instance, in many settings, follow-up care is difficult or non-existant, and more problems may result from treatment than from non-treatment. The overwhelming desire to relieve suffering and help others may color a surgeon’s decision. Boston also noted that healthcare is often used as a political instrument, making the decision to treat or not treat rife with diplomatic complexities.

Drew Horlbeck, MD, director of otology/neurotology at Nemours Children’s Clinic and a former U.S. Airforce officer, conducts humanitarian work around the world. The goal of any humantiarin mission, he pointed out, is to gain access–whether it’s a religious organization trying to spread its word or a country. As a neutral person, what you can do, however, is help to raise the level of care in the local setting: “You can offer access to modern equipment, provide up-to-date medical education and train local doctors in new techniques,” he said. “If you can pass on this information, you hope to make yourself obsolete.”

Issues that surgeons on humanitarian missions are up against include poverty, lack of education/illiteracy, poor medical care, no surgical care, and the influence of witch doctors. Dr. Horlbeck mentioned that you need to be prepared for a lot of bad pathology. His guidelines to taking on humanitarian missions include focusing on a specific area of care, ensuring that there will be local physician follow-up, keeping risk to a minimum, and maintaining a standard of care if possible.

Even so, the best course of action is sometimes to do nothing, Horlbeck recognized–you don’t want to do anything too complex or that might result in unintended complications.

Brennan believes that absolutely H&N subspecialists do need to be in the war zone. If you can treat the traumatic injuries within an hour, there is a much higher rate of survival. “This is critically important.” He added. “If you’re going to send these guys to get wounded, you need to have the best care out there, and the best care these kids can get is with a multidisplinary team.”

As far as whether the U.S. should have H&N outpatient clinics in the deployed setting, Brennan feels that it is definitely a good addition to the surgical role.

Maj Brendan Farrell, MD, an oral and maxillofacial surgeon at Wilford Hall Medical Center, joined the discussion to talk about his experience in 2009 and illustrate how the war zone had changed in four years. While the types of combat injuries soldiers sustained were similar to those Dr. Brennan treated, the case load had dropped significantly. Dr. Farrell was deployed for six months in 2009, and he noted that the trauma mix had also dramatically changed by that time, with much more of it non-combat related. Because of the decrease in combat injuries, Brennan was able to do more definitive care in theater.

Because advanced teams are now in place in Iraq, the majority of the care they receive is done in theater rather than being sent to higher levels of care in Germany or elsewhere. And because there are a lot of surgeons there who are ready to work, every Tuesday, Brennan said they set up Iraqi clinic where they saw locals who had been injured earlier in the war–which he felt was good for humanitarian reasons. Clinics were conducted six days a week, during which the doctors took care of injuries that were more sports-related, accidental or self-inflicted, as well as elective surgeries such as removal of wisdom teeth.

An audience member urged the medical personnel in the audience to volunteer to serve on boards when they are asked so that they can make sure the lessons learned in the war are passed on and lead to better care in the future.

Post-injury surveys are conducted in such a way, he said, that mild traumatic brain injuries (mTBI) are being implicated in a host of post-concussive symptoms that really may not be relate to mTBI at all, and indeed, are not part of the definition of mTBI in the first place. These post-war symptoms–depression, fatigue, headaches, insomnia, and so forth–have more than one potential cause and yet are reinforced as being related to mTBI. In addition, Hoge contends that current treatment approaches are often not evidence-based. The only intervention that has been shown to lead to postive outcomes is education that promotes positive expectations of a full recovery.

“I’m not saying that mTBI is not important,” Hoge insisted. “I’ve been accused of that.” Rather, he wants to make sure that diagnosis and treatment lead to accurate clinical decisions. The expertise most informative for care of mTBI, he believes, comes from the primary care setting. Hoge recommends a patient-centered treatment plan, regular primary care visits, sympotomatic response to health concerns, and treatment of mental health problems without causal attributions.

Dr. Peterson mentioned that data collection related to PTSD has stepped up significantly in the last several years within the military, so much more information is available than it has ever been before. Peterson’s focus is on the medics–those who take care of the traumatically injured in combat.

In August 2004, Peterson and others set up an Air Force Theater Hospital in Iraq and began a study to collect data on military medics. His goal was to identify factors that contribute to risk and resilience in deployed military medical personnel.

He looked at trauma factors (severity, frequency, type), individual factors, and environmental factors.
Medics are exposed to wounded and deceased American soldiers, attacks from rocket and mortar fire, uncooperative Iraqi patients, long work hours with little sleep, removal from social support systems, and more.

Among the general population, he pointed out, about 61% of all American men are exposed to a significant traumatic event, and about 8% of that population develops PTSD. More women actually develop PTSD than men, in spite of the fact that fewer women are exposed to traumatic events. While only a small percentage of Americans are exposed to combat, the risk of PTSD is extremely high for this group, as it is for those exposed to rape. Whether the trauma involves a life threat and physical injury is also an indicator of PTSD risk.

The study identified the most stressful events in the lives of deployed medics. Those who witnessed arm amputation, leg amputation, severe pain, head and eye injuries, facial injuries and severe burns, injured women and children and exposure to dead bodies, among other traumas, reported the most stress. There is a significant relationship between those who experienced healthcare trauma and those who developed PTSD.

Protective factors that contribute to resilience include friends’ and family members’ support and respect for the officers in one’s command. Good unit cohesion is also a significant buffer to stress. Peterson noted that one’s attitudes and beliefs about the mission and training are also significant factors related to resilience. If a medic feels his or her training prepared him or her well and truly believes in the mission, there is a greater level of resilience.

Providing healthcare in an environment in which the patients are not cooperative or may even be hostile was also identified as a significant stressor, as is the case with the Iraqi patients military medics are required to treat. “When you’ve used your blood supply to take care of Iraqi insurgents and then injured Marines come in and die because there’s no blood left, that is really difficult,” mentioned Peterson.

Peterson next discussed medical resiliency training currently in use. The Army MEDCOM program, for instance, focuses on managing health, problem solving, increasing strengths and positive responses. His suggestion is that the best training should just be rigorous military training–the better people are trained overall, the better they will fare in deployed situations. And because of the importance of unit cohesion to resilience, professional military education and leadership training is paramount. The better the leaders, the more protected individuals in the unit are.

Fabian talked about the first $1.4 million in grants awarded by NTI this year and stated that the organization’s five-year goal is to reach $25 million in research awards. Studies vying for NTI’s next round of funding–totalling $2.8 million–are currently under review.

He urged attendees of the conference to participate in NTI’s Stop the Bleeding campaign to raise money for hemorrhage research by texting TRAUMA to 20222 to donate $10 or spearheading Stop the Bleeding campaigns in their own care settings.