Archive for August, 2010

2010 Symposium Highlight–Plenary Session Addresses TBI

Tuesday, August 31st, 2010

The second day of the 2010 Annual Trauma Symposium opened with a plenary session on Traumatic Brain Injury (TBI), during which a panel of surgeons discussed and debated the benefits of various therapies.

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.”

2010 Symposium Highlight–Orthopedic Session Focuses on Differing Treatment Options

Tuesday, August 31st, 2010

The final afternoon orthopedic trauma session on the first day of the Annual Trauma Symposium featured surgeons arguing for acute repair and, conversely, for delayed reconstruction of knee injuries. Maj Mark Slabaugh, an assistant professor of surgery at University of the Health Sciences San Antonio, presented research in favor of acute treatment.

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.

2010 Symposium Highlight–Adopting Checklists in the Medical Context

Monday, August 30th, 2010

Dr. Martin Croce, MD, chief of trauma and surgical critical care at the Universiy of Tennessee Health Science Center, began the session with a quick reminder of how sepsis bundles originated. The International Sepsis Forum developed evidence-based guidelines for sepsis management in order to lower the rates of infection and mortality. However, there wasn’t uniform acceptance of the guidelines because the early meetings were funded by industry and, thus, were met with suspicion.

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.

2010 Symposium Highlight–Should Humanitarian Efforts Be Made in a Deployed Setting?

Monday, August 30th, 2010

LtCol Mark Boston used different scenarios to illustrate how a military surgeon might respond to requests for humanitarian care in a deployed setting. Military surgeons are frequently called upon to provide humanitarian care, and must balance the needs of their mission with the vast needs of the civilian population in the location where he or she is deployed.

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.

2010 Symposium Highlight–Lessons from Operation Iraqi Freedom: 2005 to 2009

Monday, August 30th, 2010

Col Joseph Brennan, MD, program director of otolaryngology at Wilford Hall Medical Center, shared his experiences in Iraq in 2004 and 2005 as a head and neck surgeon in a tent hospital. Early in the war, he shared, questions that they struggled with as they were just establishing the surgery units, included: Should subspeciasts even be in a war zone? Where should they be located and what should their role be? And What is the value of a head and neck clinic within the zone?

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.

2010 Symposium Highlight–Disentangling PTSD and TBI

Monday, August 30th, 2010

Charles Hoge, MD, Walter Reed Army Institute for Research, presented evidence from a study of more than 2,500 soldiers, seeking to disentangle Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI). Hoge said that war involves many extreme stressors that are associated with post-deployment symptoms, and noted that it is important to tease them out so that certain symptoms are not attributed to physical injuries when there is no clear line of causality.

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.

Opening Plenary Session Addresses PTSD

Monday, August 30th, 2010

Dr. Alan Peterson, director of the STRONG STAR Multidisciplinary PTSD Research Consortium, kicked off the opening plenary session of the Annual Trauma Symposium with an overview of the signature injuries of the current conflicts in the Middle East. Post-Traumatic Stress Disorder and Traumatic Brain injury are two of them.

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.

Trauma Symposium Opens in San Antonio

Monday, August 30th, 2010

The 16th Annual Trauma Symposium, hosted by the National Trauma Institute, got under way this morning with an address from Chairman Timothy Fabian, MD, FACS. Dr. Fabian, of the University of Tennessee Health Science Center, pointed out that research really does have an impact on deaths, using federal funding levels for AIDS to illustrate how a sustained research commitment has successfully driven down deaths.

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.

U.S. Trauma System Underfunded and Fragmented

Tuesday, August 24th, 2010

In an article published in the August edition of the Journal of the American College of Surgeons, Dr. Brent Eastman, chief medical officer of Scripps Health and a trauma surgeon at Scripps Memorial Hospital La Jolla, says that a shortage of trauma surgeons, high death rates in rural areas and “a disconnect between existing trauma systems and regional disaster plans” all add up to an alarming state of trauma care in this country.

While the trauma systems are laudable in some areas of the country, such as San Deigo, where Eastman co-founded a successful trauma system that has reduced the percentage of preventable deaths from 22% to 2% since 1984, in many rural areas, access to appropriate trauma care is significantly hindered. “Death rates…are unnecessarily high in those areas, leading to the fact that trauma is the leading cause of death for those under age 45 in this country.”

Eastman’s article highlights some successful trauma systems, including the military trauma systems in Iraq and Afghanistan, which quickly move injured soldiers from combat zones to more sophisticated care.

Read the press release or the full article (requires registration).

Johns Hopkins Study Reports Trauma Center Care is Cost Effective

Wednesday, August 18th, 2010

In a new study titled “The Value of Trauma Center Care,” the authors report that while trauma center care is expensive, the benefits in terms of lives saved and productive life years gained outweigh the costs associated with it. Particularly, for those with severe injuries and those younger than 55, the gains have most value because the costs associated with trauma care for those who are less severely injured are higher. The findings indicate the importance of ensuring that patients are taken to appropriate levels of care in order to increase the efficiency of the system.

The results of the study are reported in the July issue of The Journal of Trauma Injury, Infection and Critical Care. Two of the authors are NTI board members: Ellen MacKenzie, PhD, at the Bloomberg School of Public Health, and Gregory J. Jurkovich, MD, at the University of Washington School of Medicine.

Read a good summary of the article.