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'Battlefield docs' converge in Iraq to hone skills

by Capt. Ken Hall
332nd Air Expeditionary Wing Public Affairs

5/23/2007 - BALAD AIR BASE, Iraq (AFPN) -- More than 40 "battlefield docs" -- surgeons and physician assistants from around Iraq -- converged at Air Force Theater Hospital May 21 here to hone their already razor-sharp surgical skills at the Tri-Service Extremity War Surgery Symposium.

Battlefield medicine has greatly improved since the beginning of Operation Iraqi Freedom, more so since Operation Desert Storm, and leaps and bounds beyond the Vietnam and Korean wars. No longer does it look like the scenes portrayed in the TV series "M.A.S.H.," although Balad Air Base's hospital is reminiscent of the one staffed by Hawkeye and Colonel Blake in the sense it's still a maze of tents.

Survival rates for U.S. patients here have reached 98 percent -- unheard of in past wars -- and surgical procedures here rival any performed in trauma centers stateside.

"One of the ways we've been able to achieve that 98 percent survival rate was defining and perfecting a standardization of care that prevents, or at least reduces, unwarranted practice variations," said Col. Brian Masterson, the hospital's commander.

While two doctors might treat a given wound differently based on their own unique experiences and training, there just plain has to be a standard way of treating wound 'X' with therapy 'X' to yield consistent, positive results, he said.

That standardization has also improved throughput capacity at the hospital. On several occasions in past months, the sheer number of casualties coming in within minutes might have shut down a trauma center back home.

Not so at Balad Air Base. Where typical Level 1 trauma centers stateside might see 2,000 admissions a year, the AFTH nets 8,000. So it is, too, with different types of trauma. Back home, only 30 percent of wounds are penetrating traumas compared to more than 90 percent in Iraq; and where high-velocity gunshot wounds are infrequent back home, here they are the norm. Finally, multiple-casualty events are rare at U.S. trauma centers, but are commonplace on today's battlefield.

"Our purpose with this symposium was to build a vision that all branches of service in the medical profession would embrace so we take optimal care of our men and women risking their lives every day," said Lt. Col. Craig Silverton of the 332nd Expeditionary Medical Group.

Symposium co-directors Col. Mark Richardson, also with the 332nd EMDG, and Colonel Silverton planned the day-long event to include interactive lectures and sessions in preoperative medical management as well as the treatment of coalition forces' vascular, soft-tissue and orthopedic wounds in order to better provide critical medical care in the theater of operations.

Speakers with first-hand combat medical experience through past deployments shared lessons learned with one another and with new members recently deployed here. As a side benefit, the course provided eight hours of continuing education credits for deployed medical professionals in Iraq. 

"We set up this symposium to build a 'standard of care for the theater,'" Colonel Silverton said. 

The colonel has a unique perspective of the care being provided in both combat theaters with a rotation at Landstuhl Regional Medical Center, Germany, under his belt. He served there as the Operation Iraqi Freedom and Operation Enduring Freedom orthopedic trauma surgeon in 2004, he then deployed to Iraq with the first group of surgeons in the fall of 2004 when the Air Force took over Balad AB's theater hospital. 

Since Balad AB became the (medical) hub in Iraq, Colonel Silverton said he noticed a difference in the way war trauma surgery was carried out at various theater locations. Each surgeon had their own training and perspective on how best to handle a trauma patient.

"So it was my feeling a 'standard' could be initiated involving all three services, not just the Air Force, and we could form a consensus as to the best treatment for wartime casualties," he said.

Colonel Silverton also noted that what is unique about this environment is most casualties are related to improvised explosive devices and EFPs -- explosively-formed penetrators and a deadlier form of IED -- and they're treated differently than typical high-velocity gunshot wounds seen with the AK-47 or the M-16.

"Debridement, or the removal of dead tissue, is crucial to preventing infection and for survival of the limb," he said. "Our first goal is to save the patient's life -- even if it requires amputation of one or both legs. Unfortunately, many times that is the case. Education is our main goal of this symposium, and if we can save just one life or one limb, it will have been worth our effort."

With the current generation of body armor and all its enhancements to better protect troops, the highest percentage of combat wounds in this war are to troops' extremities," said Lt. Col. Raymond Fang, the co-director of the intensive care unit at the AFTH. He deployed from the 435th Medical Squadron at Landstuhl Regional Medical Center in Germany.

"Many people come here with vast trauma experience and expect it'll be just like back home, but this is totally different," Colonel Fang said.

He has been caring for wounded coalition forces for the past three years at Landstuhl, but just a day or two removed from the level of care he is now seeing firsthand at the AFTH. 

Combat medical care comes in stages. Care starts right on the battlefield by medics and corpsmen then to combat surgical hospitals throughout Iraq. Next, care is given at theater hospitals and then medical evacuations fly patients to Landstuhl. Finally, definitive care is given at medical centers like Walter Reed and Bethesda in the national capitol region and Brooke Army Medical Center and Wilford Hall in the San Antonio area.

"The whole goal is that new personnel won't feel like they have to reinvent the wheel," Colonel Fang said. "Instead, they can draw and build upon past experiences so that from day one, they can provide the most up-to-date therapy available to wounded coalition forces."

What we do here is unique and different from medical/trauma care anywhere else in the Air Force. Our common goal is to provide the best care possible to wounded heroes here in Iraq," Colonel Fang said. "We sometimes have to set aside our own pride and confidence in our learned way of doing things and do it the way it's been proven here on the battlefield through experience. That's the benefit of capitalizing on the lessons learned here and creating standardized therapy."

"The care we're providing at the Air Force Theater Hospital is the best anywhere in the world," Colonel Silverton said.

The hospital here has nearly every surgical sub-specialty covered, and with the most recent advancements in medical technology such as a 16-slice CT (computed tomography) scanner and hand-held blood analyzers at their disposal, the colonel said, "We have the ability to take an injured patient into the operating room within minutes being operated on by a highly skilled team of surgeons."

That capability is critical because in the states most patients may require only one procedure and one surgeon. At Balad AB, the vast majority of trauma patients require multiple procedures, and those procedures are most often performed by a team of surgeons all around the table at the same time. 

"I would put our capability here in Iraq up against any major trauma system in the U.S.," Colonel Silverton said. The reservist works at the Henry Ford Hospital in Detroit, one of the main trauma centers in Michigan. "We are truly stellar in our ability to provide 'state of the art care' to our wounded servicemembers." 

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