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Serving ‘wounded warriors’

By Peter Pollack

When Steven J. Morgan, MD, landed in Frankfurt, Germany, on July 22, 2007, he wasn’t really sure what to expect. As the first orthopaedic surgeon in the Landstuhl Visiting Scholars Program—a joint initiative between AAOS and the Orthopaedic Trauma Association (OTA), Dr. Morgan was committed to serve the “wounded warriors” who arrived daily from Iraq.

A Critical Care Air Transport team loads a patient onto the bus.

“I thought it was a tremendous opportunity to serve my country,” says Dr. Morgan, who practices in Denver. “That’s why I did it. I wanted to be of service if I could be.”

He wasted little time settling in. He had gone to Germany to work and he didn’t want to take a chance that he might miss out on an important case.

“I wanted to maximize my experience during the relatively short time that I was there,” he says. “Every injury is different and poses some new problem. Although the injuries are somewhat similar to civilian trauma in general, the wounds experienced by soldiers tended to be of higher energy with a greater degree of variability of soft-tissue injury. They also tended to involve more extremities than we see in the civilian population. The way they get cared for is different as well. I didn’t want to miss out on any of that.”

Each day began with a morning report—a review of all the patients who were admitted to the hospital the prior day to determine treatment plans and surgical schedules. Both military and civilian surgeons would also review the reports from ‘down range,’ a list of the wounded warriors coming from forward areas, which provided an idea of what to expect and who would potentially need orthopaedic care.

By 7:30 a.m., he was in the operating room. “We’d do surgery till anywhere between 3 o’clock and 5 o’clock in the evening,” he recalls. At about 2 p.m., new wounded soldiers would arrive from Ramstein Air Force Base, and Dr. Morgan would join his military colleagues in making rounds. “We would schedule anyone who needed immediate or urgent surgery that night, as well as schedule surgeries for the remaining days of the week. That was pretty much it…day-in and day-out…seven days a week.”

Mirroring an ongoing program
The Landstuhl Visiting Scholars Program originated with a 2006 visit to Landstuhl Regional Medical Center (LRMC) by Richard F. Kyle, MD, who was then president of the AAOS, and Andrew N. Pollak, MD, a member of the OTA. Drs. Kyle and Pollak were filming a video segment on military medicine for the AAOS 75th Anniversary. While there, they met Donald D. Trunkey, MD—a well-regarded general surgeon from Oregon—who was participating in a visiting scholars program run by the general surgeons.

Upon learning about the general surgery initiative, Drs. Kyle and Pollak asked military officials about establishing a similar program with orthopaedic surgeons. Because extremity wounds are among the most common serious injuries occurring in Iraq and Afghanistan, they received an enthusiastic response from the military.

When they returned to the United States, they presented the idea to the AAOS and the OTA.

“The OTA is our key partner in the Visiting Scholar program right now,” says Dr. Kyle. Most of the initial participants are OTA members who responded to a single call for volunteers.

“The number of volunteers we got was amazing,” says Dr. Pollak. “We were looking for people with 10 or more years experience in clinical care and teaching. It’s a very select group of fellowship-trained trauma experts.”

Wounded warriors begin their journey back to the United States on the CCAT bus.

“Highly motivated people”
The spirit of the volunteers matches the spirit of the soldiers they are treating. “It’s hard to really describe the sense of reward that you get for delivering care to U.S. military personnel who have been injured in action,” says Dr. Pollak.

“First of all, they are tremendously grateful for your help. Their first words when they wake up are ‘thank you.’ That’s immediately followed by questions, asking how their buddies are doing and when they’re going to be able to get back to help them. Everything you see on television about that is absolutely real. Their commitment to their job and their country is extremely admirable and something that should serve as a model for civilians.”

Dr. Morgan agrees. He spent his spare time talking with the soldiers who passed through the hospital. LRMC, unlike most “down range” medical facilities, has a patient base made up almost entirely of soldiers.

“You could really have as much interaction with them as you wanted,” Dr. Morgan explains. “I would just ask them their stories. I learned a lot about what they did and how they were injured. It’s been said before, but these are highly motivated people, and most of them were anxious to get better and get back to their units. I think that that was one of the most interesting and refreshing things I found—a very dedicated and motivated group of people who demonstrated a tremendous commitment to their mission.”

Meeting their goals
One of the goals of the Visiting Scholars Program is to facilitate an exchange of ideas between civilian trauma surgeons and orthopaedic surgeons in the military. Another goal is to provide educational opportunities to military surgeons serving in Germany, so that they could get continuing education credits and benefit from the knowledge and experience of civilian orthopaedic trauma surgeons.

“I think it was a great benefit to both the military and potentially the civilian world,” says Dr. Morgan of his trip. “By building these bridges and gaining this experience in caring for the wounded warriors, I have developed some expertise and knowledge in the care of extremity blast injuries, which I can bring back to the civilian population. Although we don’t see the same type of injuries on a regular basis, perhaps I can serve as a regional resource in the event of homeland terrorist activity, or for a patient who experiences such an injury from other mechanisms.”

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

Why Landstuhl?
Injured soldiers from Iraq and Afghanistan are evacuated in three stages. Initial emergency treatment is provided at an in-theater hospital. After the injuries are stabilized and débrided, solders are airlifted to Landstuhl Regional Medical Center in Germany for intermediate care. Definitive treatment is provided by various military medical facilities in the United States.

“The air-evac system is incredible,” says Richard F. Kyle, MD. “The C17 aircraft are flying intensive care units. Once the patients are débrided and stabilized with an external fixator or just stabilized for blood loss, they’re evacuated to Landstuhl almost immediately. The visiting scholars see these wounds when they are fairly fresh.”

“Landstuhl is a unique location,” agrees Andrew N. Pollak, MD. “It’s not in theater; it’s not in the continental United States. Typically, patients arrive at Landstuhl 24 to 72 hours after their injuries. They’ve already been to the operating room once, they stay in Landstuhl for somewhere between a day and three days, and then they come back to the United States for treatment and rehabilitation.”

Following patients across continents
Serving at Landstuhl means that surgeons focus only on the intermediate level of care, which presents a unique set of challenges. Orthopaedic surgeons are generally accustomed to following a patient’s progress from the planning stages of a surgery through months or even years afterward. Military surgeons prefer to have that type of follow-up as well and have solved the problem with a uniquely military, high-tech approach.

Physicians at Landstuhl participate in a weekly video conference, explains Steven J. Morgan, MD. “They try to involve all of the care facilities in the evacuation chain—from the lowest level care center in theaters of operation to the tertiary definitive referral centers back in the United States. The format allows physicians from any of the facilities to ask about follow-up on any patient, and the patient’s course is presented all the way from the initial intervention to the tertiary referral center. This enables physicians to get feedback about how their patients are doing and to learn about the outcomes of their interventions.”

October 2007 AAOS Now
http://www.aaos.org/news/bulletin/oct07/cover1.asp