Distinguished Visiting Scholars Program gives civilian surgeons a unique opportunity

It is a life-changing two weeks—the ultimate volunteer experience. As part of the AAOS/Orthopaedic Trauma Association (OTA) Distinguished Visiting Scholars Program (DVSP), civilian surgeons have a unique opportunity to serve overseas at the Landstuhl Regional Medical Center (LRMC), a “halfway hospital” between battlefield care in Iraq and Afghanistan and definitive treatment in the United States. At LRMC, injured soldiers receive surgical care, sometimes within 24 hours of injury.

Working tirelessly, civilian traumatologists assist military surgeons with cases of blast injuries, burns, complex fractures, soft-tissue injuries, and endless débridements. Treating these injuries requires a unique combination of clinical expertise and maturity of judgment. The purpose of the DVSP is to lend the expertise of the seasoned orthopaedic trauma surgeon to the care of the injured soldier. Additionally, the Visiting Scholars bring insight and perspective regarding process improvement and systems of care. Ultimately, the program enables the widest possible range of experienced surgeons to see these injuries and ensures that wounded soldiers receive the best possible care.

Dedication and tenacity
Michael J. Bosse, MD, an academic orthopaedic trauma surgeon practicing at the Carolinas Medical Center, participated in the program in November 2007. “The orthopaedic trauma mission is accomplished due to the dedication and tenacity of the surgical staff,” he states.

The volume and complexity of cases encountered during a single week at LRMC varies, but during a typical week surgeons may see 30 to 40 patients who require critical care and as many as 200 patients with less critical injuries. Major surgical cases are brought to LRMC by the Air Force’s Critical Care Air Transport Teams, the equivalent of a flying intensive care unit. In many cases, the surgical patients are within 4 to 6 hours of a surgical procedure performed on or near the battlefield.

Complex cases—including multiple extremity injuries, orthopaedic trauma with multisystem injuries, major vascular repairs, traumatic amputations, and major burns (many with fractures)—are all seen in any given week at LRMC. Most critically ill patients are transported with ongoing mechanical ventilation, intravenous sedation, and intra-cranial pressure monitoring as needed.

An extraordinary learning experience
Christopher T. Born, MD, chief of orthopaedic trauma at Brown University’s Alpert Medical School, served as a Visiting Scholar in Spring 2008. Dr. Born assisted in the treatment of more than 30 patients, frequently helping to débride combat-related injuries that would later be treated with internal fixation or limb salvage procedures in the United States.

“Seeing these soldiers with blast/burn/penetrating combinations (in many cases within 48 hours of injury) was an extraordinary learning experience for me,” he recalls.

“I specifically remember two sentinel cases. One soldier struck by shrapnel sustained a severe penetrating injury that fractured the femoral head and the acetabulum. He had no evidence of a penetrating abdominal injury. A hip-spanning external fixator had been applied in theater. The general surgical traumatologist who evaluated him on his arrival at LRMC ordered a computed tomography scan of the abdomen, based purely on the mechanism of injury. Free air was found and the patient underwent laparotomy and bowel resection. It would not be a stretch to credit her with saving that soldier’s life.

“The other situation was a coalition soldier who had severe mangling injuries to both feet and ankles as the result of an improvised explosive device. The injuries were débrided and bilateral spanning frames had been placed in theatre. On his first trip to the operating room (OR), we could see that he would need a below-knee amputation (BKA) on one side, but I thought a Symes amputation might work for the other leg. When he returned to the OR 48 hours later, the wound had continued to evolve and bilateral BKAs were performed on the following day.”

Advancing military, civilian trauma care
Military and civilian trauma care have been inextricably linked throughout history. Advances in battlefield medicine have been incorporated into civilian trauma care in the United States after each major armed conflict. During the recent conflicts in Iraq and Afghanistan, the U.S. military adapted many of the basic tenets of trauma system care to emphasize the synergy between the civilian and military orthopaedic trauma communities.

LTC Ellis O’Neal Cooper III, MD, chief of orthopaedics at LRMC, noted the benefits of the DSVP. “From our perspective [it] has been an unqualified success. … You have all had a significant impact on our ability to provide the best care to our wounded soldiers. Your efforts, expertise, and recommendations have led to [a number of] improvements here at LRMC.”

In addition to assisting with surgical cases, Visiting Scholars give lectures to the LRMC medical staff. Lawrence B. Bone, MD, professor and chairman of the department of orthopaedic surgery at the State University of New York, presented three talks during his 2-week visit. The lectures focused on management of the multiply injured patient—including early total care and damage control orthopaedics, subtrochanteric femur fractures (rodding and plating), and management of humerus fractures. He also gave a brief talk on direct and indirect reduction techniques.

“I cannot say enough about the physicians and staff working at the hospital,” Dr. Bone declares. “They were totally dedicated to giving the best care possible to these injured warriors. For me, it hit home hard because I have a son in the military who was injured and [it was] very reassuring to know how well he was cared for.”

The Visiting Scholars learned as much as they taught. “The experience at Landstuhl was valuable to me both personally and professionally,” Dr. Born says. “I gained firsthand experience and knowledge with injury patterns that were different from my civilian practice but which I consider to be of growing importance.

“The surgeons and staff at LRMC seemed to be genuinely grateful for the time that we contribute to caring for the wounded and remarked on how our perspective enhanced their learning experiences.”

Lessons to remember
The sacrifices of wounded soldiers provide lessons for all. By working together, civilian and military surgeons improve the care of each casualty. More importantly, as the complexity of the injuries and the courage of those injured become evident to more people, the process of treating the injured and new research venues are vastly expanded. The results will benefit everyone—soldiers and civilians alike.

COL (ret) Roman A. Hayda, MD, and Michael J. Bosse, MD, cochair the AAOS/OTA Distinguished Visiting Scholars Program subcommittee of the Extremity War Injuries and Disaster Preparedness Project Team.

Learn more
Visiting Scholars are distinguished surgeons with at least 10 years experience who have demonstrated excellence in teaching and have substantial experience in civilian orthopaedic trauma clinical care. Observing and assisting at Landstuhl Regional Medical Center, Visiting Scholars see how the military has been able to reduce combat mortality.

For more information or to apply to serve as a Distinguished Visiting Scholar, please visit www.aaos.org/ewi or contact COL (ret) Roman A. Hayda, MD (roman-hayda@brown.edu); Michael J. Bosse, MD (michael.bosse@carolinashealthcare.org), or the Orthopaedic Trauma Association (ota@ota.org).