By Cheryl Pellerin, American Forces Press ServiceJanuary 27, 2012
LANDSTUHL, Germany -- Medical-surgical teams at Landstuhl Regional Medical Center here save the lives every day of warriors wounded in Afghanistan and, until recently, saved troops wounded in Iraq. But that's only part of their success.
Here, a side benefit of providing relentlessly superior care from the point of injury in the war zone to what doctors call "definitive care" -- care given to manage a patient's condition -- has been to advance the practice of military medicine and, ultimately, the practice of medicine everywhere.
For medical teams at Landstuhl, the brutality of combat and the urgent need to respond to the wounded have yielded advances in en-route lung bypass, whole-blood transfusion, and even combat tourniquets that can be applied with one hand and in the dark.
"Ten years ago, we had to stabilize [patients] before we could move them," said Army Col. (Dr.) Jeffrey B. Clark, commander of the Landstuhl Regional Medical Center.
"Now what our Air Force can do is basically put an intensive care unit in the back of a C-17 with a critical-care air-transport team so we can continue to stabilize while we are moving," Clark said.
The critical-care team program is part of the Air Force aeromedical evacuation system. A team consists of a critical care physician, a critical care nurse and a respiratory therapist, along with supplies and equipment.
Over the past 70 years, and especially over the past 10, a combination of evolving surgical capabilities, technology-intensive critical care and long-range air transport have pushed medical-surgical capability far forward. This saves lives and helps to reduce the load on teams at Landstuhl, a military hospital operated by the Army and the Defense Department, whose staff since 2004 has treated nearly 66,000 patients from Iraq and Afghanistan and military personnel and their families stationed in Germany.
From the United States, 48 visiting civilian trauma surgeons rotate in to Landstuhl for two weeks at a time from hospitals at Johns Hopkins University in Baltimore, the University of Cincinnati in Ohio, the Oregon Science and Health University in Portland, and others.
Also under the Landstuhl command are seven clinics: two in Belgium, two in Italy and three in Germany.
Landstuhl is the only hospital outside the United States designated a Level I Trauma Center by the American College of Surgeons. Its survival rate for trauma patients is 99.5 percent.
"About 14,000 of the 60-some thousand were actual battle injuries," Clark said. "We have returned to duty about 20 [percent] to 21 percent of those who have come to us from Iraq or Afghanistan, which is huge."
Every week, every critically ill patient is discussed on a video teleconference that spans nine time zones on three continents. Attendees include "our NATO colleagues such as MERT [Medical Emergency Response Team], the British paramedic units that have physicians on the helicopter teams, to the forward surgical team, the [three] combat support hospitals [and] Landstuhl … as well as our partners on the East Coast and San Antonio and the [Air Force] Aeromedical Evacuation service," said Air Force Maj. (Dr.) David H. Zonies, Landstuhl's trauma director.
"Everyone discusses their care that's provided along the continuum," he added.
The broad influence of Landstuhl's medical-surgical innovations is seen 25 to 30 times a day, Zonies said, every time a patient undergoes surgery in an operating room.
"From the last 10 years, a lot of the evidence that we've gathered has changed not just the practice of military medicine, but has now been completely translated back into civilian practice," Zonies said.
For example, he added, the way patients are resuscitated has changed significantly since 2001.
For the past 50 years, he explained, the standard practice for storing blood has been to break it up in to components such as red blood cells, platelets and plasma.
When it was time to give stored blood to a patient, "we'd give them a bunch of red cells, and maybe for every four of those we'd give a unit of platelets [and plasma]. That was how it worked," Zonies said.
"Well," he added, "we noticed that our mortality rate was extremely high doing that, and it was standard practice."
Then six or seven years ago, Army surgeon Dr. John Holcomb and Air Force surgeon Dr. Donald Jenkins, now both retired, observed that transfusions with 1-to-1 ratios of plasma and platelets to blood cells lowered patient mortality rate by about 15 percent. They began to use the practice for combat trauma patients, Zonies added.
"That is how we changed our guidelines for how we resuscitate all our patients," he said. "We have now taken that evidence back to our civilian counterparts, and they've been able to replicate the same approach in civilian practice, and it has decreased mortality there."
Another life-saving innovation involves a procedure called extracorporeal membrane oxygenation, or just extracorporeal life support. This is basically a lung bypass, or cardio-pulmonary bypass, that a special team from Landstuhl flies downrange to perform en route as the patient is evacuated from the war zone.
The suitcase-sized device takes the patient's blood through an artificial membrane that replaces carbon dioxide with oxygen.
The technology, developed by a team at the University of Regensberg, about a four-hour drive from Landstuhl, has been around for 30 or 40 years, but only in the past decade, Zonies said, "has it gotten to the point where everyone feels this is a safe modality that truly … improves patient outcomes."
So far, Landstuhl has the only capability in the Defense Department of providing that kind of support, Zonies said.
At Landstuhl, the hospital itself is a sprawling complex built in the early 1950s. By 2018, a new hospital that's more contemporary and flexible will replace it, to be called the Kaiserslautern Community Medical Center.
"It's a very special mission," Clark said. "We take a tremendous amount of pride in what we do, and so we consider it a privilege. In many ways, it is so terribly uplifting to take care of wounded warriors, to take care of our own. But … it can wear on you, so we try very hard to look out for each other."