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Process of Care for Battle Casualties at Walter Reed Army Medical Center: Part I. Orthopedic Surgery Service

Posted on: Sunday, 26 March 2006, 03:03 CST

By Javernick, Matthew A; Doukas, William C

Walter Reed Army Medical Center has been a primary hub in the United States for receiving Army battle casualties from Operation Enduring Freedom and Operation Iraqi Freedom. We detail the process of care that was developed to effect the timely effective management of these casualties.

Introduction

Walter Reed Army Medical Center (WRAMC), an echelon V facility, has been a primary hub in the United States for receiving Army battle casualties from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). The care of soldiers from injury to final disposition has been a joint service and specialty effort. We present a four-part series that represents the experiences of the orthopedic surgery service, physical therapy service, physical medicine and rehabilitation service, and occupational therapy service. The purpose of this article was to detail the process of care that was developed to effect the timely effective management of these casualties, with emphasis on a predetermined multidisciplinary approach to patients and recommendations to facilitate this process at our medical center and others in the future. The structure of the process has been modified and integrated in the care of a continuous flow of large numbers of contaminated, multiple extremity-injured soldiers, who frequently require multiple surgical procedures and complex medical management, followed by extensive rehabilitation and strong social support (Fig. 1). This series attempts to describe the process of care of battle casualties that has been established at WRAMC for the four respective services within the Department of Orthopedics and Rehabilitation.

Before Casualty Arrival

The orthopedic surgery service became involved with specific battle casualties via electronic mail and ongoing communication with care providers at overseas regional medical facilities. This initial communication was paramount in managing resources and operating room schedules within the orthopedic surgery service. This information, in the face of a continuous influx of patients requiring multiple surgical procedures and extensive rehabilitation, many with complex social situations, allowed orthopedic surgeons to direct the treatment of numerous patients, as well as the census on the wards and in outpatient facilities. This process included decreasing elective orthopedic surgery procedures and clinic sizes and placing the hospital on divert status for non-Tricare Prime orthopedic patients.

Transfer of the bulk of battle casualties out of country back to the continental United States was completed by the Air Forcerun Air Evacuation System (Aerovac). The Aerovac system routinely provided a manifest of casualties with the definitive inbound manifest, which was often finalized after Aerovac departure. This manifest and estimated time of arrival were communicated to the Aerovac office at WRAMC and were then made available to a variety of personnel, including the orthopedic surgical resident on call. It was a responsibility of the orthopedic resident to check with the Aerovac office daily to acquire flight manifests. This resident then used prior e-mail information and the manifest to estimate the number and acuity of patients to be Waged upon arrival. This review process also allowed the resident to anticipate the number of admissions, to determine the need for consultation with other medical/surgical specialties, and to plan for potentially urgent surgical cases. This information was conveyed to the charge nurse, who coordinated with other health care providers and administrators for the anticipated arrival. The majority of patients arrived during off-hours, usually in the middle of the night; therefore, it was imperative to preplan to ensure that appropriate personnel, equipment, and bed space were available. It was also the responsibility of the orthopedic resident, with the assistance of the patient administration division, to ensure that the demographic data for arriving orthopedic casualties had been appropriately entered into the WRAMC computer system. This allowed casualties to be formally admitted to the hospital and orders to be written immediately upon arrival, including pharmacy (primarily analgesics), radiology, laboratory, and nutritional services (diet) orders.

Triage

The orthopedic surgery resident on call was paged and notified when the Aerovac would arrive. WRAMC nursing personnel escorted all patients in need of evaluation to the orthopedic cast and treatment room. This was established as the center for triage because of its large open size, which could accommodate both high volumes of patients and the required number of health care providers. The orthopedic cast room is equipped with multiple beds, with an attached radiology suite. Given the communication before arrival, the most seriously injured patients were escorted to the cast room for evaluation first, followed by those with less severe injuries, who were placed in other examination rooms throughout the adjacent orthopedic clinic. All patients, however, entered through the cast room for triage, which allowed an orthopedic surgeon or general surgeon to see the patient before transport, and facilitated placement in a less acute clinic examination room. A military medical technician or nurse was assigned to each patient and escorted him or her through the entire triage process while initiating appropriate paperwork. Patients were than evaluated in a routine triage fashion, including primary and secondary surveys, with attempts to evaluate the most seriously injured first; this was based primarily on prior communication and the Aerovac manifest.

Fig. 1. Process of care. Gen, general; Ortho, orthopedic; Con, convalescent; Rehab, rehabilitation; RTD, return to duty; Mobs, mobilization; MEB, medical evaluation board; TDRL, temporary disability retired list.

The primary triage process was based on the injury complex, as determined from the manifest and listed injuries, with either a general surgery resident or an orthopedic surgery resident in the lead. The remainder of the triage team consisted of an anesthesiology resident, a pharmacist, a radiology technician, the charge nurse, a critical care nurse, aides, and technicians. Pending primary and secondary survey, including radiographie imaging and wound assessment (with the assistance of the anesthesia service), patient dispositions were made. This was facilitated by communication between members of the orthopedic surgery service, general surgery service, and anesthesia service. Patients requiring surgery were taken directly to the operating room for irrigation, debridement, wound exploration, and, less frequently, definitive treatment. If patients were not taken to the operating room, they were either directly admitted to the hospital or referred to one of the WRAMC outpatient facilities, with instructions to return for appropriate outpatient management and definitive disposition.

Inpatients

The orthopedic surgery service admitted all patients who needed further extremity reconstruction, wound management, and/or rehabilitation. The general surgery service admitted all patients with chest, abdominal, or uncomplicated extremity wounds. The two services worked together to manage the volume of casualties, with frequent consultations with each other as well as other specialties throughout the hospital, often involving the vascular surgery, neurosurgery, plastic surgery, and physical medicine services. A standard set of physician orders was established by the orthopedic surgery service to maintain continuity and quality of care for the orthopedic inpatients. This included deep venous thrombosis and gastrointestinal prophylaxis with unfractionated heparin (5000 U, s.c., b.i.d.) and ranitidine (150 mg, p.o., b.i.d.), respectively, continuation of all previously prescribed antibiotics (pending species identification), and aggressive pain management. Based on early laboratory values demonstrating that the majority of casualties were malnourished in their healing stages, all casualties received diet orders that included nutritional shakes. The orthopedic resident was also responsible for identifying and initiating treatment for patients arriving from overseas who needed malaria prophylaxis.

The following morning, all patients were presented by the orthopedic on-call resident at daily morning report, which routinely consists of a review of all preoperative and immediately postoperative patients, as well as all patients evaluated on call. All attending orthopedic surgeons and in-house orthopedic residents attend this meeting. The battle casualties were presented in the usual fashion, which stimulated further discussion among attendees, and a preliminary care plan was established. The use of digital photographs obtained at the time of triage by the orthopedic resident was important in accurately presenting the complex contaminated wounds sustained by many of these patients. It was also at this forum that information was shared regarding incoming casualties and tentative plans were made. The chief resident then reviewed and updated posted 2-week future plans for all battle casualties needing operative treatment. This was imperative to effectively manage all resources and to ensure that patients needing serial irrigations and de\bridements were adequately treated. This also allowed the resident teams to complete and to submit the appropriate operative request slips and purchase orders ahead of time, as well as to contact equipment representatives and to coordinate with consulting services to prepare the battle casualty for surgery.

After morning report, the junior orthopedic resident or intern submitted nine routine consultations throughout the hospital for every 0IF/OEF patient (audiology, discharge planning, nutrition care, occupational therapy, pastoral, psychiatry, physical medicine and rehabilitation, physical therapy, and social work). For all contaminated open wounds, the infectious disease service was consulted and routine operative tissue cultures were obtained. It was the responsibility of the orthopedic resident to coordinate all consultations and to ensure that the orthopedic team had addressed the recommendations.

The orthopedic management of inpatients was based on routine trauma management, but the type of trauma differed from routine civilian blunt trauma. The average battle casualty consisted of a blast injury involving multiple extremities, with multiple soft tissue and bony injuries. The wounds were often contaminated, requiring serial irrigation and debridement and aggressive wound management with delayed primary closure vs. skin, free, or local flaps and grafts. The orthopedic treatment consisted of a large number of wound vacuum-assisted closure devices, antibiotic- impregnated polymethylmethacrylate beads, amputations, revision amputations, flaps, and a variety of fracture stabilization procedures for limb salvage.

The orthopedic resident made a continuing effort in the disposition of patients to other medical treatment facilities. The disposition of patients to other military medical treatment facilities was difficult because of the extensive number of casualties encountered during an ongoing war. which limited the number of continental U.S. Aerovac flights. The disposition of active duty soldiers was routine, pending travel arrangements to their home duty station. The disposition of National Guard or reserve component soldiers was challenging because of the complex social situation, with their home of record differing from their mobilization site, and the associated lack of surrounding military medical facilities in the same region. Every effort was made to return soldiers to their mobilization site, assuming appropriate follow-up care and therapy could be obtained. Medical evaluation boards, if required, were completed at the time of discharge or the time of optimal functional improvement.

Outpatients

An orthopedic nurse case manager expedited the management of outpatient battle and nonbattle casualties. This nurse case manager coordinated all appointments and expedited surgical scheduling, with attempts to schedule operative intervention within a 2-week time frame. All patients who were triaged to an outpatient setting were given follow-up dates with appropriate attending physicians. If a patient was seen at triage and no orthopedic issues were identified, then he or she was referred to the appropriate service for medical care. Outpatient surgical cases received priority over all non-OIF/ OEF elective cases, in an attempt to decompress the large volume of outpatients.

Conclusions

The evolution of the process of care for battle casualties continues to this day. It is imperative to initially establish and to implement a hospital-wide plan addressing logistics and process of care. The most important issue, however, remains open, ongoing, bidirectional communication between the transferring and receiving facilities, as well as between departments, services, and providers. We recommend that appropriate legal personnel within the institution establish a working protocol that allows transfer of patient information while remaining in compliance with the current Health Insurance Portability and Accountability Act regulations. We also suggest unification of the digital radiographie systems and/or establishment of communication links between overseas systems, to prevent duplication of effort. This will be cost effective and safer for patients, ultimately improving efficiency. Finally, we suggest implementing a plan that automatically incorporates all of the routine consultations that are required in the care of battle casualties. The myriad of administrative tasks (e.g., discharge planning, human immunodeficiency virus testing, tuberculosis testing, malaria prophylaxis, and family travel) cannot be left to the primary surgical team to address, in the face of large numbers of battlefield multitrauma patients returning from out of country. The disposition of soldiers to their home unit or region from the receiving institution is still not seamless, and our institution continues to modify this protocol.

Guarantor: COL William C. Doukas, MC USA

Contributors: CPT Matthew A. Javernick, MC USA; COL William C. Doukas, MC USA

Department of Orthopaedics and Rehabilitation, Walter Reed Army Medical Center, Washington. DC 20307.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army or the Department of Defense. All authors are employees of the U.S. government. This work was prepared as part of their official duties and, as such, there is no copyright to be transferred.

This manuscript was received for review in October 2004. The revised manuscript was accepted for publication in April 2005.

Copyright Association of Military Surgeons of the United States Mar 2006

Source: Military Medicine

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