Managing host nation and orthopaedic war injuries

By: Maureen Leahy

By Maureen Leahy

Since October 2001, more than 34,000 U.S. military personnel have sustained musculoskeletal injuries in Iraq and Afghanistan. In addition, military orthopaedic surgeons face unique challenges in providing host nation orthopaedic care in these countries.

New treatments and research opportunities designed to address these challenges were the subject of yesterday’s Orthopaedic War Injuries Symposium, “Advances in Research, Treatment, and Host Nation Care.” Moderated by CAPT Dana C. Covey, MC, USN, the symposium featured presentations by COL Mark W. Richardson, MC, USAF; LTC Kevin L. Kirk, DO; V. Franklin Sechriest II, Commander, Medical Corps, United States Navy; Christopher E. Gentchos, MD; Col. James R. Ficke, MD; and Andrew N. Pollak, MD.

Col. James R. Ficke, MD

Treating blast injuries
Most orthopaedic injuries to local Iraqi civilians are due to exploding improvised explosive devices (IEDs). Among the many challenges in treating these patients are language, culture, disposition, follow-up, host nation capability, and mission requirements, according to Dr. Richardson, who served in Balad.

Proper treatment, he said, should include hemorrhage control first, followed closely by careful débridement. Other essential procedures include fasciotomy, bony stabilization, adjuncts to keep the wounds contained, repeat irrigation and débridement, open reduction and internal fixation (ORIF), and appropriately timed delayed primary closure (DPC), flaps, and split-thickness skin grafts (STSGs).

“We’ve also learned the importance of security, of professional interactions (military surgeons working with local surgeons and with volunteer organizations), of controlling blood pressure in the operating room (OR), of communicating (making notes) on the dressing, and of monitoring fragment wounds,” he said.

“You’d be amazed at the large fragments that can enter through small wounds,” said Dr. Richardson. “You need to palpate the wound, and if a deep ooze rises up, the wound needs to be opened.”

He concluded, “We need to improve cooperation with local surgeons to rebuild host nation care. We can learn many lessons from war surgery that we can then apply in humanitarian environments.”

One of the major challenges in providing host nation care in Afghanistan—where the injuries are similar to those in Iraq—is that the country has very little infrastructure, according to Dr. Kirk.

“We had very limited capabilities at the Orgun-e hospital, which is located in one of the poorer provinces in the country,” he said. “There was an OR and an emergency room, but no anesthetic or monitoring capabilities.”

He added, “With only two surgeons, you’re sometimes forced to work outside your comfort level, underscoring the importance of being a team player.”

Care, collaboration, and rehabilitation
“Tourniquet use for combat casualty care is as old as war itself,” said Dr. Gentchos, who described the changing opinions regarding its military use. The recent conflicts and the experiences of U.S. Special Operations and the Israeli Defense Force (IDF) have made widespread tourniquet use the standard of care.

“As the conflicts in Iraq and Afghanistan continued … and as a result of the concurrent experience of forward deployed surgeons, there was an effort to reconsider the current guidelines,” said Dr. Gentchos.

In part, the new guidelines instruct military personnel who are under fire to apply the tourniquet over the uniform, and then move it to the skin when safe to do so.

When dealing with the many problems that arise in treating patients in foreign countries, “collaboration is mission critical,” stressed Dr. Sechriest. Whether the problems are due to time-limited missions, complex cases, follow-up care, knowledge transfer, or language and cultural barriers, collaboration with host nation orthopaedic surgeons is the solution.

“There is real evidence that opinions about the U.S. are improving as a direct result of these missions,” he said.

“We can’t do it alone,” said Dr. Ficke, as he described the role of multidisciplinary rehabiliation programs in improving military patient outcomes. The goal of the multidisciplinary team in rehabilition is to “provide world-renowned amputee and limb-salvage care, assisting patients as they return to the highest functional levels of physical, psychological, and emotional wellness.”

Rehabilitation teams are large and include orthopaedics, physical medicine and rehabilitation, pain management, nursing, physical therapy, occupational therapy, prosthetics and orthotics, case management, and counselors. At the rehabilitation centers of Walter Reed Army Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego, recovering military personnel rebuild their physical skills with the help of an indoor track, running gait lab, treadmill with dual-force running plates, climbing towers, uneven terrain/incline parallel bars, vehicle and firearms training simulators, swimming pool, and functional strength training.

The need for research funding
Finally, Dr. Pollak addressed the need for Department of Defense (DOD) funding of orthopaedic research and outlined the progress that has made in recent years.

“You may wonder, ‘Why should the DOD fund medical research?’” Dr. Pollak asked, and then answered his own question. “The DOD needs to fund research in the area of ortho­paedics because of the disproportionate burden it faces based on battlefield injury and non-battlefield injury.”

Orthopaedic trauma research funding has increased from $7.5 million in 2006 to $29.8 million in 2008, but that amount “pales in comparison to the amount of money funneled to traumatic brain injury research, breast cancer research, and prostate cancer research.”

“Our goal was to make a significant difference in the federal investment in musculoskeletal research based on the burden of injury and disease that the military was facing,” Dr. Pollak said. In 2009, $117 million was appropriated and the long-term goal, he says, is $150 million.

The Major Extremity Trauma Research Consortium (METRC) was established in September 2009 with funding from the DOD and the Orthopaedic Extremity Trauma Research Program (OETRP). METRC consists of a network of clinical centers and one data-coordinating center that will work with the DOD to conduct multicenter clinical research relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. The goal is to produce the evidence needed to establish treatment guidelines for the optimal care of the wounded and ultimately improve the clinical, functional and quality of life outcomes of both service members and civilians who sustain high energy orthopaedic trauma.

“With this consortium, we’ll really be able to develop the infrastructure necessary to do prospective randomized trials in large numbers. Clinical guidelines can be developed with this type of research, which takes a lot of money,” Dr. Pollak said. NOW