The nation's military surgeons, working in an era of peace, are getting little of the experience they need most: treating horribly injured patients. They're turning to the Maryland Shock Trauma Center in Baltimore and others across the country, where victims of urban violence, car crashes and industrial accidents are almost like wounded soldiers.
About 150 surgeons from the Army, Navy and Air Force, meeting here through tomorrow, talked yesterday about the changing nature of military medicine. In the next few days, they will get refresher classes in the fine points of limb injuries, amputations and field anesthesia at Shock Trauma at the University of Maryland Medical Center. But they will also hash out ways to bridge the gap between the ordinary surgery they do daily and the extraordinary demands they might face.
The surgeons spend most of their time caring for 11 million military personnel, retirees and dependents. The doctors remove gall bladders and perform C-sections in comfortable military hospitals stocked with MRIs and specialists. But they must also be able to deal with the battlefield, where blown-off legs and bullets embedded in muscle and bone are routine. And there they often won't have the help of specialists or the latest scanners.
"We need to do more training," said Rear Adm. Michael L. Cowan, a physician and deputy director for medical readiness at the Pentagon. "This is recognized by the organization."
A report released this month from the General Accounting Office calls on the Department of Defense to develop a long-term strategy to train military medical personnel in trauma care. But because of their workloads, many surgeons struggled to get permission to attend the conference. The surgeons acknowledged they need more than a few days of classes.
The numbers tell the story. A 1995 Congressional Budget Office report found that only 5 percent of the cases that military medical personnel encounter match cases they would face on the battlefield. But 98 percent of the cases at a civilian trauma center match battlefield injuries.
"They're more similarities than there once were," said Dr. Thomas Scalea, chief of the Maryland Shock Trauma Center. He attributes that to the use of larger and more powerful guns on the streets.
Some high-volume centers like Shock Trauma have been quietly training small numbers of military physicians for years. Now, Shock Trauma wants to expand the program, bringing in more physicians and professionals like nurses, to create military medical teams that could be quickly deployed.
"So if someone decides they need to be in Somalia, you've got people to rock 'n' roll," said Dr. Howard Champion, director of research at Shock Trauma. "Military people should be training here. It doesn't give you the exact same situation, but it prepares you better than gall bladder patients and big-toe surgery."
About 6,000 patients a year -- one of the highest volumes in the country -- go through Shock Trauma. Roughly 35 percent suffer a penetrating injury like a stab wound or a gunshot. The remaining 65 percent of patients have blunt trauma from car crashes, falls or industrial accidents.
Even after training at a place like Shock Trauma, experts say, military surgeons must learn that some techniques are unique to the battlefield. In civilian trauma systems, for instance, the use of tourniquets to stop bleeding is discouraged. But in a war, the tourniquet is the most reasonable way to stop bleeding until the patient can reach medical care.
The issue of medical readiness surfaced during the Persian Gulf war, when physicians inside and outside of the Department of Defense said military health personnel weren't prepared to care for severely injured soldiers. According to the GAO report, many military medical personnel, including physicians and nurses, had either never treated trauma patients or had no recent trauma experience.
On one Navy hospital ship, for example, only two of 16 surgeons had recent trauma surgical experience. Also, none of the more than 100 medics at a surgical support company "had ever seen actual advanced trauma life support given to a trauma patient," according to the report.
Dr. George R. Dulabon, a 33-year-old surgeon stationed at Seymour Johnson Air Force Base in North Carolina, said he fears he may be in that situation himself. He mostly cares for elderly people. And considering the downsizing of military hospitals and shifting of work to the private sector, Dulabon says he's lucky to remove a gall bladder once a month.
He's tried to work with the local trauma center at East Carolina University. But similar to other military surgeons around the country, he has been stymied by bureaucratic issues -- such as whether he needs malpractice insurance.
"I'm trapped in a situation where I can't do what I was trained to do," said Dulabon. "If you don't do it on a regular basis, your skills are gone. You lose confidence to handle major injuries. This will mean unnecessary deaths in a wartime situation."
Pub Date: 4/17/98