Trauma Training from One War Zone for Another

By Douglas H. Stutz, Naval Hospital Bremerton Public Affairs

It’s a war zone out there of non-stop gunshot casualties, stabbing victims, and blunt-force trauma wounded. The patients arrive at all hours – many bloodied, some bandaged, even a few unbowed.

Inside, Navy doctors, nurses, and hospital corpsmen are helping provide medical support in handling the seemingly never-ending influx of injured patients.

Welcome to the Trauma Center at Los Angeles County and University of Southern California (LAC/USC) Medical Center, where Navy Medicine personnel such as Naval Hospital Bremerton’s Lt. Cmdr. Richard Lawrence, are assigned to Navy Trauma Training Center (NTTC) for extensive trauma care training before being assigned to surgical platforms prior to deployments or operational requirements. (Continued below … )

20130915-175931.jpgNaval Hospital Bremerton’s Lt. Cmdr. Richard Lawrence (front row, second from left) poses teams members assigned with him to Navy Trauma Training Center (NTTC) as they went through extensive trauma care training at Trauma Center at Los Angeles County and University of Southern California (LAC/USC) Medical Center. The photograph is where the life flights arrive at LAC/USC with the skyline of downtown Los Angeles visible behind them (Official Navy photo courtesy of Lt. Cmdr. Lawrence)

The LAC/USC Trauma Center is located just east of downtown Los Angeles in the Boyle Heights area, and is an ideal trauma training environment. There are over 25,000 trauma evaluations and more than 6,000 trauma admissions annually. On a daily basis, treatment is provided to approximately 20 major penetrating and blunt trauma wounds and injuries. Being exposed to the daily emergencies in such a setting is valuable training for Lawrence, a Board certified perioperative nurse and perioperative clinical nurse specialist, before reporting to Role 3 multinational medical unit at Kandahar Air Field, Afghanistan.

“We have a mix of working environments here with classroom settings, simulation labs and clinical time in the operating room, burn intensive care unit and the Emergency Department,” said Lawrence, adding that Navy personnel work directly with their clinical preceptors as well as staff and students of LAC/USC, creating relationships and trust that show they are capable and willing to hone their skills, strengthen their weaknesses and increased their knowledge.

As a Level I Trauma Center, LAC/USC provides a full range of medical professionals, surgical equipment and expert surgical care around the clock for any trauma patients.

“Our clinical and didactic days and times vary but we are participating for at least eight hours and to up 16 hours per day. Communicating with family, friends and loved ones has to be prioritized because there is not always enough time in the day to do what you want or need, (such as) the case once deployed,” explained Lawrence, a San Francisco native who has been assigned to NHB for a little over two of his 14 years in the Navy.

The LAC/USC medical staff is comprised of world-renowned teaching faculty, with NTTC arranging didactic and clinical trauma exposure that enhances personal and team knowledge, and skills. The 21-day training schedule gives Navy personnel the opportunity to work alongside LAC/USC and NTTC staff as teams care for critically ill and injured patients. Lawrence attests that as valuable as the training is, understanding the importance of working as a team has also been very beneficial.

“A bigger part of this training is about teams and team relationships. While teams have not been typically sent here, we are fortunate that the group that is here is going forward as a team. Starting the learning curve of the team earlier will help us work through issues before we get into theater,” stated Lawrence, noting that another benefit is that nurses are helping corpsmen gain skills that they may not have yet, citing a prime example that several corpsmen had served with Marines but had never been stationed at a military treatment facility.

“They have great battlefield skills but are missing other skills such as setting up rapid infusers, intubating, advanced suturing and FAST (Focused Assessment with Sonography in Trauma) exams. Additional exposure to the operating room and burn/intensive care unit (ICU) patients is also covered. All of this provides rudimentary training and familiarization in the event they find themselves in a situation where they need to step out of their comfort zone due to a mass casualty situation or if assistance is needed on a temporary basis.”

The overall mission for NTTC is to provide orthopedic surgery, neurosurgery, plastic surgery, anesthesiology, emergency medicine, radiology, internal medicine, oral and maxillofacial surgery, and critical care experience to Lawrence and his class of six corpsmen, seven nurses (six perioperative and one critical care), two nurse anesthetists, four anesthesiologists, two orthopedic surgeons, one internist and one cardiothoracic/vascular surgeon.

“My personal goal is primarily to refresh my surgical knowledge of neurosurgical procedures. I have been away from that specialty for a few years and since I will be heading to a facility that has this surgical subspecialty, I need the refresher. My first day in the operating room at LAC/USC helped work toward that. We had a patient with a severe subdural hematoma from a motorist versus bicyclist accident that required an emergent craniectomy to relieve the pressure from the swelling brain. I was pleased to see how much came back so quickly,” Lawrence said. (Continued below … )
20130915-175907.jpgSharing a smile between suturing, surgery and support, Lt. Cmdr. Richard Lawrence, NHB perioperative nurse, who went through extensive trauma training at Los Angeles County and University of Southern California (LAC/USC) Medical Center Trauma Center with the Navy Trauma Training Center, takes a breather in the operating room of the old LAC/USC hospital (Photo courtesy of Lt. Cmdr. Lawrence).

According to Lawrence, while reinforcing skills that are infrequently used is always important, equally necessary is helping others with steeper learning curves such as the junior Sailors. It’s them, attests Lawrence, who will be the first line in the trauma continuum.

“Knowing that we are sending them forward with as much information and skills as possible provides a sense of comfort in realizing our troops will have the best chance of reaching a Role 3 for care that can return them to their families,” said Lawrence.

The initial phase of the course commenced with classroom training, covering various topics and skills reinforced with using advanced simulators, and various other hands-on training. Lawrence explained this way helped those with less experience get up to speed.

“Speed is important. With only three weeks of training and clinical time, the learning curve can be steep and overwhelming for some. The team approach ensures that there is support to ensure learning is reinforced and patients aren’t injured,” said Lawrence.

The class quickly evolves into clinical rotation, which for the nurses and corpsmen include working side by side with NTTC instructors and LAC/USC staff in the operating room, ICU (including the Burn ICU) and the emergency room’s resuscitation section. The trauma experiences are varied by how, when, and where a patient ends up at the medical center. They come by ambulance, helicopter, ward-transferred and even dropped off by ‘friends.’ But the patients all have one thing in common. They are in immediate need of emergency medical care.

“Trauma is all about identifying and treating life-threatening conditions while managing various reports of other patients, team availability and the supply chains. The training affords us the opportunity to gain experience at one of the nation’s busiest Level 1 Trauma centers. Other training has provided some similar experience, but no simulation can accurately create the stress of real life situations on actual patients. Building confidence during practical application in this setting is irreplaceable,” Lawrence said, who has been involved in general, vascular, cardiothoracic, orthopedic, and neurosurgical trauma during his civilian and Navy medical career.

As vital as it is in being medically prepared to deal with trauma victims, it is also equally important to understand the emotional aspects of handling severely wounded casualties, some who very well might not make it. Although Lawrence and other Navy personnel focused primarily on helping patients as part of a trauma team, they also prepared for the uncomfortable possibility of a patient dying.

“To help us prepare for death with the personal emotions and issues, we spent half a day at the LA County Coroner’s office. While we were there we learned about their general operations while also learning what goes into investigations, some applicable to the military as well.”

They also watched a pediatric autopsy that had most feeling awkward.

“We trained so hard to prevent death, and regardless of what we did, it was not enough to save the patient in the simulation lab. The results of the day were an emotional roller coaster forcing us to deal with death. I can academically consider death as an option but knowing that death will be a very realistic outcome only creates more of a reason to pause and start addressing those feelings and emotions. Death is a topic that never put so much thought into when training for care for those in harm’s way,” Lawrence shared.

Traditionally, says Lawrence, a trauma team has at least a physician, nurse, medical technician, with radiology, laboratory and various other ancillary support available. A Trauma team actually begins with the corpsman, medic and buddy-care on the battlefield. The trauma team then moves on to the next level of care (or role), the higher up the role signifying the more definitive care that can be delivered. The Role 3 is the highest level of care available in theater.

The Role 3 multinational medical unit at Kandahar Air Field, smack in the midst of the Taliban’s heartland, includes additional capabilities such as specialist diagnostic resources, specialist surgical and medical capabilities, and preventive medicine.

Role 1 refers to emergency medical care in the field, historically handled by independent duty corpsmen. Role 2 has been traditionally defined as Battalion Aid Station, where the wounded are linked up with a nurse and physician in the chain of evacuation. Landstuhl Regional Medical Center, Germany, is the largest American hospital outside the United States and an example of a Role 4 facility. Role 5 sites are stateside rehabilitation facilities.

“While a trauma team can consist of even one person, the people and specialties you can add into the combined efforts of caring for those coming from being in harm’s way, the better the chance the individual has or surviving,” said Lawrence.

Lawrence and his team will have their collective hands-on full as they join a core-contingent of approximately 100 trauma team staff at the Role 3 to handle nearly 200 patients a month. Trauma casualties suffer from the signature improvised explosive device injuries of concussions and severe lower-limb impairments to bullet and bomb-blast wounds. There’s also a steady stream of Afghan National Police and Army who receive medical care, as well as Afghan civilian and even enemy combatants.

Compiled statistics show that 98 percent of all patients who make it to NATO’s Role 3 at Kandahar Air Field survive. Aided by his three weeks at LAC/USC, Lawrence intends to keep it that way, if not better. One trauma patient at a time.

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