Military's hospital system stretches from stateside to Afghanistan
December 8, 2002
Army Sgt. Ricardo Padron was on duty in Afghanistan in May when the fingers on his left hand were almost severed by a knife during what the special operations soldier will only describe as an “accident.”
Although his injury occurred in Afghanistan, his treatment crossed three countries and thousands of miles, ending in the United States at his home base of Fort Campbell, Ky., where he is now in rehabilitation to recover use of his fingers.
Padron is one of about 1,000 U.S. and coalition soldiers and government workers who have been flown out of Afghanistan because of serious injuries received in combat or in nonbattle-related incidents since the war on terrorism began. The crucial stop along the medical route is Landstuhl Regional Medical Center, Germany — the largest American medical facility outside of the United States.
“We’re the catcher’s mitt for all of Europe, northern Africa and Southwest Asia, and for contingency operations like Operation Enduring Freedom,” said Col. David Rubenstein, the medical center’s commander.
“All OEF patients come here. We’ve received Afghans, Bosnians, Canadians, Brits, Norwegians, Australians, as well as Army, Air Force, Navy, CIA and State Department (personnel), a fascinating mix in this particular operation.”
Landstuhl receives two to six flights a week of soldiers with nonbattle-related injuries from Afghanistan, plus any wounded soldiers from combat or military accidents that occur there.
The medical route out of the war on terrorism’s front lines to Landstuhl can be circuitous, with patients receiving higher levels of military medical care at different points along the route. That care might be provided by Army, Air Force or Navy nurses, physicians or medics stationed at different places. The level of care received varies from basic first aid to sophisticated intensive care in aeromedical evacuation aircraft.
On the battlefield
This chain of care begins where the injury, illness or wound occurs in Afghanistan. The soldier, if conscious and capable, provides initial first aid to himself if no one else is around to help.
Padron, as a medic assigned to the 3rd Battalion, 187th Infantry Regiment, was more qualified than most to treat his own injury. He applied a pressure dressing to his fingers and irrigated the wound with normal saline. He used the saline to further cleanse the area because he was planning on suturing it himself, he said. But he quickly noticed the blood vessels had been cut and he was losing feeling in three of his fingers.
Had Padron not been a medic, his care would have proceeded to the second step in the chain — buddy care, essentially more first aid — supplied by a fellow servicemember until a unit medic arrives.
When a unit medic arrives at the patient’s side, he or she administers more advanced care, such as starting an IV line for fluid replacement or giving pain medication. At this point, the goal is to evacuate the soldier from the battlefield to the nearest military medical unit. This could be done by aeromedical evacuation by a military plane, helicopter or by a land vehicle, depending on the location of the aid station and the severity of the injury. The medical unit might be a specialized mobile Air Force or Army medical team.
Because special operations’ medics have advanced medical training, Padron was first taken to his unit’s makeshift hospital. The hospital is run by medics, who determined Padron needed more complicated surgery than they could provide. Special operations medics function like physician’s assistants or surgical assistants and are capable of doing advanced medical procedures, said Dr. (Lt. Col.) David Gillespie, a vascular surgeon and previously chief of OEF triage at Landstuhl.
Padron was transported to an Army forward surgical team at Bagram air base in Afghanistan, where a surgeon operated on Padron’s hand and, as he describes it, “saved my fingers.”
The Army’s forward surgical teams and combat support hospitals have replaced the traditional mobile army surgical hospitals made famous in the television series “M*A*S*H.” The Army’s last remaining MASH unit is the 212th, based near Landstuhl.
The FSTs are faster and even more mobile than MASH units. They are 20-member surgical teams composed of nurses, surgeons, medics and an administrative officer. These teams have been deployed at several locations in Afghanistan, including Kandahar Airfield and Bagram.
At the end of June, the 339th Combat Support Hospital, a reserve unit from Pittsburgh, arrived in Bagram to help reduce the flow of patients to Germany. Combat support hospitals are larger, have more personnel, and can care for patients for longer periods of time. The 339th is a level III unit, capable of treating the most serious of injuries, illness and trauma.
“The 339th is taking the lead on caring for less-severe injuries,” Rubenstein said. “But they can’t hold patients for as long as we can.”
Evacuation policies differ according to the type of medical unit and mission. Landstuhl can hold patients for about a week and then will send soldiers to the States for follow-up care if necessary or back to their units. “We need to be flexible in order to keep beds available for new patients,” Rubenstein said.
The ultimate goal of military medical care is to return soldiers to their units. But if the injury or illness requires more extensive care, follow-up or rehabilitation than an FST or combat support hospital can provide, the soldier is flown to Germany.
However, en route from Afghanistan to Germany there is usually another interim stop in the Middle East. Padron was flown by an Air National Guard unit to an Air Force base in Oman where an Air Force expeditionary medical support team is located. His wound was cleansed and the dressing changed. Patients may also be flown to other locations, such as Incirlik Air Base in Turkey or Camp Stronghold Freedom — also called “K2” — in Uzbekistan.
First Lt. Patty Robertson, a flight nurse aboard a C-130 Hercules transport with the 187th Wyoming Air National Guard, arrived in Oman in early spring. The base consists mostly of tents, but tents with air conditioning, computers, and even washers and dryers. Robertson and her unit often stage in other countries in anticipation of receiving casualties, she said.
Her unit has gone into Afghanistan to retrieve patients, although she declines to say more about those missions.
“We go into forward-deployed locations and wait and see if something happens,” she said. “I like it when we are not busy because it means soldiers aren’t getting hurt.”
Seriously injured patients may also be accompanied from Afghanistan by an Air Force critical-care air transport team, she said.
Welcome to Landstuhl
Hospital staff members refer to patients flown in from Afghanistan as OEF patients. An OEF patient who does not require intensive care is usually given a bed in a the 42-bed medical/surgical unit.
The OEF patients “come in bursts,” said Lt. Claude Fourroux, a staff and charge nurse for the unit. “CNN will announce there are injuries in Afghanistan, and about two days later the OEF patients show up.”
OEF patients currently are triaged by Dr. (Maj.) Yong Chun, a family practitioner and flight surgeon. He determines if injured soldiers can be treated at Landstuhl and then sent back to their units or, if they need further treatment, to the United States.
Chun sees almost every OEF patient and writes a daily report on his condition forwarded to Army Surgeon Lt. Gen. James B. Peake and unit commanders, among others.
“I’m more of a traffic cop,” Chun said. “I talk to the other physicians and staff to facilitate patients’ care.”
Chun can determine what level of care patients will need before they arrive at Landstuhl through a global computerized tracking system developed after the Persian Gulf War. It allows aeromedical evacuation personnel to input vital medical information about patients before they have arrived at their destination. Chun can retrieve that information 12 to 24 hours before patients arrive at Landstuhl.
The information lets the staff trace and triage patients from one place to another, enabling Chun to coordinate care with the medical specialists at the hospital and to ensure adequate staffing on the units of nurses and other hospital personnel.
“This way we are not surprised by patients arriving at our doorstep,” he said.
Many of the injuries resulting from combat include traumatic amputations, fractures, burns and shrapnel wounds. There are also nonbattle-related injuries from land mine explosions, motor vehicle accidents and hard helicopter landings. Some of these injuries would not ordinarily be seen in civilian medicine, even in a big city hospital.
“I’ve seen gunshot wounds at Madigan (Army Medical Center in Washington state), but the damage inflicted by blast injuries is horrendous,” said Capt. Gregory Hubbs, a certified critical care nurse in the intensive care unit. “You would never see muscles just left on bones the way they are in traumatic amputations.”
By the time patients reach Germany, they have received care at one or two field hospitals and are medically stable, Fourroux said. They are ready to begin physical and occupational therapy before being sent to a larger medical facility, such as Walter Reed Army Medical Center in Washington, D.C.
However, some patients, like Padron, may require more sophisticated surgery. At Landstuhl, Gillespie, a vascular surgeon, and Air Force Dr. (Lt. Col.) Jack Ingari, chief of orthopedic surgery and a hand surgeon at the Air Force medical center Wilford Hall in San Antonio and on temporary duty to Landstuhl, reattached the nerves and tendons in Padron’s fingers. Padron underwent two weeks of intensive occupational therapy and was transferred to Fort Campbell.
When OEF patients arrive, they are asked how their injuries occurred as part of the nursing assessment to better understand their physical and emotional requirements, said Air Force 2nd Lt. Tina Hall, a staff nurse at Landstuhl, adding that most soldiers will talk without much prodding. However, many of these soldiers are from special operations forces units and must be careful not to reveal any classified information.
“There’s a lot of information they can’t talk about,” Hubbs said.
Usually, such troops are accompanied by another person or “handler” so they do not inadvertently reveal classified information while under sedation. The handler also helps coordinate care and support families.
“The war to this point has mainly been fought by special forces soldiers,” Gillespie said. “These are the soldiers who have been putting their lives on the line, and that kind of security is what keeps them safe.”
Nurses, physicians and medics are aware their patients may need to censor their responses, said Staff Sgt. Scott Waters, a licensed practical nurse in the intensive care unit.
“The ICU is a highly sensitive area because of the security issues,” he said. “We don’t have a step-down unit so patients are here longer than they might be in a stateside hospital.”
The medical staff is also acutely aware soldiers injured in combat may need more than physical care. Soldiers and their families are supported in many ways from the moment they arrive at Landstuhl, from providing them free phone services and e-mail to offering support from psychologists and chaplains.
Often, soldiers who have been in battle together have not had a chance to talk with their fellow servicemembers until they have arrived at Landstuhl, said Army Lt. Col. Sally Harvey, chief of psychology services at Landstuhl.
“When they are ready, we try to get them together in a group,” she said. “Often it’s the first chance they’ve had to fill in the gaps.”
Harvey, Air Force Maj. Linda Broeckl — another psychologist — and the hospital’s chaplains are unobtrusive and make sure the soldiers’ basic physical and emotional needs, such as pain relief and contact with family, are met before approaching them about their battle experiences, she said.
The nursing staff, said Harvey, is highly trained and critical to providing emotional and psychological support to battle-wounded soldiers.
Hall, who arrived at Landstuhl in September before the attack on the World Trade Center, said, “They are doing something great, and we try to give them whatever they want.”
Hall is impressed by her patients’ resilience. “The morale they have despite their injuries is amazing. I have not met anyone with complaints or regrets about what they went through.”
The Landstuhl staff said it is a privilege to care for Enduring Freedom patients.
“I enjoy working with the OEF patients,” Waters said. “Where else would you take care of special ops soldiers or soldiers from other cultures? I’ve met people I would never meet anyplace else. I’ve learned to adapt my care to my patients’ cultural beliefs.”
Hall said she wouldn’t trade the OEF experience for anything. “I’ve gotten letters from patients who have been so thankful,” she said. “It’s so rewarding to me.”
Padron expects to regain 85 percent to 95 percent of the use of his hand. His military future depends on how well he eventually heals.
“I would love to remain with the same unit,” he said. “I would also love to return to Afghanistan.”
Of the military medical care he received, he said, “The care I received from beginning to end was amazing. I can’t begin to thank the people involved for saving my hand. I will always be indebted to them.”
Janet D’Agostino Boivin, a former Stars and Stripes reporter, is editorial director for Nursing Spectrum magazine.