You have just finished your morning team ICU rounds on a mix of nine critically injured US and host-nation trauma patients. A tenth US casualty with multiple gunshot wounds to the chest and abdomen rolls in after a damage control laparotomy. He had become pulseless in the ED trauma bay during his initial evaluation, so he underwent an emergency thoracotomy and aortic cross clamp and was immediately taken to the OR while undergoing multiple blood transfusions. In the OR, he received over 40 units of products (PRBCs, FFP, PLTs, Cryo, whole blood) as well as a dose of tranexamic acid (TXA) . The liver is packed and the abdomen left open with wound VAC placement. The patient is on high-dose Levophed and epinephrine and acidotic. Post-op ROTEM looks like a champagne flute.

This patient scenario is just one example among the many critically ill patients commonly encountered in a combat support hospital setting where robust surgical capabilities exist. In order to optimize care and resultant outcomes, it is necessary to maximize capabilities in this setting to have it match the quality of care delivered at any busy trauma center with a Level 1 American College of Surgeons designation. As such, a multidisciplinary team approach with the right people with the right training and experience needs to be applied. This team is naturally led by a trauma surgeon and complemented by a multidisciplinary mix of providers experienced in the care of critically ill patients.

A multidisciplinary team approach is widely considered to be best practiced in the care of complex critically ill trauma patients. Our goal is to deliver the same level of care available at any premier trauma center around the world. It is important to understand that this capability should be scalable. A larger and more diverse team may need to be assembled the busier and more complex the patients. In a less busy setting where both the volume and acuity of patients are not high, assembling a robust team may not be necessary. Given that the vast majority of combat hospital admissions are trauma related, the most appropriate type of individual to lead this multidisciplinary team would naturally be a surgeon specifically trained and board certified in trauma and/or acute care surgery and appointed as the trauma director. The trauma director oversees the entire trauma program ensuring that the highest quality of surgical and critical care is delivered throughout the hospitalization from presentation to discharge. It is also important to appoint a medical director of ICU. Although it is feasible to assign the duties of the ICU medical director to the trauma director, a separate individual is preferred in a busy combat hospital. Best practice is to appoint a physician who is fellowship trained in critical care of trauma and surgical patients. Physicians obtain subspecialty fellowship training in critical care via multiple pathways. The most common are through general surgery, anesthesia, internal medicine , and emergency medicine. Although a critical care-trained surgeon can easily take on the role of the ICU director, a nonsurgical subspecialist is preferred so that all available surgeons are available to operate. It is also important to note that internal medicine-trained intensivists have two separate pathways for critical care subspecialty training: pulmonary critical care and straight critical care medicine. Most pulmonary critical care physicians practice in a pulmonary and internal medicine-focused environment with very little trauma and surgical patient interaction, while critical care medicine physicians, like anesthesia and emergency physicians, typically practice regularly in surgical, burn, and trauma ICUs. Thus, the specific skill set, experience, and philosophy may differ from one type of intensivist to another.

Perhaps the most important member of the ICU care team is the bedside registered nurse. It is imperative that bedside registered nurse has critical care training and has at least some trauma critical care experience. Certification as a Critical Care Registered Nurse (CCRN) is preferred but not required for staffing although it is the opinion of the author that it should be. The head nurse of the ICU should be the most experienced CCRN willing to jump in at the bedside to assist at a moment’s notice. The head nurse should also be experienced with appropriate staffing of busy ICU with a focus on the maintenance of nursing competencies among critical care staff, especially for support of procedures not routinely performed (such as intraventricular drain management, renal replacement therapy, burn care, etc.).

Respiratory therapists are vital to the multidisciplinary team. All respiratory therapists should attend daily rounds with the team and have a constant presence in the ICU. The medical director of the ICU should be in complete synch with the respiratory therapists regarding ventilator management philosophy and overall respiratory care. Once this relationship of trust is established, great respiratory therapists can attain significant degrees of autonomy, allowing the intensivists to focus on other matters in the care of the critically ill.

Combat hospitals typically have an inpatient pharmacist on staff. Given the complexity and acuity of combat-related trauma patients, the inpatient pharmacist needs to be an integral part of the ICU team and attend rounds on a regular basis. Appropriate drug dosing and identification of drug-related adverse events and interaction are crucial for optimal care in the ICU.

An inpatient registered clinical dietician should also be an integral part of the ICU team. An important principle in the care of trauma patients in the ICU is optimizing the conditions for wound healing and overall organ health. Optimizing nutrition is often the centerpiece of that principle.

Overall, superior care of the trauma patients can be achieved by leveraging the expertise that can exist across multiple disciplines. Prepositioning key providers from each of these disciplines in a combat hospital setting is 90% of the solution that will allow for optimal outcomes (Table 32.1).

Various ICU models exist in the civilian setting depending on the type of ICU. For example, most medical ICUs operate as a “closed” ICU where the ICU team is the admitting service and subspecialists do not typically engage in direct patient care regardless of where the patient came from. Alternatively, many surgical ICUs operate as an “open” ICU, whereby the admitting surgeon maintains primary responsibility of the patient, while ICU physicians are strictly consultants and participate only when invited. In the combat hospital ICU, the best model is a “semi-closed” or “hybrid” ICU. In this type of structure, the primary surgeon maintains responsibility of the patient but defers most ICU-related care to the ICU team who assumes care of every patient in the ICU. Ideally, it is important for the primary surgeon to take part in multidisciplinary rounds when able, to be able to contribute to important aspects of care. For those not so infrequent non-trauma or nonsurgical patients who get admitted to the ICU, the ICU team and ICU medical director should assume complete responsibility of the patient until the patient is transferred out of the ICU.

During active combat operations in Iraq and Afghanistan, there has been significant variation in the way that combat hospitals have run their ICUs. The following are a few examples: