The nature of wartime military trauma care leads to distinct clinical and logistical challenges. Transferring a casualty through staged, geographically disparate sites of care can impair communication and impact clinical decision-making. It is impossible to know with certainty what has fully transpired before you receive a patient. Although a segmental and dynamic trauma system is in place, the potential for fragmented care requires thorough review of the patient and extreme vigilance on the part of the clinician. When the patient reaches the Role 4 facility, any missed or neglected details must be captured and corrected. For the decade-plus of combat operations in Iraq, Afghanistan, and other areas, the primary Role 4 receiving facility was Landstuhl Regional Medical Center (LRMC) in Germany. This chapter highlights some of those key lessons that we learned as we went to war and ramped up a relatively small military medical center into a high volume and highly effective facility for providing care to thousands of wounded US and coalition service members and civilians.

Documentation may be sparse or easily misplaced by transferring teams. In a mature theater, lab data, radiologic reports, and clinical notes are all documented in the electronic medical record (EMR ). Non-mature sites and some forward operating bases that are controlled by coalition allies may not have information reliably input into the EMR , demanding greater dependence on paper charting and manual transfer of data. The development of a central e-mail box is an additional means by which downrange providers can transfer data electronically. The Patient Movement Record (PMR ) that is generated by the system notifies receiving facilities of incoming patients but should not be considered a transfer summary: critical information may be lacking. The PMR is only a first step in the investigation into the prior care received.

Details of initial presentation may be inaccurate or incomplete, and complete details of intervening treatment may be difficult to obtain. If a patient presented during a multiple casualty event (a fact which may be unavailable), there may have not been time for the expected attention to detail. Make no assumptions: reassess for cervical spine and thoracolumbar injury and look for retained sponges or Combat Gauze. The mechanism of injury data, which is important for guiding injury evaluation, is often unknown when the patient reaches the Role 4. Many patients may have multiple mechanisms of injury and thus more than one injury pattern, for example:

The regularly scheduled turnover of downrange provider teams results in a frequent need to relearn best treatment practices. Clinical practice guidelines (CPG) provided by the Joint Trauma System (freely available online for download) minimize this relearning curve but may be unknown to the deploying surgeons. It is ideal to know these downrange team members and their capabilities and to monitor how well CPGs are being followed. Staff at the Role 4 facility are well positioned to note when standards are not being met.

Role 4 facilities are most likely staffed by a combination of permanent party and temporarily deployed staff. Permanent party staff is responsible for onboard training and education as well as monitoring practice-deployed staff . Varying standards of quality and experience exist among providers, and rapid turnover of Role 4 nursing staff and physicians may be the norm. Therefore, standard operating procedures (SOPs) should exist for many issues.

Permanent staff at the Role 4 are in a distinct and potentially stressful situation: they are stationed OCONUS for 3 or more years, with the comforts of family and home, yet they are caring for casualties on a daily basis. Some refer to it as “being deployed with your family.” Depending on the pace of casualty flow, they may experience compassion fatigue. Leaders would be well advised to implement programs to educate, monitor, and intervene in those situations.

While a Role 4 facility is able to provide services and specialty care not available downrange, there are still potential limitations. These may include:

American College of Surgeons Level II trauma center optimal standards should be practiced at all Role 4 facilities. There should be a designated Trauma Director, Trauma Program Nurse Director, Registrar, etc. Trauma protocols and policies should be developed. Mass casualty and disaster plans are especially critical for military facilities. The Role 4 surgeons should assist the Joint Trauma System (JTS) in monitoring care from the different downrange facilities and may be required at times to intervene if the stressors of flight are not being properly addressed before transport.

The Role 4 ICU should be a Trauma Surgeon led, multidisciplinary team available to care for critically ill patients. ICU admission criteria should be standardized, admitting all intubated patients and those non-intubated patients whose injuries or diseases qualify them for intensivist coverage, at the discretion of the surgical and medical intensivists on the team. Care should involve a combined ICU team with pulmonary/critical care, general surgery, and surgical critical care, with employment of Role 4-specific SOPs.

Twice daily ICU rounds are expected. Pre-rounding should be carried out by the assigned resident and staff so that daily team rounds are meaningful. Morning rounds should be multidisciplinary, led by a surgical critical care provider including representatives from nutrition, pharmacy, infectious disease, and the trauma performance improvement program, in addition to the members of the primary ICU team. The nurses assigned to the patients, the ICU charge nurse, and the critical care clinical nurse specialist should attend rounds as their clinical duties allow. For discharge planning, the regional validating USAF flight surgeon should round on the days preceding CONUS flights to assist with mission planning. At the end of rounds, daily tasks should be assigned by the service chief. Afternoon team sign-out rounds should be conducted daily, and performance improvement (PI) rounds should occur daily to capture PI events.

In-house coverage should be provided 24/7 for critical care patients. The on-call physician (or another designated team member) “must” be present for the arrival and departure of all Critical Care Air Transport (CCAT) teams to provide patient care and to interact as needed with the transport teams, answering questions and assisting with review of x-rays, labs, etc. Providers should limit (as much as possible) elective clinic appointments and operative cases during their ICU weeks. These “should not” be performed during AM rounds or on a team members’ designated “on-call” day without previous discussion with the service chief.

Table 39.1 outlines a checklist for receiving injured patients from the forward medical treatment facilities. Typically, Role 4 providers have forewarning of incoming patients. Patients arrive near simultaneously, so any tasks that can be completed in advance can greatly streamline patient care. Providers should review downrange documents from the EMR in advance and any paper documentation upon arrival and transfer this information into the accepted electronic medical record. Providers should have access to an online radiology system so they can confirm the presence of downrange radiologic films, coordinating with the Role 4 radiology department to load the films into the hospital’s radiology system. The development of this system is complex and time-consuming but is worthy of the initial investment. Note that missing films or images of certain studies may not have been included in the downrange evaluation and will require either reformatting at the Role 4, or new imaging will need to be completed (i.e., coronal and sagittal reconstructions of the spine in high-energy blunt trauma). Upon patient arrival (Fig. 39.1), the admitting surgeon should review the entire downrange medical record, including any radiographic data available (e.g., CDs). Providers may need to have downrange films reread by the on-call Role 4 radiologist if an official report is not available from the downrange radiologist.

While the PMR and downrange records are useful for preparation, casualties often arrive at the Role 4 with significant interval changes. Upon arrival of new patients, the provider should receive sign-out from the CCAT team and perform a thorough tertiary exam to evaluate for missed injuries (e.g., spine fracture) or newly developed complications (e.g., compartment syndrome). The provider should perform or review appropriate studies to rule out common injuries. For blunt trauma, falls or blast injury, possible cervical/thoracic/lumbosacral spine injuries must be evaluated with CT scans. Plain films alone are inadequate , and physical exam may be unreliable in predicting thoracolumbar injuries. Patients with blunt trauma, falls, blast injury, or close proximity penetrating injury (e.g., high-velocity injury to the neck or face) should be evaluated for intracranial injury with CT of the head without contrast. High-velocity injuries to the head and face have resulted in pseudoaneurysms and have resulted in delayed hemorrhage and death prompting a call by many to perform delayed CT angiograms. Patients with blunt trauma or blast injury should be evaluated for thoracic, abdominal, and pelvic injury with CT scan if not already accomplished downrange. Casualties with trauma suspicious for vascular injury should be assessed with CT angiogram or conventional angiography when multiple fragments exist. The latter can be accomplished either in the OR using a C-arm or preoperatively in the angiography suite. Penetrating extremity injuries that are suspicious by proximity alone do not warrant further vascular evaluation beyond physical exam unless the ankle-brachial or brachial-brachial indices are less than 0.9. (Note: suspicious exam findings such as thrill and bruit will also warrant further evaluation.)

Patients often arrive to the Role 4 at the end of their physiologic reserve. Casualties with severe injuries who would not be considered “stable enough” for a CT scan at a stateside civilian trauma center may be transported by the military system via air for 5–10 h. Critical care transport teams may have been doing everything that they could just to keep the casualty alive. Immediate care and assessment is often required to salvage these critically injured. The following exam and laboratory values are encouraged to facilitate assessment of resuscitation status: