With less need for their services in Afghanistan and Iraq, a handful of surgeons from the 633rd Medical Group at Langley Air Force Base in Hampton are honing and maintaining their trauma skills at Riverside Regional Medical Center's trauma and emergency department.

"There's a waxing and waning, an ebb and flow of cyclical knowledge," said Col. David Blake, a master clinician in surgery. "As we wind down our current operations, we need to maintain a certain level of readiness."

Blake was the trauma director at Balad Air Base in Iraq and oversaw trauma care throughout the Iraqi theater from 2009 to 2010. He now leads the Sustainment of Trauma and Resuscitation Skills Program — "STARS-P" in military-speak.

"The goal of STARS-P is to allow practice so there's not a rapid, frantic spin-up on deployment," Blake said.
The program is in line with a national agreement forged in the fall between the Department of Defense and the American College of Surgeons to maintain wartime surgical skills learned in more than a dozen years of warfare in Iraq and Afghanistan.

"The honing and perfecting of the Joint Theater Trauma System paid huge dividends to patients. If someone reached a base hospital with a pulse, they had a 98 percent survival rate," said Blake. "That's never happened in a previous conflict. The system is as near perfect as we can get it."

The Air Force surgeon hammered out an agreement in January with Riverside to rotate surgeons through the Peninsula's only Level 2 Trauma Center and acute surgery wing.

The program started with four general surgeons — two of whom have deployed overseas — taking weekend shifts in tandem with Riverside's two on-call physicians

The shifts are adjusted to maximize exposure to trauma, said Daniel Munn, the Riverside center's director for trauma and acute care surgery, and himself a Navy veteran who served in Afghanistan. "We're not training surgical residents. They're fully qualified attending physicians. There's a likelihood of their involvement in every case," he added.

Each year, of 60,000 patients treated in Riverside's emergency department, between 1,500 and 1,700 require surgical intervention for injuries or multiple traumas. Trauma surgeries primarily involve the torso, soft tissue and vascular injuries, along with some neck injuries, according to Munn.

"Over there, most injuries are explosive injuries with some penetrating components. They might be covered in rocks, parts of vehicles," said Munn, noting similarities to injuries sustained in a high-speed car accident. "How the body responds to critical illness is very similar, it's very reproducible. There's a lot to be gained from working with these kinds of injuries," he said.

Every case provides a learning experience, said Blake, a 25-year veteran of the operating room. "Every gunshot wound is not the same — it's not uncommon for each patient to have a little twist," he said. "You can do 15 different things, but which is the best could be up for grabs. You learn how to get out of trouble with a patient that's not responding."

Air Force Maj. Robert Swanson, back from deployment in Qatar, where he had some exposure to trauma surgery in forward situations, has completed a month of duty at Riverside.

"I've worked with a significant number of general surgery cases on very sick individuals that I wouldn't normally see at Langley," he said.
He has also been exposed to multisystem trauma patients, which he described as "a good refresher, a good training opportunity," as well as victims of car accidents, gunshot wounds and broken glass. Swanson has also tended to crush injuries, penetration wounds from stabbings and industrial accidents.

"It's a very collegial atmosphere with a lot of mutual teaching, sharpening each other's skills," he said. "It's a great learning experience."

Swanson's the first to have gained the full breadth of the experience — days, nights and weekends — as the public-private program ramps up slowly, Blake said.

The rotations also show the military surgeons trauma center management practices that can be used in the field.

"Trauma management was gained from the military — it's a very paramilitary pathway, the way the teams work," said Munn.

Blake added, "One person has to be in charge of the patient, one person directing traffic. When we go downrange in a deployed setting, we may have only one surgery team and may be on 24/7 for the duration of the deployment. In Bagram or Balad, there are numerous surgical teams, so it's a different operational tempo — there's a wider breadth of injuries than in most trauma centers in the U.S."

Munn noted the convenience for Langley service personnel of being able to maintain their skills locally at Riverside. "We have a lot more flexibility. In the Navy, we would have to go to Los Angeles for a month or six weeks. We're doing it as a service to the military," said the Riverside surgeon.

Support personnel are also taking advantage of the partnership to gain hands-on trauma experience. The first participant, 1st Lt. Bridget Henry, a critical care nurse, has started working three 12-hour shifts weekly at Riverside.

"We simply don't get those things at Langley," she said, referencing patients with strokes, trauma and open-heart surgery. "It's a great opportunity to get the experience and education for when we're deployed." She expects a second Langley nurse to join her soon.

The colonel is also intent on maintaining his own surgical skills. Under a similar affiliation to STARS-P, Blake puts in one to two weeks a month and several nights on call at Sentara Norfolk General's burn unit, the only one in the region.

"We need continued high level skills training, especially in medical specialties related to wartime," he said.

And then, there are still the general surgeries — appendix, gall bladder, and hernias— that occur wherever you are.

"When you're far forward, you are it," said Blake.

Published: July 14, 2015