Landstuhl Medical Center Saves Lives, Advances Medicine

LANDSTUHL, Ger­many — Med­ical-sur­gi­cal teams at Land­stuhl Region­al Med­ical Cen­ter here save the lives every day of war­riors wound­ed in Afghanistan and, until recent­ly, saved troops wound­ed in Iraq. But that’s only part of their suc­cess.

Here, a side ben­e­fit of pro­vid­ing relent­less­ly supe­ri­or care from the point of injury in the war zone to what doc­tors call “defin­i­tive care” — care giv­en to man­age a patient’s con­di­tion — has been to advance the prac­tice of mil­i­tary med­i­cine and, ulti­mate­ly, the prac­tice of med­i­cine every­where.

For med­ical teams at Land­stuhl, the bru­tal­i­ty of com­bat and the urgent need to respond to the wound­ed have yield­ed advances in en-route lung bypass, whole-blood trans­fu­sion, and even com­bat tourni­quets that can be applied with one hand and in the dark.

“Ten years ago, we had to sta­bi­lize [patients] before we could move them,” said Army Col. (Dr.) Jef­frey B. Clark, com­man­der of the Land­stuhl Region­al Med­ical Cen­ter.

“Now what our Air Force can do is basi­cal­ly put an inten­sive care unit in the back of a C‑17 with a crit­i­cal-care air-trans­port team so we can con­tin­ue to sta­bi­lize while we are mov­ing,” Clark said.

The crit­i­cal-care team pro­gram is part of the Air Force aeromed­ical evac­u­a­tion sys­tem. A team con­sists of a crit­i­cal care physi­cian, a crit­i­cal care nurse and a res­pi­ra­to­ry ther­a­pist, along with sup­plies and equip­ment.

Over the past 70 years, and espe­cial­ly over the past 10, a com­bi­na­tion of evolv­ing sur­gi­cal capa­bil­i­ties, tech­nol­o­gy-inten­sive crit­i­cal care and long-range air trans­port have pushed med­ical-sur­gi­cal capa­bil­i­ty far for­ward. This saves lives and helps to reduce the load on teams at Land­stuhl, a mil­i­tary hos­pi­tal oper­at­ed by the Army and the Defense Depart­ment, whose staff since 2004 has treat­ed near­ly 66,000 patients from Iraq and Afghanistan and mil­i­tary per­son­nel and their fam­i­lies sta­tioned in Ger­many.

From the Unit­ed States, 48 vis­it­ing civil­ian trau­ma sur­geons rotate in to Land­stuhl for two weeks at a time from hos­pi­tals at Johns Hop­kins Uni­ver­si­ty in Bal­ti­more, the Uni­ver­si­ty of Cincin­nati in Ohio, the Ore­gon Sci­ence and Health Uni­ver­si­ty in Port­land, and oth­ers.

Also under the Land­stuhl com­mand are sev­en clin­ics: two in Bel­gium, two in Italy and three in Ger­many.

Land­stuhl is the only hos­pi­tal out­side the Unit­ed States des­ig­nat­ed a Lev­el I Trau­ma Cen­ter by the Amer­i­can Col­lege of Sur­geons. Its sur­vival rate for trau­ma patients is 99.5 per­cent.

“About 14,000 of the 60-some thou­sand were actu­al bat­tle injuries,” Clark said. “We have returned to duty about 20 [per­cent] to 21 per­cent of those who have come to us from Iraq or Afghanistan, which is huge.”

Every week, every crit­i­cal­ly ill patient is dis­cussed on a video tele­con­fer­ence that spans nine time zones on three con­ti­nents. Atten­dees include “our NATO col­leagues such as MERT [Med­ical Emer­gency Response Team], the British para­medic units that have physi­cians on the heli­copter teams, to the for­ward sur­gi­cal team, the [three] com­bat sup­port hos­pi­tals [and] Land­stuhl … as well as our part­ners on the East Coast and San Anto­nio and the [Air Force] Aeromed­ical Evac­u­a­tion ser­vice,” said Air Force Maj. (Dr.) David H. Zonies, Landstuhl’s trau­ma direc­tor.

“Every­one dis­cuss­es their care that’s pro­vid­ed along the con­tin­u­um,” he added.

The broad influ­ence of Landstuhl’s med­ical-sur­gi­cal inno­va­tions is seen 25 to 30 times a day, Zonies said, every time a patient under­goes surgery in an oper­at­ing room.

“From the last 10 years, a lot of the evi­dence that we’ve gath­ered has changed not just the prac­tice of mil­i­tary med­i­cine, but has now been com­plete­ly trans­lat­ed back into civil­ian prac­tice,” Zonies said.

For exam­ple, he added, the way patients are resus­ci­tat­ed has changed sig­nif­i­cant­ly since 2001.

For the past 50 years, he explained, the stan­dard prac­tice for stor­ing blood has been to break it up in to com­po­nents such as red blood cells, platelets and plas­ma.

When it was time to give stored blood to a patient, “we’d give them a bunch of red cells, and maybe for every four of those we’d give a unit of platelets [and plas­ma]. That was how it worked,” Zonies said.

“Well,” he added, “we noticed that our mor­tal­i­ty rate was extreme­ly high doing that, and it was stan­dard prac­tice.”

Then six or sev­en years ago, Army sur­geon Dr. John Hol­comb and Air Force sur­geon Dr. Don­ald Jenk­ins, now both retired, observed that trans­fu­sions with 1‑to‑1 ratios of plas­ma and platelets to blood cells low­ered patient mor­tal­i­ty rate by about 15 per­cent. They began to use the prac­tice for com­bat trau­ma patients, Zonies added.

“That is how we changed our guide­lines for how we resus­ci­tate all our patients,” he said. “We have now tak­en that evi­dence back to our civil­ian coun­ter­parts, and they’ve been able to repli­cate the same approach in civil­ian prac­tice, and it has decreased mor­tal­i­ty there.”

Anoth­er life-sav­ing inno­va­tion involves a pro­ce­dure called extra­cor­po­re­al mem­brane oxy­gena­tion, or just extra­cor­po­re­al life sup­port. This is basi­cal­ly a lung bypass, or car­dio-pul­monary bypass, that a spe­cial team from Land­stuhl flies down­range to per­form en route as the patient is evac­u­at­ed from the war zone.

The suit­case-sized device takes the patient’s blood through an arti­fi­cial mem­brane that replaces car­bon diox­ide with oxy­gen.

The tech­nol­o­gy, devel­oped by a team at the Uni­ver­si­ty of Regens­berg, about a four-hour dri­ve from Land­stuhl, has been around for 30 or 40 years, but only in the past decade, Zonies said, “has it got­ten to the point where every­one feels this is a safe modal­i­ty that tru­ly … improves patient out­comes.”

So far, Land­stuhl has the only capa­bil­i­ty in the Defense Depart­ment of pro­vid­ing that kind of sup­port, Zonies said.

At Land­stuhl, the hos­pi­tal itself is a sprawl­ing com­plex built in the ear­ly 1950s. By 2018, a new hos­pi­tal that’s more con­tem­po­rary and flex­i­ble will replace it, to be called the Kaiser­slautern Com­mu­ni­ty Med­ical Cen­ter.

“It’s a very spe­cial mis­sion,” Clark said. “We take a tremen­dous amount of pride in what we do, and so we con­sid­er it a priv­i­lege. In many ways, it is so ter­ri­bly uplift­ing to take care of wound­ed war­riors, to take care of our own. But … it can wear on you, so we try very hard to look out for each oth­er.”

U.S. Depart­ment of Defense
Office of the Assis­tant Sec­re­tary of Defense (Pub­lic Affairs)