Special considerations of military cardiothoracic surgeons

Accepted Manuscript Special Considerations as a Military Cardiothoracic Surgeon LTC Bryan S. Helsel, MD, USA, Maj Elizabeth A. David, MD, USAF, CDR Jared L. Antevil, MD, USN PII:

S0022-5223(16)30307-5

DOI:

10.1016/j.jtcvs.2016.04.089

Reference:

YMTC 10593

To appear in:

The Journal of Thoracic and Cardiovascular Surgery

Received Date: 15 October 2015 Revised Date:

22 March 2016

Accepted Date: 28 April 2016

Please cite this article as: Helsel BS, David EA, Antevil JL, Special Considerations as a Military Cardiothoracic Surgeon, The Journal of Thoracic and Cardiovascular Surgery (2016), doi: 10.1016/ j.jtcvs.2016.04.089. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT

Special Considerations as a Military Cardiothoracic Surgeon

1 2

By LTC Bryan S Helsel, MD, USA1,2, Maj Elizabeth A David, MD, USAF 3,4,CDR Jared L.

3

Antevil, MD, USN5

RI PT

4

Disclosure: This editorial is an independent expression of the authors and does not

6

represent the view of the United States Government, the US Army, the US Air Force, or the

7

US Navy.

SC

5

8

1 Department of Surgery – Cardiothoracic, San Antonio Military Medical Center, Joint Base

M AN U

9

San Antonio, Texas 78234

11

2 Department of Surgery – Cardiothoracic, Audie L. Murphy Veterans Affairs Medical

12

Center, San Antonio, Texas 78229

13

3 Heart Lung Vascular Center, David Grant Medical Center, Travis AFB, CA 94535

14

4 Section of General Thoracic Surgery, UC Davis Medical Center, Sacramento, CA 95817

15

5 Department of Surgery – Cardiothoracic, Walter Reed National Military Medical Center,

16

Bethesda, Maryland 20889

EP

TE D

10

17

Corresponding Author:

19

LTC Bryan Helsel

20

Department of Surgery – Cardiothoracic

21

San Antonio Military Medical Center

22

3551 Roger Brooke Dr.

23

San Antonio, Texas 78234

AC C

18

ACCEPTED MANUSCRIPT

24 25

Military cardiothoracic surgeons have unique perspectives, experience, and job demands. We attempt to operate a routine cardiothoracic surgical practice similar to our

27

peers, but face some specific challenges. This editorial will review our perspective on

28

current military cardiothoracic surgery practice. We dedicate this discussion to the memory

29

of our colleagues who have paid the ultimate sacrifice and to the warfighter, who is the

30

reason for our existence. We will describe the current state of our combat surgical practice

31

and peacetime/non-deployed practice as these are two distinct areas of life as a military

32

cardiothoracic surgeon.

M AN U

SC

RI PT

26

33 34

Throughout history, military conflict has led to advancements in surgical care.1,2,3,4 Many historical publications from master surgeons have reviewed their military experience

36

and reviewed applications and implementation from military surgical practice.1,7 There are

37

several concepts that have emerged as a result of recent combat experience: the

38

resurgence of the tourniquet, care of amputees, and the Air Force (USAF) critical care air

39

evacuation teams (CCAT). Tourniquets are frequently used at the point of injury because

40

they have been shown to prevent massive hemorrhage and exsanguination allowing

41

patients to reach surgical care. Modern tourniquets can be placed with one hand by the

42

injured patient also increasing the use. Tourniquets are now even a focus of the American

43

College of Surgeons (ACS) to implement these lessons from combat casualties into civilian

44

trauma care as discussed by ACS leadership and experts at the Hartford Consensus III.5

45

These extremity injuries have also paved the way for an amazing new generation of

46

prostheses and care for amputees. CCAT has revolutionized the evacuation system. CCAT

AC C

EP

TE D

35

ACCEPTED MANUSCRIPT

provides a “mobile ICU” environment that can be used to transport patients out of the

48

combat theater to sites with higher levels of care and more resources available. Thus, we

49

utilize the typical “ICU time” between operative interventions of damage control surgery to

50

move patients with minimal impact on their continued care and gaining the benefit of arriving

51

at facilities with more resources and/or capability. This has significantly contributed to the

52

decreased overall risk of dying from a combat injury in our current conflicts.2,3,6,8,9,10,11

RI PT

47

SC

53

Recent conflicts have yielded low rates of thoracic injury in allied forces, largely as a

55

result of improvements in personal protective equipment for our combat troops, and surgical

56

intervention for thoracic or vascular injury is required in only about 10% of cases.1,2,6,8,9,12

57

Although surgical intervention for thoracic injury is uncommon and index cardiothoracic

58

surgical procedures are rarely performed in a combat trauma setting, cardiothoracic

59

surgeons contribute valuable skills to combat trauma management beyond the treatment of

60

thoracic injuries.2 McNeil, Propper, Chambers, Holcombe, Zouris and Ivey have all

61

separately published the typical experience of thoracic surgeons and forward surgical

62

elements during our recent conflicts.2,3,6,7,8,13 Our general surgery training, proficiency in

63

vascular techniques, routine care of critically ill patients, and familiarity with basic and

64

advanced techniques for hemorrhage control make us well suited to provide for the initial

65

surgical management of all traumatic injuries. Cardiothoracic surgeons can function

66

extremely effectively as a trauma surgeon in busy or mass casualty situations, or as an

67

experienced consultant to the trauma surgeon. In addition, our expertise in critical care

68

management is a valuable asset in the deployed setting.

69

AC C

EP

TE D

M AN U

54

ACCEPTED MANUSCRIPT

70

In addition to the practical skills that deployed surgeons offer our combat troops, we provide a sense of security and peace of mind to the service members who travel outside

72

the protective walls of our bases and fortifications because they know we are waiting to help

73

them if harm comes their way. There is a positive palpable effect for the combatants who

74

face the enemy more directly; they understand and appreciate our commitment to them.

RI PT

71

75

Military surgical deployments are typically for periods of between three and nine

SC

76

months, and military and transitional requirements lengthen the interval of inactivity in

78

elective cardiothoracic surgery for an additional two to three months. The frequency and

79

location of deployments have varied with military strategic surges, but there are deployed

80

thoracic surgeons currently. Some surgeons find themselves very close to military action

81

and thus in a busier surgical situation while others find themselves with minimal work and

82

located distant to active conflict. The way these requirements fluctuate to meet

83

requirements of higher commands to support strategic military goals. This extended period

84

of clinical inactivity within our primary field is associated with a detriment in surgical skills

85

upon the resumption of elective practice, particularly in the current environment of low

86

cardiothoracic surgical volume practice at most military hospitals. There is also the potential

87

for the deployment of cardiothoracic surgeons to impact the continuity of care and staffing

88

levels for stateside military facilities, patients and surgical programs.

90

TE D

EP

AC C

89

M AN U

77

Although most military cardiothoracic surgeons practice both cardiac and thoracic

91

surgery, the recent development of separate training pathways for thoracic and cardiac

92

surgery dictates that more recent program graduates have a more focused practice. The

ACCEPTED MANUSCRIPT

relatively new development of integrated 6-year (I6) training programs may further impact

94

the breadth and versatility that cardiothoracic surgeons will provide in the future. Military

95

cardiothoracic surgeons are a limited resource, and when deployed may work alone without

96

the benefit of general or trauma surgery support. Graduates of I6 programs will certainly be

97

well suited for elective cardiothoracic surgical practice, and the I6 training programs are

98

attracting some of the brightest students, but I6 graduates will have less experience in other

99

areas of surgery. It is uncertain whether graduates from the new integrated pathway will be

SC

RI PT

93

able to provide the same contribution to the military medical team as their historical

101

counterparts.

M AN U

100

102 103

In general, our non-deployed/peacetime elective cardiothoracic programs are and have been successful, but some significant challenges have arisen over the past decade.

105

Military cardiothoracic surgeons in peacetime provide care for service members, their

106

families, and retirees. With policy changes in the military health care system over the past

107

decade, more patients receive care in the local civilian network, rather than at regionalized

108

military medical centers. Although these policy changes may provide for greater patient

109

convenience, the policies have been associated with a dramatic decline in cardiothoracic

110

surgical case volumes at all military medical centers. Many facilities now struggle to

111

maintain adequate cardiac and thoracic surgical volumes to ensure surgical proficiency.

112

This decline in case volume has also led to the closure of the military’s two thoracic surgery

113

training programs.

114

AC C

EP

TE D

104

ACCEPTED MANUSCRIPT

115

Mentorship of military cardiothoracic surgeons from within the military remains another challenge as military career length varies. By the time a surgeon gains adequate

117

experience to serve as an effective mentor, he or she typically can retire from military

118

practice or may choose to pursue a focus on military leadership roles rather than clinical

119

practice. As a result, many military cardiothoracic surgeons are dependent on civilian

120

mentors, who may or may not understand all of the challenges faced in our current practice

121

environment. We are developing a multiservice morbidity and mortality conference which

122

would allow increasing collaboration amongst institutions hopefully leading to further

123

solutions to common problems on a more global scale. Locally, military facilities are trying

124

to make more affiliations with local VA medical centers and academic centers as a strategy

125

to achieve increased mentorship and cumulative expertise as we will describe.

M AN U

SC

RI PT

116

126

Declining cardiac surgical volumes have given way to creative means to support

TE D

127

surgical proficiency as a solution to these problems. The Air Force has established

129

proficiency metrics for each specialty. For cardiac surgeons, the Air Force mandates at

130

least 50 annual cardiac cases per surgeon. This requirement is supported by authorizing

131

clinical activity in non-military facilities to achieve this requirement. However, this metric is

132

arbitrary, difficult to establish, and currently does not exist in the Army or Navy. At San

133

Antonio Military Medical Center (SAMMC), the combined Army and Air Force cardiothoracic

134

surgery service has established a relationship with the South Texas Veterans Health Care

135

System (STVHCS) in San Antonio. Surgeons from SAMMC now provide all of the

136

cardiothoracic surgery services for the STVHCS. This collaborative agreement has led to a

137

three-fold annual increase in surgical volume for military cardiothoracic surgeons assigned

AC C

EP

128

ACCEPTED MANUSCRIPT

to SAMMC. This is a much more robust surgical experience and the cost savings for the

139

Veteran Affairs (VA) are profound. The VA perfusion service is also augmented by the

140

military perfusion service. VA patients appreciate our presence, and they enjoy seeing

141

surgeons in uniform in clinic and during their care. This model for surgical skills retention

142

offers the potential for translation to other military medical centers co-located with VA

143

facilities.

RI PT

138

145

SC

144

The Air Force has created collaborative arrangements in Northern California and San Antonio, Texas, which are also designed to augment clinical volume for active duty

147

surgeons, and provide training opportunities for staff and surgeons alike. These

148

relationships involve military facilities, VA facilities and public academic institutions. At

149

David Grant Medical Center (DGMC) at Travis Air Force Base in California, there are

150

training affiliation agreements with UC Davis Medical Center and the VA which include many

151

specialties and training programs. These relationships are mutually beneficial for surgeons,

152

patients and support staff at DGMC via shared resources, training and practice

153

opportunities. UC Davis Medical Center and the Air Force have recently partnered to

154

create an opportunity for military trainees to pursue integrated cardiothoracic surgery

155

residency in their combined I6 residency program.

157

TE D

EP

AC C

156

M AN U

146

Collaborative relationships between military and civilian institutions are likely a

158

necessity for military cardiothoracic surgeons in the future, as they provide critical

159

opportunities for practice in higher volume facilities. However, because these agreements

160

are a product of local surgeon/institutional efforts, fluctuations in personnel make their

ACCEPTED MANUSCRIPT

maintenance a significant challenge. These relationships were the focus of an Early-Riser

162

Session at the 2015 Society of Thoracic Surgeons (STS) Annual Meeting in San Diego,

163

California in an effort to raise awareness for surgeons who are commonly faced with low-

164

volume environments. Hopefully, these relationships will continue to gain momentum for all

165

military facilities, and provide enhanced clinical experience for all military cardiothoracic

166

surgeons.

RI PT

161

168

SC

167

We strive to provide excellent surgical care to our patients. Our commitment to quality and our successful efforts to bolster surgical volumes have led to success in this

170

regard. SAMMC is unique amongst military cardiac surgery programs in that institutional

171

data is reported to the STS database. Other military facilities have been deterred from

172

similar participation due to legal and administrative constraints. Participation in the STS

173

database at SAMMC has reaffirmed the high quality of cardiothoracic surgical care that the

174

military provides, at least at SAMMC. SAMMC also recently received an exemplary rating

175

from the American College of Surgeons National Surgical Quality Improvement Program for

176

overall cardiac surgery morbidity. Most other military facilities across all three services use

177

standard risk predictors (STS, Euroscore, VA) to derive expected morbidity and mortality

178

rates, and rigorously compare these rates to observed outcomes as a means to ensure

179

quality and provide a metric for process improvement. The morbidity and mortality review

180

process is also a crucial part of process improvement and optimizing clinical outcomes. This

181

is a focus at each facility, and efforts are underway to create multi-service/facility combined

182

military cardiothoracic surgery conferences to share experience and foster excellent

183

outcomes.

AC C

EP

TE D

M AN U

169

ACCEPTED MANUSCRIPT

184 185

The military cardiothoracic surgeon is well suited for broad range applications in combat surgery. We face many challenges in our peacetime/non-deployed practice, and

187

are working to establish creative solutions to maintain our proficiency and excellent

188

outcomes. The future success of our critical field within military medicine will require

189

continued diligence, effort and commitment.

AC C

EP

TE D

M AN U

SC

190

RI PT

186

ACCEPTED MANUSCRIPT

191

1

Debakey ME: History, the torch that illuminates: lessons from military medicine. Mil Med 161:711-716 , 1996.

192

2

McNeil JD, Pratt JW: Combat casualty care in an Air Force theater hospital: Perspectives of a recently deployed

193

cardiothoracic surgeon. Semin Thorac Cardiovasc Surg 20:78-84, 2007.

194

3

195

Thorac Surg 89:1032-1036, 2010.

196

4

197

Institute, 2014.

198

5

199

Bulletin of American College of Surgery, July 2015.

200

6

201

during operation Iraqi Freedom. Arch Surg 140:26-32, 2005.

202

7

Holcomb JB: The Fitts Lecture: current perspective on combat casualty care. J Trauma 59:990-1002, 2005.

203

8

Zouris JM, Walker GJ, Dye J, et al: Wounding patterns for U.S. Marines and sailors during Operation Iraqi Freedom,

204

major combat phase. Mil Med 171:246-252, 2006.

205

9

206

continental United States from March to June 2003. J Am Coll Surg 201:7-13, 2003.

207

10

208

Conflict. Br J Surg 92:637-642, 2005.

209

11

210

2006.

211

12

212

with 417 operative combat casualties during a 12 month period of Operation Iraqi Freedom. J Trauma 60;1155-1164,

213

2005.

214

13

215

Enduring Freedom and Iraqi Freedom. J Trauma Acute Care Surg 73:S514-519,2012.

RI PT

Propper BW, Gifford SM, Calhoun JH, McNeil JD: Wartime thoracic Injury: perspectives in modern warfare. Ann

Cubano MA, Lenhart MK (eds): Emergency War Surgery: fourth United States revision. Ft Sam Houston, TX, Borden

SC

Jacobs,Jr. LM and Joint Committee to create a National Policy to enhance survivability from mass shooting events.

M AN U

Chambers LW, Rhee P, Baker BC, et al: Initial experience of US Marine Corps’ forward resuscitation surgical system

TE D

Montgomery SP, Sweicki CW, Shirver CD, The evaluation of casualties from Operation Iraqi Freedom on return to the

Hinsley DE, Rosell PAE, Rowlands TK, et al: Penetrating missile injuries during asymmetric warfare in the 2003 Gulf

EP

Holcomb JB, Stansbury LG, Champion HR, et al: Understanding combat casualty care statistics. J Trauma 60:397-401,

AC C

Chamber LW, Green DJ, Gillingham BL, et al: The experience of the US Marine Corps’ surgical shock trauma platoon

Ivey KM, White CE, Wallum TE, et al: Thoracic injuries in US combat casualties: A 10-year review of Operation

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT