s military anesthesiology residents, we spend a good deal of our training providing anesthesia support, intensive care and pain management for injured service members returning home. Given the number of extremity injuries we see, a strong regional anesthesiology program is a necessity. We have recently been privileged to be some of the first residents in our program to spend one month doing regional anesthesia at the Landstuhl Regional Medical Center (LRMC) in Germany. In reviewing the Accreditation Council for Graduate Medical Education (ACGME) general competencies <www.acgme.org>, one can see how this experience fulfills these requirements in a unique way that also aids us in our primary mission — to care for soldiers, sailors, airmen/women and Marines. What follows are brief examples of how important this rotation is in our education and professional development and how clearly it integrates the six core competencies into care that positively impacts our patients.

Systems-Based Practice
LRMC is a military treatment facility (MTF) similar to those in which we may find ourselves following graduation. It serves as an important casualty care node in the evacuation of wounded service members from the Iraq and Afghanistan operational theaters. Military medicine is typically a series of care locations where injured service members are either treated and returned to their unit or stabilized and evacuated to a point of higher care. This system provides many challenges and is one that we have not encountered previously at this critical point in the system between injury/initial stabilization and patients’ evacuation to an MTF in the United States. Working under the supervision of faculty trained in interventional regional techniques, we are able to provide regional analgesia for wounded service members either by single injection or continuous peripheral nerve block (CPNB) catheters.

Professionalism
Given the nature of the morning operating room schedule and sheer volume of potential regional anesthesia patients, it was not always possible to place catheters preoperatively. For this reason, some patients received their CPNB catheters in the postanesthesia care unit (PACU) following surgery. Several PACU nurses were extremely valuable in assisting with the blocks and acting as proponents of CPNB for the pain management of their patients. Their involvement has been key to the success of the regional anesthesia program at LRMC, and their role was nurtured by positive communication and mutual professional respect. Furthermore positive interactions with the orthopedic and general surgeons have led to their enthusiastic support of regional anesthesia for their patients. An example of this is daily interaction with two Army Reserve orthopedic surgeons who initially sought out the regional team while both teams were rounding on the wards to discuss incoming patients who might benefit from regional anesthesia after seeing the success with existing patients.

Interpersonal and Communication Skills
In addition to the interactions with our surgical and nursing colleagues mentioned above, our regional program initiative necessitated the ability to communicate with those who would receive our patients in the United States. As a result, the Regional Anesthesia Tracking System (RATS) was developed, and we are able to track our patients’ clinical course throughout their evacuation. The goal of RATS is to provide feedback to those who performed the block, provide information to the teams receiving patients at the MTFs and, most importantly, to determine the long-term impact of advanced acute pain management on psychological and physical recovery. Its role in our ability to manage acute pain patients with advanced technologies like CPNB cannot be overestimated. A few patients have arrived at LRMC with CPNB placed in theater; they are already entered into the database, providing a seamless transition to continued care in Germany and beyond. RATS appears to be the only Internet-based clinical system allowing real-time control and communication concerning patient pain management as they travel thousands of miles from point-of-catheter placement to the United States.

Practice-Based Learning and Improvement
The large number of extremity injuries created vast opportunities to place dozens of CPNB catheters and single-shot blocks during the one-month Combat Casualty Anesthesia rotation. Building on a prior month of regional anesthesia at Walter Reed Army Medical Center, the competence in identifying landmarks, needle placement and attaining successful nerve blocks improved exponentially. Further, confidence is gained in the autonomy of managing blocks to include patient selection and education, local anesthetic selection, catheter troubleshooting and maintenance, and daily acute pain management of patients until their medical evacuation. The independence and responsibility afforded by our attending physicians in the management of the regional anesthesia service are formative.

A wounded soldier receives treatment at the Landstuhl Regional Medical Center. Photos by John K. Zaugg, M.D.

Medical Knowledge
As we strove to improve our technique and skills with regional anesthesia, we took every opportunity to review anatomy and regional reference materials. The supporting faculty also was very good in providing current regional anesthesia literature, and daily discussions served to reinforce both the literature and the practical applications of the knowledge gained from placing and managing the blocks.

Patient Care
The primary benefactors of this rotation are our service members. Many of those we talked with describe great discomfort at two points: during transport and postoperatively. The vast majority of those injured servicemen and women who are candidates for regional anesthesia are amenable to the procedure, with most reporting greatly decreased pain and continued satisfaction. Those with catheters placed and maintained throughout their stay at Landstuhl, and subsequently used after air evacuation to the United States, were very satisfied with the benefits offered.

The CPNBs not only reduce pain during transport and surgery but also improve operating room efficiency by allowing rapid re-establishment of surgical blocks for frequent wound debridement. Our early results indicate that CPNB also may have far-reaching benefits in the reduction of emotional stress and chronic pain of traumatic injuries. The initiative to provide regional anesthesia support closer to the front lines plays an important role in making travel between points of care safer and less painful for our service members. Upon return to the United States, we have the opportunity to follow up on many of the patients we met and in whom we placed catheters in Germany, many of whom still had the same functioning catheters in place. The continuity of care is a pleasant reinforcement of all the lessons learned in the month prior.

In our opinion, the Combat Casualty Anesthesia rotation in Germany is likely the most rewarding and the best training month in residency. The positive interaction with attendings, surgeons, PACU and ward nurses all working toward the common goal of treating our nation’s heroes to the best of our abilities using cutting-edge equipment and technology, the sheer numbers of blocks placed and managed (and the skill set developed as a result) and the opportunity to serve one step closer to the action all combined to create a memorable and invaluable experience.

Tammy J. Penhollow, D.O., Lt. Cmdr., Medical Corps, U.S. Navy, is a CA-2 Resident, National Capital Consortium, National Naval Medical Center, Bethesda, Maryland, and Walter Reed Army Medical Center, Washington, D.C.

John K. Zaugg, M.D., Capt., Medical Corps, U.S. Army, is a CA-3 Resident, National Capital Consortium, Walter Reed Army Medical Center, Washington, D.C., and National Naval Medical Center, Bethesda, Maryland.