The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

ne of the challenges being faced by military anesthesiologists in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) is the treatment of the severely burned wounded warrior. As with other combat-related injuries sustained during the global war on terrorism (GWOT), we are witness to advancements in evacuation from time of injury through Landstuhl Regional Medical Center in Germany to the United States Army (USAISR) Burn Center at Brooke Army Medial Center, Fort Sam Houston, Texas.

The USAISR Burn Center is located within Brooke Army Medical Center and is the Department of Defense’s only military facility treating severely burned soldiers. The burn center has dedicated operating rooms, an independent anesthesia department and a surgical team of 11 surgeons and six physician assistants. The burn center also provides care to patients of the U.S. Department of Veterans Affairs, several federal agencies and civilians in the south Texas region. The burn center consists of 16 ICU beds and 24 intermediate-care patient beds. Over the past four years, the USAISR has treated more than 662 (36 percent) severely burned soldiers from OIF in Iraq and OEF in Afghanistan, with total admissions of 1,845 patients. During the 2006 fiscal year, there were 389 burn admissions of which 156 patients (40 percent) had injuries sustained during the GWOT, with an average patient age of 33.6 years.3 Of the 389 admissions, 102 patients (26 percent) had an average total body surface area (TBSA) burn > 20 percent, an average injury severity score (ISS) of 12.7 and a mortality rate of 8.2 percent, compared to 5.3 percent from the National Burn Repository.1,3 When compared to the 2006 National Burn Repository report, only 16 percent of patients treated nationally had a total TBSA > 20 percent, with 63 percent having a TBSA < 10 percent.

Figure 1: Severe burn of upper extremities and polytrauma (open abdomen and lower extremity orthopedic injury).

Figure 2. Burn escharotomies and severe airway edema.

As part of their military service as anesthesiologists, Peter A. DeSocio D.O., and Christopher V. Maani, M.D., have been given a unique opportunity to provide care to the severely burned soldier. This great responsibility requires a multifaceted anesthesia approach when treating this severely burned patient population. The majority of burn patients reaching the USAISR Burn Center are typically scheduled for their initial surgical procedure within 24 to 48 hours upon arrival. Patients have an average ASA Physical Status classification of 3 to 4 (82 percent of patients are ASA 3 or above, and 38 percent of patients are ASA 4 or above). Typically, patients have multiple traumatic injuries in addition to the severe burns sustained [Figure 1]. USAISR burn patients often present with difficult airways [Figure 2] and have a higher percentage of inhalational injury (10.3 percent with inhalational injury, compared to 5.7 percent of patients from the 2006 National Burn Repository report).¹ Scheduled operating room procedures reach an average estimated blood loss of 1.6 liters. This large amount of average estimated blood loss is due to operations utilizing multiple surgeons and physician assistants simultaneously excising the majority of burned skin during the initial surgical procedure. Aggressive resuscitation, acute and chronic pain management, advanced airway control, and maintenance of normothermia are the mainstays of perioperative medicine in the USAISR burn center. Long operating room times and long hospital stays are common at the USAISR Burn Center. During the 2006 fiscal year, average surgical times were 14 hours a day calculated over a five-day work week. Patients’ average length of stay was 18 days for all admissions (compared to 12.8 days for women and 11.8 days in men, from the 2006 National Burn Repository report).1 Large initial excision and grafting in the burn population decreases their ability to maintain core body temperature and predisposes them to coagulopathies. Therefore, patient rooms and the operating rooms must be kept between 85° F and 100 °F to avoid hypothermia. The extreme O.R. temperatures increase the risk of heat stress in O.R. personnel. The Occupational Safety and Health Administration defines heat stress as any process or job site that is likely to raise the worker’s deep core temperature — often listed as higher than 100.4 degrees F (38°C).²

At the USAISR, Dr. DeSocio and Dr. Maani are participating in research advancing the surgical and resuscitative care of the wounded warrior at the time of injury. Owing to their involvement in the Combat Casualty Care Research Program, Dr. DeSocio and Dr. Maani work with triservice anesthesia and surgical consultants from across the United States as well as with international consultants from military and federal medical services. From these partnerships, a global network of ideas for new product development in the arena of battlefield pain control and resuscitative medicine is being created. Use of the newly developed trauma registries and databases, along with video teleconferencing advancements, allow more efficient communication between anesthesiologists and surgeons from the USAISR, physicians from civilian and military medical centers within the United States, and deployed health care teams in Iraq and Afghanistan. Real-time video communication provides the benefits of following trends in battlefield injuries and earlier problem recognition for focused medical research. In addition, this creates a continuity of care for injured soldiers between medical corps physicians that was not recognized as possible in earlier military conflicts.

Another important responsibility for USAISR anesthesiologists is professional development and graduate medical education contributions. Teaching burn anesthesiology to residents is an important aspect of working in the USAISR. Anesthesia residents (PGY-2, PGY-3 or PGY-4) receive training in resuscitative medicine (crystalloid; colloid and blood product administration; and blood component replacement with thromboelastography and point-of-care laboratory testing); advance airway (retrograde wire intubations, awake fiberoptic intubations); and advanced venous access techniques, regional anesthesia with ultrasound-guided or nerve-stimulation techniques, and acute and chronic pain management. Early hands-on experience with critically ill patients and aggressive utilization of state-of-the art medical technologies (intravascular temperature management, continuous renal replacement therapy and automated intraoperative data acquisition) creates an ideal environment for maximal resident learning. For rotating anesthesia residents, developing a clinical platform of academic knowledge and technical skill is the primary goal.

Secretary of Defense Robert M. Gates meets wounded warriors during a tour of the burn rehab center at Brooke Army Medical Center in San Antonio, Texas, May 4, 2007. DoD photo by Cherie A. Thurlby.

The severely burned wounded warriors are one of the most challenging patient populations treated by physicians in the GWOT. In the face of difficult airways, poor I.V. access, hemodynamic lability-associated burn shock, hypermetabolic states, cardiovascular compromise often requiring multiple vasoactive infusions, multiple procedures and painful rehabilitation, these brave heroes maintain the attributes of professional military men and women by being physically and mentally tough, never accepting defeat and never quitting. Anesthesiologists in the USAISR strive for excellence in clinical-based medicine and combat casualty care research in order to provide the highest level of care to these American soldiers, sailors, airmen and Marines.

References:
1. Latenser B. et al. National Burn Repository 2006: A ten-year review. J Burn Care Research. 2007; 28(5):635-658.
2. Occupational Safety & Health Administration. Heat Stress. OSHA Technical Manual Section III, Chapter 4. www.osha.gov.
3. Brooke Army Medical Center Trauma Registry.

Peter A. DeSocio, D.O., is a staff anesthesiologist, U.S. Army Institute of Surgical Research and Army Burn Center; Assistant Faculty, Uniformed Services University of the Health Sciences, Department of Anesthesia; U.S. Army Institute of Surgical Research, Brooke Army Medical Center, Fort Sam Houston, Texas.

Christopher V. Maani, M.D., is Chief of Anesthesia, U.S. Army Institute of Surgical Research and Army Burn Center; Staff Anesthesiologist and Burn Anesthesia Clerkship Director at Brooke Army Medical Center; Assistant Faculty, Uniformed Services University of the Health Sciences, Department of Anesthesia; Staff Anesthesiologist, Wilford Hall Medical Center, Fort Sam Houston, Texas.