Out of Afghanistan
Soldiers Take Circuitous Route to Medical Care

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ARMY SGT. RICARDO PADRON was on duty in Afghanistan when the fingers on his left hand were almost severed by a knife during what this necessarily secretive special operations service member will only describe as an “accident.” Although his injury occurred in Afghanistan, his treatment crossed three countries and thousands of miles, ending in the US at his home base of Ft. Campbell, KY, where he is now in rehabilitation to recover use of his fingers.

Padron is one of more than approximately 1,000 service members and government workers who have been flown out of Afghanistan because of serious injuries received in combat or in nonbattle-related incidents. The crucial stop along this medical route is Landstuhl Regional Medical Center (LRMC) in Germany — the largest American medical facility outside of the US.

“We’re the catcher’s mitt for all of Europe, northern Africa, and southwest Asia, and for contingency operations like Operation Enduring Freedom (OEF),” says Col. David Rubenstein, the medical center’s commander. “All OEF patients come here. We’ve received Afghans, Bosnians, Canadians, Brits, Norwegians, Australians, as well as Army, Air Force, Navy, CIA, and State Department [personnel], a fascinating mix in this particular operation.”

LRMC receives four to six flights a week of service members with nonbattle-related injuries from Afghanistan, plus any wounded service members from combat or military accidents that occur in the mideast country. The medical route out of the war on terrorism’s front lines to Landstuhl can be circuitous, with patients receiving higher levels of military medical care at different points along the route. That care might be provided by Army, Air Force, or even Navy nurses, physicians, or medics stationed at different strategic locations. The level of care received varies from basic first aid to sophisticated intensive care in aeromedical evacuation aircraft.

It Begins on the Battlefield

This chain of care begins at the place the injury, illness, or accident occurs in Afghanistan. The service member, if conscious and capable, provides initial first aid, or self-care, to himself if no one else is around to help him.

Padron, a medic for the New York City Fire Department in the Bronx, was more qualified than most to treat his own injury. He applied a pressure dressing to his fingers and irrigated the wound with normal saline. He used the saline to further cleanse the area because he was planning on suturing it himself, he says. But he quickly noticed the blood vessels had been cut and he was losing feeling in three of his fingers.

Had Padron not been a medic, his care would have proceeded to the second step in the chain — buddy care — supplied by a fellow service member until a unit medic arrives. Buddy care essentially consists of more first aid.

When a unit medic arrives at the patient’s side, he or she administers more advanced care, such as starting an IV line for fluid replacement or giving pain medication. At this point, the goal is to evacuate the service member out of the battlefield to the nearest military medical unit. This can be done by aeromedical evacuation by a military plane or a helicopter or by a land vehicle, depending on the location of the aid station and the severity of the injury. The medical unit might be a specialized mobile Air Force or Army medical team.

Because special forces’ medics have advanced medical training, Padron was first taken to his unit’s makeshift hospital. The hospital is run by medics, who determined Padron needed more complicated surgery than they could provide. Special forces medics function like physician’s assistants or surgical assistants and are capable of doing advanced medical procedures.

Padron was transported to an Army forward surgical team (FST) at Bagram Air Base in Afghanistan, where a surgeon operated on Padron’s hand and, as he describes it, “saved my fingers.”

A Stop in the Desert

The ultimate goal of military medical care is to return service members to their units. But if the injury or illness requires more extensive care, follow-up, or rehabilitation than a military field hospital can provide, the service member is flown to Germany. However, en route from Afghanistan to Germany there usually is another interim mideast stop first. Padron was was flown by an Air National Guard unit to an Air Force base in Oman where an Air Force expeditionary medical support team (EMEDS) is located. His wound was cleansed and the dressing changed. Patients may also be flown to other locations, such as Turkey or Uzbekistan.

Welcome to Landstuhl Regional Medical Center

Hospital staff refer to patients flown in from Afghanistan as OEF patients. An OEF patient who does not require intensive care is usually given a bed on the 43-bed medical/surgical unit 14 CD. By the time patients reach Germany, they have received care at one or two field hospitals and are medically stable, says Lt. Claude Fourroux, RN, a staff and charge nurse on 14 CD. They are ready to begin physical and occupational therapy before being sent to a larger medical facility, such as Walter Reed Army Medical Center.

However, like Padron, some patients may require more sophisticated surgery. At Landstuhl, a vascular surgeon and a hand surgeon reattached the nerves and tendons in Padron’s fingers. Padron underwent two weeks of intensive occupational therapy and was transferred to Ft. Campbell.

Many of the injuries resulting from combat include traumatic amputations, fractures, burns, and shrapnel wounds. There are also nonbattle-related injuries from landmine explosions, motor vehicle accidents, and hard helicopter landings. Some of these injuries would not ordinarily be seen in civilian medicine, even in a big city hospital.

“I’ve seen gunshot wounds at Madigan (Army Medical Center in Washington state), but the damage inflicted by blast injuries is horrendous,” says Capt. Gregory Hubbs, RN, BSN, a certified critical care nurse in the ICU. “You would never see muscles just left on bones the way they are in traumatic amputations.”

Psychological Needs Not Forgotten

The medical staff is also acutely aware service members injured in combat may need more than just physical care. Service members and their families are supported in many ways from the moment they arrive at Landstuhl, from providing them free phone services and e-mail to offering support from psychologists and chaplains.

Often, service members who have been in battle together have not had a chance to talk with their fellow service members until they have arrived at Landstuhl, says Army psychologist Lt. Col. Sally Harvey, chief of psychology services at LRMC. “When they are ready, we try to get them together in a group,” she says. “Often it’s the first chance they’ve had to fill in the gaps.”

Harvey, Air Force psychologist Maj. Linda Broeckl, and the hospital’s chaplains are unobtrusive and make sure the service members’ basic physical and emotional needs, such as pain relief and contact with family, are met first before approaching them about their battle experiences, she says.

The nursing staff, says Harvey, is highly trained and critical to providing emotional and psychological support to battle-wounded service members. Air Force Lt. Tina Hall, RN, who arrived at LRMC in September before the attack on the World Trade Center, says, “They are doing something great, and we try to give them whatever they want.”

Walter Reed Army Medical Center — The Last Stop

Col. Jean Dailey, RN, MSN, chief of the surgical/neuroscience nursing section, is notified ahead of time when OEF patients from Landstuhl are being transferred to Walter Reed Army Medical Center in northwest Washington, DC, to continue their treatment and rehabilitation. A team of nurses, physicians, psychologists, social workers, and occupational and physical therapists are prepared to meet any physical or psychosocial needs service members may have.

Before a wounded service member arrives at Walter Reed’s wards 57 (orthopedic/physical medicine and rehabilitation) or 58 (neuroscience — neurology and general surgery), Dailey learns what military unit the service member is from and the service member’s current medical status. She also reviews the care the service member has received at Landstuhl and if the service member’s family has any special needs, such as lodging in the area or transportation.

As at Landstuhl, service members who have been injured in a combat situation are grouped together on a unit to provide added moral support, says Dailey.

Many of the combat injuries service members receive are to the limbs because bullet-proof body armor has reduced injuries to the abdomen. Almost every service member (about a dozen) who has lost a limb from combat injuries in Afghanistan has received care at Walter Reed, which has gained a national reputation in this speciality. It has one of only two on-site prosthetic laboratories at Army hospitals and has about 600 outpatient visits a year.

OEF patients are high profile guests at Walter Reed — the Army’s premier hospital. Deputy Commander for Nursing Patricia A. H. Saulsbery, RN, and medical center commander Maj. Gen. Kevin C. Kiley, MD, are briefed on a regular basis about OEF service members’ treatments and conditions. These patients also have high profile visitors, from Atlanta Falcon’s quarterback Chris Chandler, who visited a wounded service member with the same name, to Sen. Hillary Clinton to the Army’s chief of staff Gen. Eric Shinseki, who awarded medals to some service members.

2nd Lt. Ron Stephens, RN, a staff nurse on ward 58, says as an Army nurse he is grateful to the service members for whom he has cared. “I’ve learned the real price of freedom,” he says.

Service members in turn are thankful for the military medical care they receive, whether at Landstuhl, Walter Reed, or small Army hospitals throughout the country. Of the military medical treatment he underwent, Padron says, “The care I received from beginning to end was amazing. I can’t begin to thank the people involved for saving my hand. I will always be indebted to them.”

Janet Boivin, RN, is editorial director of the Greater Chicago/Tri-State edition of Nursing Spectrum.

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