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Military residents now learn from wartime challenges

As they care for veterans and war wounded here at home, housestaff prepare for the possibility of being deployed

From the April ACP Observer, copyright 2006 by the American College of Physicians.

By Yasmine Iqbal

Landstuhl Regional Medical Center in Rheinland-Pfalz, Germany, is the largest American hospital outside the U.S.—and the first stop for soldiers and American civilians wounded in Iraq and Afghanistan. Earlier this year, it was also an invaluable training ground for Cpt. Patricia J. DeHaan, ACP Associate Member, a second-year resident based at Madigan Army Medical Center in Tacoma, Wash. Dr. DeHaan volunteered for a 26-day rotation at Landstuhl, serving as primary caregiver for 20 ICU patients.

She witnessed firsthand the advances in military medicine that now contribute to unprecedented high survival rates among wounded soldiers. She helped stabilize patients who had sustained blast and motor vehicle injuries.

"One of the main benefits of the rotation was the opportunity to care for trauma patients," Dr. DeHaan said, "and do more procedures, including central line and arterial line placements, intubations and bronchoscopies"—procedures that in her ICU rotation at Madigan would typically be covered by the surgical service. As a result, her comfort level with intensive care medicine has risen sharply. "Adjusting a ventilator or caring for someone in neurogenic shock is more comfortable for me now."

But the rotation did more than hone her clinical skills. It also helped prepare her for a possibility all military residents now face—post-training deployment to a war zone.

In the 11 internal medicine residency programs offered by the Army, Navy and Air Force, residents are learning more than medicine. They're also training to apply their skills under adverse conditions and in hostile environments as key members of medical teams treating war casualties. ACP Observer spoke with several residents and internal medicine program directors about how residents are being prepared—clinically and mentally—to be physicians in the military.

Specialized training

The Landstuhl rotation is only one of many unique training opportunities given to Madigan's residents, according to internal medicine program director Maj. Cecily K. Peterson, ACP Member.

"After their training, residents might be asked to do any number of jobs, from serving on a humanitarian aid mission to treating wounded soldiers, anywhere in the world," she said. "We need to train them to be flexible and ready to take on anything."

That breadth of experience is one factor that attracts residents to the military in the first place, according to third-year resident Cpt. Cristin A. Kiley, ACP Associate Member, a member of the College's Council of Associates who is stationed at Madigan.

Her residency so far has included field-training drills that simulate mass casualty events as well as in-depth courses on malaria and leishmaniasis, a disease spread by sandflies that affects many soldiers returning from the Middle East. "There are many areas, like tropical disease medicine and combat casualty care, where we're expected to know more and do more than our civilian counterparts," she said.

In the Air Force, internal medicine residents learn to be part of critical care air transport teams, which are like medical SWAT teams that will fly anywhere in the world on a moment's notice to retrieve seriously injured patients. At the same time, Air Force residents—like Associates in other military branches—also learn about specific injuries they might see in wartime.

"When we're discussing kidney failure, for instance, we'll include a segment on crush injuries and how they can cause kidney failure," said Col. Thomas C. Grau, FACP, program director at Wilford Hall Medical Center in San Antonio, the Air Force's largest medical facility. "We're always looking for ways to weave preparedness into the curriculum."

Army and Air Force residents have "continuous contracts," which means they can't be deployed before they complete their residency. Navy residents, however, can be deployed for a one-year general medical officer (GMO) tour any time after their first year.

Lt. David M. You, ACP Associate, a second-year resident at the National Naval Medical Center in Bethesda, Md., did a one-year GMO tour in Okinawa, Japan, serving as primary physician for 600 Marines. He provided everything from basic physicals to emergency medical care, treating in one harrowing day three Marines with acute appendicitis who needed to be medevaced to a nearby hospital.

The GMO experience was "initially overwhelming," he said, "but then you realize that your training has given you a good knowledge base, and you have ancillary staff to help you." In fact, it was only after his GMO tour that he started considering a long-term Navy career. "The camaraderie of the military really helped influence my decision."

Treating the wounded

For most of their residency, military Associates treat veterans and their families. However, those who do rotations or complete their residency at large military hospitals, such as the National Naval Medical Center and the Walter Reed Army Medical Center in Washington, also treat war casualties.

Advances in military medicine have now led to record high survival rates. According to the Jan. 22, 2006, New York Times, for example, between seven and eight solders survive injuries for every soldier killed in Iraq, compared to only two survivors per death in World War II.

Those survival rates are being driven by technological advances, both in the war zone and at subsequent treatment centers. Battlefield advances range from clotting agents that help control bleeding moments after a soldier has been injured to surgical procedures that help save limbs that would have been amputated just a few years ago.

According to Dr. DeHaan, interventions that help wounded soldiers arriving at Landstuhl include prompt initiation of tube feeds with high protein nutrition in intubated patients, as well as operating rooms right across from the ICU and reliable access to CT scans taken at the theater hospital.

Her Landstuhl rotation also immersed her in a broad multidisciplinary team. "Our daily rounds consisted of a team with a number of specialties: intensive care; vascular, general, trauma, orthopedic and neurosurgery; infectious diseases; respiratory therapy; and nutrition and nursing," she said.

The experience of caring for young soldiers with severe injuries, particularly patients who had become paraplegics because of head and spinal cord injuries, can be emotionally taxing. "But the more you do medicine, the more you're able to handle these things," Dr. DeHaan said, "and the more you appreciate the sacrifices these soldiers make."

Cpt. Paige E. Waterman, ACP Associate Member, who will be chief resident at Walter Reed next year, said that partly because her patients are so young, she and her colleagues are constantly "putting ourselves in their places, thinking what we would do and what we would want if we were them."

Residents have access to informal and formal support systems, including psychiatric counseling, to help them deal with such stresses, noted Col. Gregory J. Argyros, FACP, Walter Reed's program director and Governor for ACP's Army Chapter. "We try to let residents know that it's normal to identify with their patients, and they'll be better off talking about their feelings rather than keeping them inside."

Often the patients themselves provide emotional ballast for their physicians. "They're working so hard to get well," said Dr. Kiley, "that you don't have time to feel overwhelmed or upset."

Preparing for war

Every military resident knows that as long as the conflicts in the Middle East continue, eventual deployment to a war zone is a near certainty.

To help prepare them clinically, "we have continued to rotate our internal medicine residents through the surgical intensive care unit at [the civilian facility] Washington Hospital Center to expose them to trauma victims," said Dr. Dwyer, who pointed out that internal medicine civilian training programs offer only medical intensive care rotations. "That exposure will ready them for when they are on the frontlines of trauma."

Programs also give residents the opportunity to air their concerns about deployment with mentors and provide plenty of access to physicians who have recently returned.

"All residents struggle with the fear of the unknown," said Capt. Terrence X. Dwyer, FACP, program director at the National Naval Medical Center. "It's tough not knowing whether, six months from now, you might be in Iraq." According to Lcdr. Timothy M. Quast, MD, the chief resident at Bethesda Naval, residents seek him out almost every week to talk about their deployment concerns. "They all wonder, 'How am I going to do this?,' especially if they have families to consider."

Talking with physicians who have been to Iraq can help calm those fears. "Every physician whom I've heard speak about deployment has had a positive experience," said Capt. Melissa M. King, ACP Associate Member, a third-year resident at Wilford Hall. "They say they form a strong bond with each other, and they felt good about what they were doing over there."

Dr. Grau noted that most residents see deployments as part of the job. "The thing that they worry about most, however, is multiple deployments, and the impact on their families," he said. In fact, multiple deployments might become more common if the military's struggle to recruit new physicians continues.

In October 2005, military officials told an armed services subcommittee that for the first time since 2000, the Army did not meet its goals for health professional scholarship applicants in the medical and dental corps. The Air Force is also working to recruit and retain physicians.

Long-term plans

Residents say that there are plenty of reasons to leave the military after they fulfill their service, which typically means a commitment after residency of four years' service or less. (Residents may have to commit to a longer term if all or part of their education was funded by the military.) Civilian practices offer higher pay, particularly for residents who subspecialize.

But there are many incentives to stay. Dr. King cited one big difference in the population she treats vs. that of her civilian colleagues: She doesn't have to consider their ability to pay. "I don't have to worry that my patients are skipping their medications or not returning for follow-up visits because of cost," she said.

Dr. Kiley, whose commitment will end in 2013, feels she's following a family tradition—her father is still an active-duty Army obstetrician—and she appreciates the military's camaraderie.

"The Army is a small place," she said. "Many of our mentors at Madigan did their residencies here, and all the residents really get to know and support each other. That makes a difference in patient care." It also makes a difference in job satisfaction, she added.

"It's an honor to take care of wounded soldiers and military veterans."

Yasmine Iqbal is a freelance health and science writer in Philadelphia.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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