The Combat Hospital ICU

Abstract

You have just finished your morning team ICU rounds on a mix of nine critically US and host-nation trauma patients. A tenth US casualty with multiple gunshot wounds to the chest and abdomen rolls in after a damage control laparotomy. He had become pulseless in the ED trauma bay during his initial evaluation, so he underwent an emergency thoracotomy and aortic cross clamp and was immediately taken to the OR while undergoing multiple blood transfusions. In the OR, he received over 40 units of products (PRBCs, FFP, PLTs, Cryo, whole blood) as well as a dose of TXA. The liver was packed and the abdomen left open with wound VAC placement. The patient is on high-dose norepinephrine and epinephrine and acidotic. Post-op ROTEM looks like a champagne flute.

Civilian Translation of Military Experience and Lessons Learned

• Matthew J. Eckert 

Key Similarities

• 1. The multidisciplinary intensive care unit team is the hallmark of modern critical care, led by specialty-trained critical care physicians.

• 2. Bundled pathways, practice guidelines, and protocolized management help ensure that the details of complex critical care are not overlooked during periods of high unit census, increased acuity, and staff turnover or that these practices become provider dependent.

• 3. Multisystem organ support with the goal of reestablishing homeostasis in the body remains the underling concept in critical care.

• 4. Critical care is a practice, not a place.

Key Differences

• 1. Civilian ICUs are more likely to have a greater depth and variety of subspecialty consultants available to assist the primary ICU attending.

• 2. Extensive resources such as mechanical ventilators capable of salvage modes of ventilation, ECMO , hemodialysis, and seemingly endless pharmacy options are frequently found in civilian ICUs.

• 3. The civilian ICU patient is much more likely to have chronic medical conditions that may greatly influence the complexity of illness and level of support required.

• 4. While the combat ICU faces immense challenges in patient acuity, most patients are rapidly evacuated to a higher level of care. The civilian ICU may care for critical patients over prolonged periods, through numerous rounds of organ failure and/or complications; thus, throughput becomes secondary to completion of care in the civilian world.

In this chapter Dr. Chung provides a concise and timely description of the contemporary practice of critical care medicine across the recent conflicts in Iraq and Afghanistan. The descriptions of ICU team compositions and particularly the strengths and weaknesses of various ICU models in numerous combat support hospitals attest to the fact that no two ICUs are identical, in military or civilian hospitals, but some function better than others. Dr. Chung’s emphasis upon a multidisciplinary approach, scalable in size based upon patient volume and acuity, and a team emphasis are key principles for any critical care setting.

Civilian critical care practice spans a wide spectrum of resource availability from community and critical access hospitals to major university settings. Many university medical centers today have numerous subspecialty ICUs organized around a particular body system or specialty of medicine. Huge multidisciplinary medical teams provide around-the-clock care utilizing cutting-edge monitoring equipment and the newest and best treatments and medications, with seemingly endless options for a patient’s failing organs. Despite the obvious differences at the surface between the combat support hospital ICU and the major medical center ICU, the principles of critical care medicine are the same, regardless of location .

One of the key concerns in any ICU setting is ensuring clear, timely communication and continuity of care. Dr. Chung describes the challenges in managing numerous critically injured patients and the constant planning and consideration of interventions and treatments in the face of impending evacuation from the combat zone. While evacuation is likely to be less of a concern in the civilian ICU, continuity of care and communication among multiple consultants and teams contributing to the overall care of the patient represents a continuous challenge. Development of electronic communication tools, checklists, patient tracking mechanisms, and formalized rounds and meetings between contributing services are required to avoid iatrogenic injury and ensure all team members have a similar plan of care in mind. Even with all of these mechanisms to help ensure adequate communication, frequently details are missed and complications or derailments in efficiency occur, hence the importance of a supervising critical care professional who is overall responsible for coordinating care and adjudicating decisions in management when divergent opinions arise .

While the combat ICU may face resource limitations routinely, the civilian ICU often has the opposite problem: endless resources and a compelling desire to “do everything and anything possible.” Despite the increased relevance and consciousness of cost and resource utilization, civilian ICU patients frequently enter a pipeline of seemingly endless interventions, moving from one treatment to another, even if the possibility of a functional recovery is slim. Defining goals of care in the civilian ICU help the medical team, patient, and family achieve the most effective, efficient, and humane care possible. These considerations are more pertinent to the patient with chronic or end-stage medical conditions but may be relevant to any patient with an overwhelming burden of injury or disease.

Finally, one unique and rarely discussed concern in any ICU is the emotional, mental, and physical effects that burden ICU staff, particularly in periods of high acuity and volume. Often, ICU nurses, physicians, and team members will suppress the stress, anxiety, and emotional effects as long as possible, placing their own health last. The “health” of the team must remain a concern, despite our altruistic intentions, or else collective detrimental effects can bring down the effectiveness of the ICU team. Frequently, the supervising intensivist is blind to the early signs of stress in the team or individuals or in himself or herself. The routine presence of a pastoral care professional can provide an objective evaluation and be an essential member of the team when stress begins to accumulate. Recognizing the signs of these effects is critical before the development of interpersonal conflict, communication breakdown, compassion fatigue, loss of attention to detail, and serious self-harm. The overall goal is the health of the patient, but without a healthy multidisciplinary team, that goal cannot be achieved.