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Fri Aug 4 17:13:56 BST 2006

Mike,

Some months back, an Army Major appeared on the Opra Winfey show and
detailed his experiences in Iraq, specifically the medical care he
received after sustaining a devastating injury to his right arm from an
IED explosion.  His brachial artery was divided/destroyed, his humerus,
radius and ulna were badly fractured, and the only reason why he
survived long enough to reach medical care was because his medic applied
a fiend tourniquet.

This Major was brought to the 912th Forward Surgical Team, the unit
that I joined about on month after he was injured.  At that time the
912th FST was staffed by three "general/trauma" surgeons and one
orthopedic surgeon.  These 3 surgeons were a colorectal surgeon, a
pediatric surgeon, and a VA general surgeon.  None were vascular
trained, and like you described, had done no vascular surgery since
their residencies, and the most recently graduated of the 3 was 6 years
previous.

To make a long story short, this team of surgeons reconstructed the
artery with a dacron graft, and ex-fixed the orthopedic injuries (to the
point where there were no further interventions needed down the line). 
The soldier was then evacuated to the CSH, and then back to CONUS. 
Major White has since returned to full active duty status, and has been
promoted to LTC.

My hat is off to LTC's Cataldo, Danielson and Feldman!! 

"Some of the best work is by general surgery trained trauma surgeons
with an interest is vascular."

Nuff said!

Ron Gross
COL, USAR, MC, (Ret - for now....)

>>> "Sise, Mike MD" <Sise.Mike at scrippshealth.org> 8/4/2006 10:52 AM
>>>
To my colleagues,

I help teach TRACS, a refresher advanced trauma surgery course for Navy
Surgeons headed to Iraq and Afghanistan. Many of the attendees have
already done  a tour there and I always learn from their experience.
This week we had an interesting discussion on vascular repairs. All have
and will have to treat complex vascular injuries. They have taught us
much about damage control and evacuation with the use of shunts.
However, there is a basic question always faced by the combat surgeon
who hasn't done an unsupervised vascular repair since his or her
residency - What should I take on? 

I've recommended two somewhat conflicting suggestions. 1. Try to do
only what you are comfortable and capable of doing - fix 'em if you can,
shunt 'em if you can't - and - 2. Dirty Harry's law - A man's (women's)
got to know his (her) limitations - with Sise's corollary - When you're
all alone, the sky's the limit - take your best shot.

In our civilian trauma centers in our community and, I suspect, around
the US there is no standard approach to who should repair injured
vessels. Two of us on our trauma panel are also board certified vascular
surgeons with a small elective practice and we cover all of our center's
vascular injuries. At the same time, some of the worst errors I'm asked
to review from out of town are the tragedies perpetrated by "elective"
vascular or cardiovascular surgeons. Some of the best work is by general
surgery trained trauma surgeons with an interest is vascular.

Who should perform vascular surgery for trauma and how do we insure
quality coverage for our patients?

Mike Sise
Scripps Mercy Trauma

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Who should perform vascular surgery for trauma?