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Landstuhl, Germany, and Hospitals in the Continental United States

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Landstuhl, Germany, and Hospitals in the Continental United States The Home Base: Landstuhl, Germany, and Hospitals in the Continental United States Chapter 50 THE HOME BASE: LANDSTUHL, GERMANY, AND HOSPITALS IN THE CONTINENTAL UNITED STATES † CRAIG C. MCFARLAND, MD,* AND CHRISTOPHER J. SPEVAK, MD, MPH, JD INTRODUCTION LANDSTUHL REGIONAL MEDICAL CENTER History Current Capabilities Specialty Services MILITARY HOSPITALS IN THE UNITED STATES Military Medical Centers Institute of Surgical Research Military Medical Activities Veterans Affairs Medical Centers SUMMARY *Lieutenant Colonel, Medical Corps, US Army; Chief, Department of Anesthesia and Pain Management, Landstuhl Regional Medical Center, Division of Surgery, Building 3711, CMR 402, APO AE 09180 †Professor of Clinical Anesthesia, Georgetown University School of Medicine, 3900 Reservoir Road, NW, Washington, DC 20007 561 Combat Anesthesia: The First 24 Hours INTRODUCTION Before leaving the combat theater, injured soldiers provides a robust healthcare system capable of are surgically stabilized, although considerable definitive care for all of the combat casualties who surgery usually remains to be done. In the typical survive to evacuation from the combat theater. This combat-wounded veteran, most restorative surgical system is also supported by a small number of ci- procedures are performed at Role 4 facilities. The vilian or Veterans Affairs (VA) medical centers that network of US military hospitals in the continental provide unique or specialty care for some soldiers United States, as well as in Landstuhl, Germany, (based on need). LANDSTUHL REGIONAL MEDICAL CENTER History (which includes Iraq and Afghanistan), African Command (AFRICOM), and European Command Located in southwestern Germany in the state of (EUCOM) areas of responsibility. Since the Cold War Rheinland-Pfalz, Landstuhl Regional Medical Center ended, medical capabilities have been consolidated (LRMC) is the largest American military medical center at LRMC because 23 other hospitals in Europe have outside the United States. The US Army has main- closed, making LRMC the sole US tertiary referral tained a hospital presence in the town of Landstuhl facility for military forces, their families, and other since November 28, 1951, when the 320th General beneficiaries in EUCOM, CENTCOM, and AFRICOM. Hospital took over operational control from an existing EUCOM alone comprises 245,000 beneficiaries (Table German military hospital. Soon thereafter, construction 50-1). In addition to being a tertiary referral center, began on a new hospital, and the 320th General Hos- LRMC is a primary care facility serving 100,000 pital moved patients into the new facility on March 9, beneficiaries, with the remaining 145,000 EUCOM 1953. This hospital has been continuously operational beneficiaries receiving primary care at outlying clin- since that day, although the name has changed three ics. The specialties represented at LRMC are myriad. times. It was renamed the 2nd General Hospital in In addition to the surgical specialties listed in Exhibit 1954 and Landstuhl Army Medical Center in 1994. 50-1, many medical specialties and ancillary services In November 2003, it was redesignated Landstuhl are offered, including addiction treatment, nutrition Regional Medical Center. care, physiatry, physical and occupational therapy, Throughout its history, LRMC has been a key medi- and social work. cal resource for the European theater and the Middle The specific capabilities of each of these services East. Among the service men and women treated at tend to be weighted toward military combat care Landstuhl were the Marines injured during the 1980 hostage rescue attempt in Iran and in the 1983 Beirut barracks bombing, as well as 500 casualties of the 1988 TABLE 50-1 disaster at the Ramstein Air Show.1 In the post-9/11 era, the bed capacity at LRMC was A TYPICAL DAY AT LANDSTUHL REGIONAL expanded by almost 50%. The greatest expansion was MEDICAL CENTER (BASED ON AVERAGES a tripling of the intensive care unit beds from 6 to 18, FROM DECEMBER 2009 TO NOVEMBER 2010) and an increase in the number of inpatient psychiatry beds, from 12 to 22. A smaller increase was seen in the Admissions 25 number of medical-surgical beds (now 74). There are Outpatient visits 2,908 eight main operating rooms, two obstetric operating rooms, and two urologic operative procedure rooms. Operating room cases 31 From January 1, 2004, through January 5, 2011, LRMC Intensive care unit census 9 treated 64,892 patients, returning 20.9% back to duty Laboratory services 2,396 within Central Command (CENTCOM). Radiology services 789 Current Capabilities Births 3 LRMC’s top priority, as published by the com- Pharmacy products 1,297 mander at the time of this writing, is casualty reception Meals served 1,769 for wounded warriors from across the CENTCOM 562 The Home Base: Landstuhl, Germany, and Hospitals in the Continental United States Specialty Services EXHIBIT 50-1 Because penetrating and blast injuries to the eye are LANDSTUHL REGIONAL MEDICAL common in combat trauma, ophthalmologists have CENTER SURGICAL SPECIALTIES active roles in maintaining or restoring eyesight to injured service members. The ophthalmology service • anesthesiology/pain clinic providers perform initial, mid-term, and long-term • otolaryngology management of all anterior segment trauma, and mid- • general surgery term and long-term management of vitreoretinal and • plastic surgery orbital trauma; that is, they can perform initial globe • hand surgery repair, but subsequent vitreoretinal surgery is sent to • podiatry a local hospital if urgent and deferred until arrival in • neurosurgery • spine surgery the United States if not urgent. Routine nontrauma • obstetrics/gynecology cases include all commonly performed refractive sur- • trauma geries, cataract surgeries, strabismus, and oculoplastic • ophthalmology procedures. The LRMC ophthalmology service typi- • urology cally receives one to eight telephone calls or emails • oral surgery daily from optometrists, primary care physicians, and • thoracic surgery physician assistants in the combat zone via an Army • orthopedics Medical Department telemedicine site. In addition, providers participate in a monthly teleconference with forward-deployed and stateside sites to discuss cases. LRMC has dedicated an extracorporeal membrane needs to a greater degree than most civilian or stateside oxygenation (ECMO) team to support cases of devas- facilities of similar size. For example, the LRMC neu- tating lung injuries. The team consists of physicians, rosurgical service is geared to provide state-of-the-art intensive care nurses, and respiratory technicians who care for complex spine injuries and traumatic brain have undergone specific ECMO training. Although the injuries, but is more limited in its ability to care for majority of ECMO cases have been initiated at LRMC, intracranial vascular cases and tumors due to imaging there have been several ECMO cannulations in the limitations and an absence of interventional neurora- combat theater, with ECMO care continuing during diologists. Urgent cases that require such services are evacuation to LRMC. The first ECMO cannulation in immediately transferred to local German hospitals the combat theater was performed in Kandahar in Oc- with these capabilities. tober 2010. Regardless of where ECMO is initiated, the The consultants at LRMC and stateside medical ECMO team cares for the injured service member until centers frequently interact with medical staff in the he or she arrives at University Hospital Regensburg, combat zone, either as part of a formal consultation a German facility with significant ECMO expertise. program or an informal peer-to-peer communication. Because of its role in the care of combat casualties, For instance, primary care physicians examining LRMC is also actively involved in the organ donation an uncommon skin lesion can take a digital photo program with its European counterparts.3 and email it, along with a case description, to derm. The vast majority of US patients received from the [email protected]. A telemedicine administrator combat theater spend only a short time at LRMC before at Fort Sam Houston in San Antonio, Texas, screens continuing their journey to the United States. There are the request and sends it to a dermatologist on call at typically three scheduled air evacuation/critical care LRMC or one of the stateside medical centers, who will air transport team flights to the United States from then send recommendations back to the originating Germany per week, and there is capability to “spin up” doctor within a few hours. This process allows many additional flights, if necessary. Thus, the average US service men and women to avoid unnecessary travel combat surgical patient receives one to two surgeries within or from the combat theater,2 and it is available at LRMC. The destination of patients departing from for many other specialties. Modern communications LRMC is determined by several factors, such as type also support peer-to-peer communication between of injury (eg, all major burns go to the burn center in surgeons in the field and LRMC receiving surgeons. San Antonio; see Institute of Surgical Research, below), This exchange has facilitated LRMC surgical teams location of the service member’s unit, the location of in anticipating the logistical and medical needs for a the service member’s family, and potentially by the patient before his or her arrival. available bed space at stateside hospitals. 563 Combat Anesthesia: The First 24 Hours MILITARY
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