Vol. 16 •Issue 9 • Page 36
Burning Beacon of Hope
RTs hold a prominent place within the military’s premier burn unit.
Many a Texan badly burned from a car crash, house fire, or barbeque accident is alive and well, thanks to swift and soothing care at the U.S. Army Institute of Surgical Research Burn Center in San Antonio.
In these troubled times, though, another type of patient more frequently visits the burn center, located on the fourth floor of Brooke Army Medical Center at Fort Sam Houston.
Since 2003, more than 600 patients have been admitted to the burn center with war-related burn injuries. About one-third of those patients were air evacuated by the center’s Special Medical Augmentation Response Team-Burn, which includes physicians, registered and licensed vocational nurses, an operations non-commissioned officer — and respiratory therapists.
“You see guys coming back from overseas with multiple trauma,” said Staff Sgt. Anthony Rakofsky, CRT, one of 15 military RTs on staff in the burn center. “You’re seeing it all in one patient: head injuries, amputations, burns.”
When terrorists succeed in detonating an improvised explosive device (IED), anyone in the vicinity not blown apart by the blast can still suffer acute tissue damage, blunt trauma from flying fragments, tertiary injury from the violent pressure forces, crush injury from structures collapsing around them, flash and flame burns, and inhalation injury.
Inhalation injury from IEDs can cause pulmonary complications such as hemothorax, pneumothorax, pulmonary contusion and hemorrhage, fistulas, airway epithelial damage, aspiration pneumonitis, and sepsis.
“Many times, an inhalation injury complicates recovery from the severe burn,” said Lt. Col. Maria L. Serio-Melvin, head nurse of the acute care burn ward/step-down unit and former burn ICU and flight nurse. “It’s hard to describe how sick these people are.”
Only unit of its kind
The burn center in San Antonio is the only unit of its kind within the U.S. Department of Defense.
“We have 16 dedicated burn ICU beds,” Serio-Melvin said. “You won’t find that in any other burn center in the U.S. or in the world.”
The facility has an additional 24 beds in an acute care burn ward/step-down unit.
The burn center staff can care for up to 40 burn patients at one time. An outpatient burn clinic follows these patients for years to come.
Ventilator management volume is about six vents a day, according to another military RT, Staff Sgt. Gabriel Wright. “Some days we have none; other days every single bed has a vent, and you don’t have a chance to eat, chart, or anything else,” he said.
Wright and Rakofsky are two of the six RTs on the flight team. They’re on-call 24/7 and ready to fly at any time. “You could be in line at the grocery store or out to dinner,” Serio-Melvin said. “You have to stop everything and prepare to go overseas. You could be gone over a week.”
When the call comes in that one or more soldiers are wounded in Iraq or Afghanistan, the burn center’s transport team arranges to leave the U.S. on a commercial flight to Landstuhl Regional Medical Center in Germany.
Meanwhile, on the other side of the Atlantic, a critical care air transport team takes the wounded soldiers from the combat field to Landstuhl, timing it so they arrive at the same time as the San Antonio team.
Once the two teams meet at Landstuhl, “the waters part, and we take over,” Wright said.
First order of business: RTs use fiberoptic bronchoscopy under the supervision of the team’s physician to gauge the severity of a soldier’s inhalation injury.
Cleared for flight
Determining if a burned soldier is OK to fly demands exquisite care — and a high index of suspicion. For one thing, a patient’s PaO2 needs to be a minimum of 100 mm Hg on 50 percent FiO2, minimum.
“We look at the patient’s arterial blood gases to see if he or she has any metabolic or respiratory issues,” said Wright, who has flown on five rescue flights so far. “We transport them on the military’s transport pressure ventilator. We must do a trial on them for 30 minutes and get an ABG to see how well they can tolerate the vent.”
Depending on the severity of the inhalation injury, the pressure ventilator may not suffice. RTs may have to put patients on high-frequency percussive ventilation on the aircraft to get the wounded warriors home. Also, the team only uses heat moisture exchangers up in the air, not humidifiers.
Once the Air Force flight surgeon approves a patient for flight, the team evacuates the patient back to San Antonio.
They set up a portable ICU on the back of an Air Force cargo plane. All the equipment comes from Texas: IV pumps and fluids, vents, monitors, drugs, dressings.
“The team very much relies on RTs’ expertise as to what needs to happen,” Serio-Melvin said. “They are supporting a critically ill patient for 12 hours over the Atlantic Ocean, maintaining the same quality of care as if they were in an intensive care unit in a hospital.”
Prolonged stay in Germany
Most times, wounded warriors are back in the U.S. and reunited with their families in about 72 hours.
“It takes three days, on average, for patients to arrive at San Antonio after being wounded, compared to Vietnam, where it was weeks or months before they could come home,” said Rakofsky, who has been on four transport flights.
Sometimes, though, due to complications, RTs may be forced to remain in Germany for up to nine days. In these cases, they stay in close contact with hospital personnel at Brooke Army Medical Center.
“That stay in Germany can result for many reasons,” Rakofsky said. “It may be due to circulation problems, their oxygen requirements, pain control. There are certain criteria patients must meet to be cleared for travel. Also, if we have another burn patient, we may just wait there and pick up that other patient. Our ultimate goal, though, is to get patients back and reunited with their families as soon as possible.”
One patient was burned over 85 percent of his body and also had an inhalation injury, Wright recalled. On the February flight mission back to San Antonio, the heater broke, and the temperature dropped into the 30s. The team didn’t have winter gear, so they put sleeping bags around the patient to keep him warm.
“Your skin regulates your temperature,” Wright said. “Once it is destroyed, the patient can go into hypothermia very easily. É You must be able to think on your toes up there because there is no backup. You must know your stuff.”
Currently, the patient is stable and recovering on the acute burn ward/step-down unit.
Back in San Antonio
Once the team and the patient land at San Antonio International Airport and arrive at Brooke Army Medical Center via ambulance, they hand off the patient to the other burn center RTs, and they continue on with the mission. They’ll do another fiberoptic bronchoscopy of the patient’s airways to reevaluate.
Then the patient is taken to the shower to wash and clean his wounds, a process that can last two to three hours. It’s not uncommon for that shower to reach 100 degrees.
“RTs are right there with nurses, watching the airway and making sure the vent is working,” Serio-Melvin said. “They are the specialists. We call these guys to come and help us troubleshoot.”
For example, someone with badly burned epithelial cells of the airway sometimes gets multiple bronchoscopies a day to remove mucous plugs. “We hook these guys up on vents with end-tidal CO2 monitors, to monitor their EtCO2,” Wright said. “With burn patients, it should be in the high 30s, low 40s. If it’s elevated, they may have a plug and need suctioning or another bronch.”
Also, sloughing tends to dry out the airway. Patients may need a device to allow high flows of warmed and water-saturated breathing gases to be delivered by connecting the high flow device into the ventilator circuit.
“With sloughing, the ET tube or trach itself could get plugged up, so we nebulize heparin to help with this,” Wright said. “It’s a constant process; you need to keep an eye on these patients and their vitals.”
Burn patients are trauma patients and are experiencing an inflammatory response at the minute of injury. As patients are resuscitated, nurses administer IV fluids and albumin. When this occurs, the RTs constantly watch for pulmonary edema.
“You’ve got to push the limits in respiratory therapy,” Rakofsky said. “It’s not going to be the same therapy for every patient. You’ve got to be able to change and make suggestions.”
Pain control, weaning
Routinely, the RTs use airway pressure release ventilation, which allows patients with inhalation injury to spontaneously breathe at two levels of pressure. “It recruits the lung very well and greatly helps with oxygenation,” Wright said.
With these challenging patients, ventilation and weaning can happen repeatedly, not just once. “We might be doing well with weaning from the vent, but then he’s up for surgery and, when he’s back from surgery, you have to go through the weaning process all over again,” Wright said. “But you see how good these guys do; you constantly talk with them, get their spirits high and their hopes up.”
Weaning is a multidisciplinary process. “When weaning, the PT/OT is sitting them up to expand that diaphragm,” Wright explained. The RTs also assist the rehabilitation staff by maintaining an intubated patient’s airway as he walks down the ICU hallway.
Pain control makes weaning off the vent especially challenging. Communication between RTs, physicians, and nurses is essential to ensure the patient isn’t on too much or too little sedation.
After extubation, RTs continue to follow the patient to discharge for any airway obstruction or other problem, give him breathing treatments, spirometry, peak flow, and guard against him developing pneumonia. Sometimes, the RTs will carry on care in the outpatient clinic.
Assuming a patient has no complications, the rule of thumb holds that a burn patient will spend a minimum of one day in the hospital for each percent of his/her body surface area that is burned. With 95 percent burns, you can count on a minimum of 95 days in hospital.
“Not all patients make it out of here,” Wright said. “But we’re proud that we did our jobs to have their families see them one last time.”
It takes a “special kind of person” to work in the burn center every day, Serio-Melvin said. “For some, burns are not for them,” she said, “but every single person who works here wants to be here.”
Each of the others voiced the same sentiment.
“This is one of the hardest places in the Army to be an RT,” said Sgt. 1st Class Anthony Stewart. “I’ve been in the field for 12 years, and it’s a privilege to work here. The working relationships between docs and nurses — you have their respect and trust. You’re expected to help manage the patient, run the ABGs, do the bronchs.”
Rakofsky has worked at six hospitals, but his 15 months at the burn center have been the most labor intensive and the most fulfilling.
“This is a unique patient population,” he said. “Many members of the burn unit have themselves deployed in Iraq. We want (patients) to succeed and get out of here and get on with their lives. We’re able to give them a second chance.”
Wright, who is 20-months and counting into his stint in the burn center, said: “I love working up here. It’s very rewarding. I could do this for a long time.”
The troops patrolling the battle-seared streets of Baghdad can only hope he does.
Michael Gibbons is senior associate editor of ADVANCE. He can be reached at [email protected].
Lingering Effects from the ‘Dirtiest Battlefield on Earth’
For a war that lasted roughly 100 hours and consisted mostly of tank battles and air strikes, the first Gulf War has overachieved in a negative way: causing more lingering physical and mental maladies in the soldiers who fought it than anyone anticipated.
“What we know and understand now, that we didn’t then, are some of the health effects caused from exposure to what is called ‘the dirtiest battlefield on Earth,'” said Steve Robinson, a veteran of the first Gulf War and an activist on soldiers’ behalf.
For one thing, the Middle East is a battlefield of 2 micron-size Arabian sand. These particles are small enough to become airborne and inhaled easily, to the detriment of soldiers’ lungs.
In the first Gulf War, that sand was sprayed with insecticide, Robinson noted. Plus, diesel oil spilled on that sand, which was then kicked up with tanks and vehicles.
“One DOD official’s idea in 1991 that sand and silica exposure could damage vets’ lungs was considered ridiculous,” Robinson said. “Today, it definitely explains their respiratory symptoms.”
It’s likely that silica ingestion, he said, is to blame for “requiring many Gulf War vets at a very early age to use CPAP machines.”
For another thing, that battlefield had then, and still has now, a type of microscopic sand fly that, once inside the human body, will lay dormant for years and then attack one’s immune system.
Other health threats whose effects likely were underestimated during the first Gulf War include exposures to investigational vaccines for anthrax and other nerve agents, poor water purification, and the release of sarin gas and other toxic agents into the atmosphere as a result of bombing raids on Iraqi chemical-storage bunkers.
“The more we study, the more we find unique things that don’t exist in other vets, like a propensity toward brain cancer, Lou Gehrig’s disease, multiple sclerosis, and certain birth defects,” said Robinson, who has served as executive director of an advocacy organization called Veterans for America.
No unique syndrome
Robinson recently participated on a specially appointed committee that concluded symptoms suffered by veterans of the first Gulf War don’t collectively constitute a “Gulf War Syndrome.”
“There has never been a Gulf War Syndrome,” Robinson said. “A syndrome is a recognizable, uniformly standard disease process. That debate is over. This is a chronic, multi-symptom illness unique to each soldier.”
Now, however, since the federal government has accepted that conclusion and doesn’t recognize these symptoms as part of a syndrome, it limits the amount of free health care and disability benefits the roughly 100,000 Gulf War veterans who complain of these symptoms can obtain.
Still, government officials “uniformly admit now that these vets are ill,” Robinson said.
That’s why advocates are lobbying Congress to block impending Department of Defense budget cuts that would reduce money for research into the causes of and cures for Gulf War symptoms.
The current generation of soldiers fighting in Iraq and Afghanistan “are now in Congress’ eyesight,” leaving the health care needs of the first Gulf War vets “largely forgotten,” Robinson said. “Now we have Nobel Prize-winning scientists ready to work on the root causes for Gulf War illnesses but no money. We’re now competing for dollars with the new war generation.”