Air Force trauma surgeons stay current at UC Davis Medical Center Published Oct. 24, 2017 By Merrie Schilter-Lowe 60th Air Mobility Wing Public Affairs TRAVIS AIR FORCE BASE, Calif. – On a day-to-day basis he provides medical care for civilian pediatric patients. But when the Air Force calls, he swaps his white coat and scrubs for the Airman battle uniform to hop on a military aircraft headed anywhere to treat critically injured service members. Lt. Col. (Dr.) Joseph Stephenson is an Air Force pediatric surgeon administratively assigned to the David Grant Medical Center at Travis Air Force Base, California, but embedded full time at the University of California, Davis Medical Center in Sacramento, California. “The hardest part of a deployment is to be ready when someone is injured and you have to provide life-saving care,” said Stephenson, who trained in general surgery and received additional training in pediatric surgery and trauma. “We go on multiple short deployments lasting one to three weeks. We travel as a trauma care team with as little as 12-hour notice.” Stephenson treats infants to young adults with congenital defects, pediatric trauma oncology and childhood cancers at both UC Davis and nearby Shriners Hospital for Children. “I never know what my day will look like,” he said. “I could have a patient facing organ failure, perform surgery at UCD and Shriners and see consults from DGMC. And you have to leave room in the schedule for emergencies,” said Stephenson. Working at a Level I trauma center like UC Davis helps military surgeons maintain their critical combat surgical skills, said Col. (Dr.) Rachel Hight, 60th Surgical Operations Squadron commander at DGMC. Level I trauma centers handle the volume and types of trauma cases seen in combat. Hight, who specializes in trauma, acute care surgery and surgical care, was one of the first Air Force trauma surgeons assigned to UC Davis in 2009 to help stand up the program that now includes four trauma surgeons, a thoracic surgeon, an orthopedic oncologist and an emergency room surgeon. The cadre also includes a vascular surgeon who rotates between UC Davis and DGMC. “Now that deployments are unpredictable, your skills can degrade because there’s isn’t much happening – thankfully for the troops,” said Hight. Today when surgeons deploy, they are primarily “a safety net in case something happens,” said Hight. Unlike the other embedded surgeons, Hight rotates one week bimonthly between commander responsibilities at DGMC and surgical and teaching responsibilities UC Davis. Hight also heads the advanced trauma life support program at Travis as well as trains tactical trauma and surgical management skills to Air Force para-rescue team members in the western region. “At UC Davis, trauma is generally very busy,” she said. “We carry 50 to 80 patients with two residents and a nurse practitioner supporting your ability. Some of these are intensive care unit patients, so there’s a separate dedicated team focused on those guys, but we need to be aware because we’re taking some of them back into surgery either that day or the next.” Not only are the surgeons involved in operative and clinical decisions, they also answer trauma calls. “I may get 12 to 30 calls a day, which is similar to what was happening at the height of the war,” said Hight. The UC Davis program is modeled after the Center for Sustainment of Trauma and Readiness Skills program, which prepares medical personnel for deployment through hands-on and clinical training at trauma facilities. Air Force trauma surgeons are embedded at three C-STARS facilities: the University of Maryland’s Baltimore Shock Trauma Center, the Saint Louis University Hospital in Missouri and the University of Cincinnati Medical Center in Ohio. Hight trained at the Cincinnati Medical Center, where she met her mentors, Cols. (Drs.) Peter Muskat and Warren Dorlac and Air Force Reserve Col. (Dr.) Jay Johannigman, who are now retired. These “giants of C-STARS” recognized that, to have a large pool of trauma surgeons available and ready to deploy, the Air Force needed additional civilian trauma centers and reached out to UC Davis, said Hight. Not only does the partnership provide military physicians the hands-on trauma training they need to remain current in their fields, it also provides UC Davis with some of the best trained trauma surgeons with battlefield lessons learned. “We see very complex trauma from both penetrating and blunt injuries,” said Dr. Joseph Galante, division chief of trauma, acute care surgery and surgical critical care at UC Davis. “Additionally, we see patients who have been cared for at lower-level or non-trauma centers around Northern California. This mimics the situation downrange very well,” said Galante. The military wants to keep trauma surgeons current in trauma care, but that’s difficult because so few surgeons treat trauma patients, according to Galante. While it may be common for military surgeons to be on call at Level II facilities, he said “none of them compares with UC Davis, which is one of the nation’s busiest trauma facilities and California's only Level I trauma center north of San Francisco,” said Galante. “We are also unique in that we take care of pediatric trauma. We see many injuries in children, which is extremely useful downrange.” When Navy Reserve commander Galante was at Camp Bastion, Afghanistan, performing emergency surgeries to stabilize service members for transfer to Bagram Airfield in 2010, Hight was on the receiving end at Craig Joint Theater Hospital at Bagram. “That fall, we saw the highest number of double … and quadruple amputees coming through with just severe injuries,” said Hight. “I had never experienced anything of that complexity, acuity or volume – ever. Nothing in the civilian sectors that I’ve even seen compares,” said Hight. “It still gives me chills.” Although the experience was emotionally draining and medically challenging, the medical teams were well prepared. “We had an amazing team with amazing leadership,” said Hight. “It was a phenomenal experience. We brought that kind of mentality back.” Hight and Galante’s paths briefly overlapped when she arrived at UC Davis as he was heading to Afghanistan. The two, along with four other colleagues, would later co-author a study on how working at civilian Level I trauma centers most closely resembled working at a NATO Role III hospital in Afghanistan during the peak of Operation Enduring Freedom. The study compared the cases and schedules of surgeons at two NATO Role III hospitals in Afghanistan with those at the UC Davis trauma center, two civilian Level II trauma centers, two civilian Level III trauma centers and a U.S. military treatment facility. The researchers found that work schedules, number of trauma resuscitations (methods used to quickly control surgical bleeding) and number of surgeries performed daily at Level I trauma centers more closely resembled combat conditions than Level II or Level III facilities. Despite similarities, the researchers also found key differences between Level I and Role III facilities. For example, military surgeons face significantly more amputations, soft tissue debridement (removing damaged tissue) and trauma in the genital and urinary systems. “Blast injuries were common from people stepping on IEDs,” said Lt. Col. (Dr.) Scott Zakaluzny, who was deployed to the Role III hospital at Bagram from October 2013 to May 2014. “We also treated a lot of chest and belly injuries.” According to Zakaluzny, who deployed to Afghanistan again in April, said hemorrhaging is the most common cause of death in trauma patients. “We learned in Afghanistan and Iraq that tourniquets were useful to stop the bleeding. You may lose a limb, but they saved lives,” he said. Zakaluzny completed his fellowship in trauma surgery at one of the busiest emergency rooms in the nation, the University of California Medical Center and Los Angeles County Medical Center, which served as the backdrop for the 2014 documentary “Code Black.” That experience and his role in the desert were much like his daily routine at UC Davis. “At UCD, I’m doing trauma care all the time,” said Zakaluzny. “You might think you’ve seen everything and then something else comes around the corner. Although it’s not as dramatic at UCD, there are times when the work gets overwhelming.” People who are not surgeons sometimes find it difficult to grasp the need for programs like the one at UC Davis, said Zakaluzny. “They wonder who benefits,” he said. “The military benefits because I’m much more prepared to take care of injured patients and I’m teaching residents who will eventually deploy and take care of trauma and combat injuries. “Sometimes when I’m teaching, I’ll interject things that apply to the military residents like, ‘when you’re deployed, you may not have this so you might want to do this.’ The ultimate on-the-job training is teaching as you see patients,” said Zakaluzny. Maj. (Dr.) Steven Thorpe is the newest member of the embedded cadre at UC Davis, having arrived in January. As an orthopedic surgeon with training in musculoskeletal oncology and pediatric orthopedics, Thorpe treats osteosarcoma, a rare cancer that starts in the bones, and multiple types and soft tissue sarcoma in the extremities and pelvis. He also treats patients with bone metastases – cancer that has traveled from another body part, such the breasts or lungs, to the bones. He also treats patients with tumors that are not cancer. As one of only two orthopedic oncologist in the Air Force, Thorpe performs “unique surgeries” and works in areas of the body that other orthopedic surgeons don’t go to like the pelvis and around blood vessels. “This give me skills in traumatic issues even though I’m not a trauma surgeon,” said Thorpe. “When I deploy, I go as an orthopedic surgeon.” Thorpe’s catchment area is Northern California and northern Reno, Nevada. Most of his patients live in the Sacramento, but he also treats DGMC oncology patients at UC Davis to take advantage of the specialized resources, he said. Like the other surgeons, Thorpe likes the multidisciplinary nature of the job. “I really like big complex cases,” he said. “I have pediatric sarcoma patients so I work with Dr. Jacob Stephenson, the pediatric surgeon. I’ve also worked with the Air Force vascular surgeon here, Lt. Col. (Dr.) Joseph DuBose, on a complex vascular surgery. It’s really cool to work with other Air Force surgeons in this setting. “Every day is different. I might have a full day in the clinic and then go to the OR by 3 (p.m.) for another three to four hours. In the middle of clinic, I might get a phone call from Reno that a patient has a pelvic fracture and I have to help facilitate them here. There’s a great deal of variety and variability in this job.” The diversity of ideas military surgeons bring to UC Davis “is fantastic,” said Galante. “The military surgeons bring new ways to care for civilian trauma patients that come directly from their experiences downrange,” he said. “They are also able to ask the important research questions that the university has the resources to begin to answer.” UC Davis has taken the lead in implementing some of technologies the surgeons brought back from the war, according to Hight. For example, UC Davis was the first west coast training site for the resuscitative endovascular balloon occlusion of the aorta, or REBOA. “The use of REBOA has stemmed from our military colleagues bringing back ideas seen downrange and we have had an open mind to adopt this procedure,” said Galante. The U.S. Food and Drug Administration approved use of the REBOA catheter in January 2016. The device is inserted into a hemorrhaging vessel and stops or slows the blood flow to that injury while allowing blood flow to continue to vital organs and other body parts. The Clinical Investigative Facility at DGMC helped to develop the REBOA. “We were also one of the leading centers to use (tranexamic acid), based on experiences downrange. The list could go on and on,” said Galante. TXA was originally developed to treat hemophilia and reduce bleeding in patients undergoing oral surgery. It is now used in as a pre-operative drug to minimize the need for large amounts of whole blood during general surgery. It is also used to treat severely injured trauma patients who have or are at risk for severe hemorrhage. One reason the UC Davis and DGMC partnership works so well is because of Galante, said Hight. “We both came back from that deployment with a shared understanding of what the current modern-day trauma surgeons need to understand and even what our flight doctors need to understand,” said Hight. “Joe gets it. He knows that you can’t take a doctor who has only been treating bumps, lumps and sniffles and clear a multi-trauma patient for flight. “In theater, when you ship a patient, you literally put them on an aircraft or helicopter. At UC Davis, shipping is getting the patient out of the OR and into ICU where we continue working on them until the next day or two when they come back for more surgeries. Another reason the UC Davis program works well for the Air Force is because of the type of trauma cases they treat at UC Davis. “We get the full spectrum … from a farmer being crushed in Yuba City (California) to someone from downtown Sacramento being involved in gang violence,” said Hight. “And, we’re seeing more explosions than you might anticipate because of the increase in substance abuse. “There are some crazy things happening on the civilian side that brings the severity of injuries you would see in combat and UC Davis is on par with in theater,” said Hight.