Surgeon shares lessons from surgical experience in Iraq, Afghanistan conflicts

He discussed the ways in which the care of patients with spine injuries evolved during his 31-year military career and active duty as a field surgeon.

The second you enter the military as a surgeon, you begin training your replacement, a military surgeon said during a presentation.

Rocco A. Armonda, MD, FAANS, addressed neurosurgeons and others recently and shared with them some of the lessons that can be learned from the battlefield and brought to civilian neurotrauma, based on his experience as a military surgeon.

Rocco A. Armonda

Training is key on the battlefield and in the operating room, in the military and civilian settings, Armonda said.

Battlefield to the private sector

“It goes without saying the future of neurotrauma care, not just neurovascular care, really depends on those who instruct, inspire, and lead and it is up to the next generation to take us that much further. Any surgeon who deliberately fails to train his successors is guilty of the crime of negligence to humanity,” Armonda said at a meeting. “My objective is to have those who I give an opportunity to train to actually exceed what I was able to do. So hopefully if I ever become a patient, or someone in my family [does], they can provide better for us than I could.”

Armonda described his time in Iraq and Afghanistan where he treated wounded soldiers as an “evolution of care.”

Learning from each patient, from each wounded soldier, would lead to improved treatment and care, he said.

An evolution of care

It was possible, Armonda said, for him and his fellow surgeons to complete complicated treatments on the battlefield, including craniotomies to relieve brain pressure in soldiers who had experienced extensive blast trauma in battle.

“I take my hat off to those in the arena. You know, over time what we saw in Iraq and Afghanistan was an evolution of care, it became centralized and standardized, and we critically evaluated what we were doing for our patients and tried to improve each patient’s outcome. We tried to rapidly advance the care and take these lessons learned and push them forward with the next group of individuals that went forward,” Armonda said. “We led from the front. Every individual who is on active duty, at some point and time, if they are around long enough, went to a combat theater,” Armonda said. “So with this, there is an evolution in terms of our management from debridement of multiple bone fragments, all of the metal fragments, to the point where we are doing large decompression craniectomy, giving a large space for the brain to swell.”

Relieving cranial pressure, especially at the brain stem, Armonda said, can reduce complications for patients moving forward. Without this procedure, patients have a higher incidence of delayed deterioration in the brain, according to Armonda.

“To get the best results, a large decompressive craniotomy is beneficial to these patients. If we wait until ICP (intracranial pressure) becomes uncontrollable for these injuries, we realize that they will have irreversible brain stem compression,” he said.

Similarity seen in injuries

According to Armonda, many current surgical practices and techniques have evolved from the battlefield and injuries sustained in active combat. He mentioned the evolution of cranial surgery in World War I and the fact many of the current techniques in that area were developed from methods used to treat ballistic injuries in the war setting.

In World War I, specialties had to come together to treat injuries, out of which the basics of neurosurgery were born, Armonda said.

“When you look at this injury pattern and this type of distribution, you have to think of not only decompressing the brain, but working with your colleagues, from craniomaxillofacial and oral and maxillofacial [surgery], to try and recreate a foundation to do a later reconstruction,” he said. “Many of these buttresses are the very same that we see that are disrupted with blunt civilian trauma. In many ways ,the face is the bumper for the brain, and it is the same with blast injuries.”

Although lessons from the battlefield can be applied to the private sector, the two are ultimately different in the end. “In the private sector, it is about job security. In the military, it is about mission accomplishment,” Armonda said. – by Robert Linnehan

Reference:

Armonda RA. Wartime lessons applied to civilian neurotrauma. Presented at: American Association of Neurological Surgeons Annual Meeting; April 5-9, 2014; San Francisco.

For more information:

Rocco A. Armonda, MD, FAANS,can be reached at MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC 20010; email: rocco.armonda@gmail.com.

Disclosure: Armonda has no relevant financial disclosures.