What can civilian hospitals learn from the military? Just ask this high school dropout turned trauma surgeon

"When you’re trying to do surgery and rockets are dropping around you, and at any moment a dozen badly injured soldiers may come through your door, there’s a lot of focus on the problems at hand. And on how to make things better." 

Medical researchers find the seeds of discovery in many places: the sudden recovery of a sick patient, a great journal article, or coffee with a colleague. But for the University of Toronto's Dr. Andrew Beckett, inspiration has come much further from home, in war-torn Afghanistan and the former Yugoslavia. A high school dropout who first joined the Canadian Forces as a combat medic, Beckett is now a highly credentialled trauma surgeon who has spent nearly two decades in the Canadian Forces – and whose work in war zones has led him to ask questions that never occur to most of his research colleagues back home.

Beckett is a master’s student in clinical epidemiology at U of T's Institute of Health Policy, Management & Evaluation and a recent graduate of the Critical Care fellowship program and Global Health Education Initiative. Earlier this year, he published a paper (available to view at PubMed) that showed Special Forces could parachute and carry packed red blood cells to remote war zones in new cold-storage containers. And in 2012, he found that multidisciplinary trauma teams are able to provide better care for badly injured soldiers — a finding with implications for civilian hospitals.

Beckett recently spoke with writer Jim Oldfield about his research.

What prompted you to look at blood storage during Special Forces operations?
Hemorrhage is the second-leading cause of death among treatable combat casualties. So, quick delivery of blood products in far-forward operations is critical for effective trauma care. The challenge is that stressors in the battlefield can compromise the quality of blood — extreme temperatures, and agitation from parachuting or patrols on rugged terrain in particular. For example, blood cells can rupture and levels of potassium may increase, which can lead to cardiac arrest during a rapid transfusion.

So you tested blood in a new storage system, in Special Forces conditions?
Yes, we simulated a parachute descent from 30,000 feet, and a military patrol in a climatic chamber at 48 degrees Celsius for 12 hours. For blood storage, we used “Golden Hour” cooling containers made by Minnesota Thermal Science. We found that the descent raised acidity and potassium, and both increased over time, but not in a clinically significant way. And mechanical agitation during simulated patrols didn’t affect the biochemical or biomechanical properties of the blood cells much.

We need to build on these results with a larger sample size and longer simulated missions, and in different temperatures, but it seems that red blood cells are more resilient than we thought. This knowledge could also be useful in civilian disasters, to transport blood into austere conditions.

Your study on trauma teams with diverse expertise may hold lessons for civilian hospitals as well. Can you tell us about that?
Yes, so we looked at data from the Role III Hospital at Kandahar Airfield in Afghanistan, which was a facility similar to trauma centres in developed countries. A lot of the injuries were severe — from IED explosions, gunshots and artillery. Some patients were triple amputees, usually two legs and an arm. But in 14 months around the time of the troop “surge,” mortality was below five per cent for 2,600 patients. Canada’s largest trauma centre sees about 1,000 patients a year, and the mortality rate in Ontario trauma centres is around 12 per cent. The patient populations and patterns of injury aren’t directly comparable, but those are pretty good numbers.

What accounts for this success?
We think that multidisciplinary trauma teams account for a lot of this success. The teams include an emergency or primary care physician who acts as the team leader, nurses, several kinds of lab technicians, general surgeons, specialty surgeons and a radiologist. All team members advise on triage, provide care and give input during rounds in the days after acute care. Radiologists in particular are a very effective addition to the multidisciplinary trauma team. They provide real-time feedback on diagnosis of injuries with X-ray and ultrasound, and can quickly set up advanced imaging like computed tomography and angiography.

Have many civilian hospitals adopted this model since the success in Afghanistan?
It really varies by institution. I think it’s more common in the U.S. than in Canada, but all trauma centres are moving in this direction. When I was a fellow at Sunnybrook, we incorporated radiologists into weekly trauma rounds. At St. Michael’s the trauma teams often include a pharmacist and social worker. But many civilian trauma centres could improve triage and patient flow with a more multidisciplinary approach to care. And certainly their preparations to treat large numbers of patients in mass casualty scenarios could draw on lessons from Afghanistan and Iraq.

There is a long history of advances in military medicine finding their way into civilian care, from blood transfusions to plastic surgery and penicillin. What is it about the military that spurs innovation?
Well, when you’re trying to do surgery and rockets are dropping around you, and at any moment a dozen badly injured soldiers may come through your door, there’s a lot of focus on the problems at hand. And on how to make things better.

People think of the military as a rigid organization, but everyone is an important member of the team. Because of the uncertainty in a combat zone, everyone on the team needs to contribute to make it work. One philosophy I really learned in the military is to set up the next person or team for success. The goal is to move the patient from the battlefield to acute care to recovery and repatriation in their home country, but that can only happen through a coordinated chain of care. Always set up the next team for success — many health professionals bring that philosophy back from the front lines, and I think it’s diffusing through our health care systems.

Jim Oldfield is a writer with the Faculty of Medicine at the University of Toronto.