By Sue Campbell
Special to American Forces Press Service
Texas, Dec. 31, 2008 - Optimally managing the unique head and neck injury patterns seen in Iraq and Afghanistan has led to a successful initiative at Wilford Hall Medical Center here. Hospital officials have developed a program – the first for a military medical facility -- to send surgical fellows to a war zone for a surgical rotation.
In the past, medical and surgical residents and fellows were not deployed to combat zones for hands-on training. Concerns over issues such as preparedness for an intense experience, safety, supervision and work-hour restrictions made this type of experience difficult to plan.
"The Accreditation Council for Graduate Medical Education and individual residency review committees have very strict rules regarding a surgical resident and fellow's work hours, time away from work, supervision and fatigue management", said Air Force Col. (Dr.) David Holck, director of the Ophthalmic Plastic and Reconstructive Surgery Fellowship and chairman of the ophthalmology department at Wilford Hall.
"Yet, we realized that some of the best experience a military surgeon can receive is in a combat zone," Holck continued. "They can gain concentrated exposure to head and neck trauma and optimize their skills in the management of unique war-related injury patterns that are not routinely seen in civilian trauma centers. These include blast injuries from improvised explosive devices, burns, multisystem trauma and combinations of these injuries."
Holck initiated this project by taking his fellow, Air Force Maj. (Dr.) Lisa Mihora, to the Air Force theater hospital at Joint Base Balad, Iraq, for a surgical rotation this summer.
Mihora, a board-certified ophthalmologist, is in her second year of a two-year fellowship at Wilford Hall as an oculofacial plastics and reconstructive fellow. This specialized division of ophthalmology involves management of deformities and abnormalities of the eyelids, tear system, orbit -- the bony cavity surrounding the eye -- and surrounding face and neck. Facial trauma management is an important component of this fellowship.
"Many Air Force residents and fellows perform rotations at civilian hospitals to obtain the training they need," Holck said. "We have routinely sent our residents to South America for military-unique training and international ophthalmology. As long as appropriate supervision is available with adherence to work-hour restrictions, there really is no limit to where the training can be conducted."
Mihora spent six weeks at Joint Base Balad, performing more than 130 procedures under the direct supervision of Holck and another oculofacial plastic surgeon, Air Force Col. (Dr.) Randal Beatty.
In Iraq, Mihora said, she participated in more head and neck trauma surgeries than in her entire career. This included craniotomies, facial fractures, complex soft tissue facial injuries and enucleations, or eye removals. She also was a critical member of the head and neck team, operating routinely with neurosurgeons, otolaryngologists, and oral and maxillofacial surgeons. These surgeons treated injured U.S. and allied troops, Iraqi civilians and insurgents, anyone who came through the doors.
"Deploying to Iraq gave me unique exposure to oculoplastics patients," Mihora said. "The extent of the injuries and surgeries that I cared for were unique to a war zone. Most injuries were from explosive devices, so I am now more comfortable treating these injuries on soldiers when they return stateside."
The accreditation council evaluates training programs, residents and staff using core competencies. One of these is systems-based practice, which involves understanding and successfully working in the unique medical system that they will be practicing after graduation.
"If we are going to fully train a military surgeon in systems-based practice, a conflict zone is where they will practice their trade," Holck said. "Taking Doctor Mihora to Balad not only allowed her to gain firsthand experience, but will help her train other surgeons who may have to deploy in the future."
Mihora said one of the most important parts of the experience was the chance to work with other head and neck surgeons in a team effort to help injured troops.
"This was a unique opportunity, only available in a military fellowship program, which has enhanced my comfort and skill level in caring for these trauma patients," she said.
"With the support of the 59th Medical Wing commander, the graduate medical education department and all our staff, this inaugural rotation was a resounding success," Holck said. "This is another example of the military, and specifically Wilford Hall Medical Center, leading the way in surgical management of trauma patients."
(Sue Campbell works in the 59th Medical Wing public affairs office.)