Statewide, Duke University Medical Center has a reputation for treating many of North Carolina’s most complicated medical cases. Its healthcare providers offer comprehensive primary and specialty care services, and they have the capabilities to treat anyone who walks through its doors.
But, it’s the Department of Surgery’s focus on contributing to improving medical care for the military that is gaining growing attention. Increasingly, the institution’s clinical care and research resources are being funneled into helping wounded warriors.
It’s an added benefit, says Dr. Allan Kirk, professor and chair of the Department of Surgery, that much of the work can be translated to civilian populations, as well.
“This ongoing work is important because we’ve learned a lot about how to take care of injured soldiers and sailors,” he says. “But, it’s turned out the things we’ve learned are good for civilians, too, such as those injured in car wrecks, or with gunshot wounds, or falling off scaffolds.”
Not only do these endeavors augment treatments providers can offer in large hospitals, but they also improve therapies soldiers receive in the field and long-term rehabilitative efforts.
Using Research to Improve Care
Dr. Allan Kirk
In collaboration with the Uniformed Services University of the Health Sciences (USU) and Emory University School of Medicine, Duke is at the forefront of taking scientific discoveries and translating them into products that can care for soldiers both on the front lines and in hospitals, Dr. Kirk says.
Overall, a $44 million grant from the Department of Defense's Defense Health Program funds the partnership. The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF) provides support services for the partnership. Duke receives $2.5 million annually and shares it with Emory to recruit patients to participate. Currently, 30 Duke patients are involved, with the goal of enrolling 400 patients over four years.
As the lead civilian research institution, Duke is well positioned to fuse available brainpower and resources.
“The scientific and clinical missions of Duke are so intertwined that it makes the institution the perfect place to look for biological correlations of diseases and to do clinical trials with people who have critical illnesses,” Dr. Kirk says. “Duke has always been a much more scientifically driven and biologically driven Department of Surgery than most.”
It’s that close basic translational science relationship that positions Duke to accomplish innovative things, he says. Through the grant, this partnership has already produced several products designed to treat wounded soldiers in the field. They can also be transitioned to help civilian patients, Dr. Kirk says.
WounDX: This tool uses a patient’s individual immunological and biological responses to help physicians determine whether they should manually close a slow healing wound or let it continue to heal on its own. Making the right decision, Dr. Kirk says, could help patients avoid unnecessary follow-up surgeries.
Massive Transfusion Protocol: Deciding whether to provide a blood transfusion requires close examination and analysis of a patient’s status over time. Transfusions are resource-intensive and expensive, so it’s not a choice made lightly. Through the grant, the team developed a smartphone application that uses a sophisticated statistical model, based on admission variables, to accurately identify patients who will benefit from a transfusion. It is being beta-tested at Grady Memorial Hospital in Atlanta.
Decompensation: A significant part of successful medicine, Dr. Kirk says, is knowing when to leave a patient alone and when he or she is decompensating or worsening. Through real-time analytics, providers can keep closer tabs on when a patient is progressing or failing. The intent is to individualize care based on how a person responds to treatment specifically rather than provide services based on average responses.
These products will enable providers to offer patients therapies that meet their individual needs.
“When we talk about immune complications, people fail to recognize each person comes to their injury with a unique set of immune experiences,” says Dr. Kirk. “You have different viruses, injuries, and vaccines. That immune experience accumulated over 20 to 30 years, and it changes how you will respond to a particular injury.”
Improving Field Fidelity
While treating injured soldiers who return from the field is important, time for intervention is often limited and critical. Consequently, it’s vital for field medics to be proficient with the tools they have for diagnosing potential life-threatening issues, says Dr. Mark Shapiro, associate professor, Division of Trauma, Critical Care, and Acute Care Surgery, and Acute Care Surgery Chief.
Duke’s 18 Delta Medical Proficiency Training program exposes Special Forces medical staff to these skills. The initiative, borne out of a collaboration Dr. Shapiro experienced on a trip to Haiti, allows participants to learn about ultrasound technology in Duke’s simulation Surgical Education and Activities Lab (SEAL). It phased out a previous instruction program that relied on live tissues, and it’s a way for participants to practice risk-free and receive constructive criticism.
“These soldiers are fully engaged, and they invite criticism,” Dr. Shapiro says. “They are extraordinary heroes who want to do more, and it doesn’t matter what more is. Whatever the criticism is, they’ll fix it.”
Every four years, Special Forces medical staff are required to complete the proficiency training. Duke offers this training, and soldiers take it back with them to the base and on deployment.
Dr. Brianne Steele
Led by Dr. Brianne Steele, assistant professor, Division of Emergency Medicine and Ultrasound Director, Special Forces complete a 30-day, 6-hour-a-day course, training in multiple elements of medicine and surgery.
One day of training is devoted to diagnostic ultrasonography, and medics can opt to spend additional time in the SEAL lab with residents. They also receive training in using regional anesthetic blocks that can provide pain relief while keeping soldiers active in the field.
Alongside learning how ultrasound works in the simulation lab, participants also learn how to best hold the probe. Dr. Steele provides guidance on how to read the shadows and shades of grey that appear in any ultrasound image.
Participants, then, have the opportunity to practice on their own in the simulation lab.
“Conducting a number of exams in the simulation lab gets soldiers comfortable with the fidelity of the machines,” Dr. Shapiro says. “They can take all their rotation experience here down range and apply it to their encounters. They’ve learned how to describe what they see better and better link up with medical command.”
Extensive practice teaches participants to catch nuances of individual injuries that could be either life-altering or life-saving. And, mastering this skill set allows them to offer real-time aid to soldiers and civilians alike.
“It’s important to keep soldiers engaged in the firefight or help them recover,” Dr. Shapiro says. “But, ultrasound can be used to relive the pain of local residents. Doing so can have an enormous effect on how we are accepted in the field.”
Giving the Wounded a Hand Up
One of the most significant injuries from war is limb amputation. Including civilian needs, there are approximately 500,000 amputations in the United States annually, with an upper-to-lower limb ration of 1-to-4.
Recent combat conflicts are only driving this number up, says Dr. Linda Cendales, associate professor, Division of Plastic, Maxillofacial, and Oral Surgery, but only 30 percent, including servicemen and women, have received hand transplants. As with other organ transplants, these procedures present the same immunosuppressive and rejection issues.
This uptick led to the creation of the Duke Vascularized Composite Allotransplantation (VCA) program. With more than $5 million in U.S. Department of Defense funding, Dr. Cendales leads this five-institution consortium to investigate how to make this therapy more effective for wounded soldiers and civilians. VCA is the transplantation of tissues, such as bone, skin, muscle, nerve, and tendon as a complete, functional unit, such as the hand.
Dr. Cendales’ work, in particular, focuses on novel immunosuppressive therapy – the study of rejection – and how this work can be applied clinically. Currently, she’s recruiting servicemen and women, as well as civilians, between the ages 18 and 60 who have lost one or both hands to undergo hand transplantations, and will conduct initial and follow-up procedures.
“Hand transplantation is a high-risk, high-reward quality of life transplant,” she says. “There are more unknowns than knowns with VCA, and it will be centers, like Duke, that will provide scientific insight not only into VCA, but also to other fields that pair with VCA, including immunology and transplantation neurosciences, and psychosocial sciences.”
Dr. Cendales and her multidisciplinary team use a bench-to-bedside approach with a model they created by working with non-human primates. Specifically, they’re testing regimens that block a certain pathway in the immune response to VCA allografts, evaluating whether the regimens prevent rejection and prolong transplanted tissue survival. Their findings will improve care for patients undergoing hand transplantation at Duke, she says.
Overall, although these endeavors assist soldiers and civilians in different ways and locations, all are designed to maximize the level of health care available to individuals who suffer some of the most extensive, life-altering injuries.
“Over the last decade, with our influx of critically-injured soldiers, we’ve decided to take on and turn out new initiatives that will help those coming back from the front lines,” Dr. Kirk says.