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ER: Prepping Cool Heads for Hot Zones

By Douglas J. Gillert
American Forces Press Service

SAN ANTONIO, Texas, Dec. 9, 1998 – It's 11 p.m. Friday, Nov. 20, and the emergency department at the Wilford Hall Medical Center is eerily quiet. It's as if the staff physicians, nurses, medical technicians and residents are collectively holding their breath, waiting, wondering.

A handful of patients has arrived here, on their own or brought in by worried parents or spouses. An elderly man grimaces with chest pains as a nurse takes his vital signs and a resident asks him questions, writing the answers down on a form attached to a clipboard.

An enlisted man in camouflaged fatigues holds his head in his hands, his elbows resting on his knees, his boot-clad feet spread apart either side of fresh drops of crimson blood from a bad gash. The blood seems oddly out of place in the austere, spotless ER with its harsh white lights.

A teen-age girl thoughtfully rubs the temporary cast on her left leg.

A child hugs a stuffed toy, his dark eyes moist, alert and slightly bewildered by the big, strange room with the high- gloss floors and stainless steel furniture.

Only one of these patients at the Air Force trauma center is military. The rest are civilians from San Antonio or one of 23 counties the ER serves. Cross-town partners Brooke Army Medical Center and the University of Texas Health Sciences Center give southcentral Texas three Level 1 trauma centers capable of providing definitive, life-saving care to severely injured or wounded patients. Each receives roughly one-third of the area's emergency trauma cases. They see everything from drug overdoses to accident victims to gunshot wounds and stabbings.

Although it's quiet right now, each member of the trauma care team on duty knows at any moment the call could come: Code 3, seriously injured patients inbound.

Wilford Hall and Brooke don't have to provide care to civilians. "We do it because it provides a benefit to the community, but also because there's no substitute for the training it provides us," said Air Force Dr. (Lt. Col.) Thomas McLaughlin, commander of the 959th Surgical Operations Squadron here. "Wilford Hall is the '911' of the Air Force, and the emergency department plays a big role in that."

Here is where the Army and Air Force send their young, promising physicians to learn emergency medicine -- where graduate residents emerge with new skills and confidence to care for the kinds of patients they'd see in combat. The Navy, too, has enrolled residents here, although it has its own program at Portsmouth Naval Hospital, Va.

Currently, seven Air Force and seven Army residents fill each three-year course, so 42 residents in all pull rotations at Wilford Hall, Brooke and the university. They also spend time with emergency medics in Houston, toxicologists in New York and pediatric trauma specialists in Austin, Texas. According to Army Dr. (Lt. Col.) Alan Morgan, joint residency program director, they gain experience few trauma residency programs offer.

It's experience, he said, that prepares them for war.

"They see broken and maimed just like they would in combat," Morgan said. "They also see patients with HIV, cocaine overdoses and other similar conditions the average military doctor doesn't get to see. This experience makes them better doctors, because they aren't centered on limited diagnoses."

Most current and past residents first completed internships and two to three years' field experience before entering the residency program. Their field experience not only helped them mature as doctors but also taught them what they need to know as emergency medics.

"They're motivated when they come here, and we provide them a demanding course with a great deal of reading," Morgan said. "They'll also see hundreds of Code 3 trauma cases while they're here. When they leave, they are capable of operating in any environment anywhere."

Morgan credits student maturity, high training standards and vivid, hands-on experience as reasons the American Board of Emergency Medicine named the program No. 1 in the nation for the past three years. In an effort to get trained trauma specialists to the field faster, the program next year will begin admitting new medical school graduates with no field experience. "We'll lose some of the maturity and experience, but new residents will be among the top medical school graduates in the country," he said.

Even now, only the top candidates make it to the residency program, Morgan said. About one-third come from the Uniformed Services University of the Health Sciences in Bethesda, Md., and most of the rest are top graduates from medical schools they attended on DoD scholarships. Those with field experience also demonstrated solid management and patient skills, he said.

About one of every six candidates is selected for the residency program. Of those, one or two drop out each year, mostly due to the stress of treating severely sick or injured patients.

"You don't have time to read about it or think about it," Morgan said. "You have to make your decision rapidly and live with it."

Physician confidence is what the training's really all about, said Air Force Dr. (Maj.) John Josephs, chief of trauma surgery at Wilford Hall. "Every physician here has the capability to provide good care," he said. "It's the confidence in your decisions in this environment that will provide military people with doctors who are vastly more capable than they are when they begin their residency."

At 1 a.m. Nov. 21, the Wilford Hall ER remains quiet. No Code 3s have come in. A few noncritical patients linger, waiting to be given medicine and sent home or admitted and sent upstairs for specialty care.

Air Force Dr. (Capt.) Ira Tilles, a second-year resident, stretches his arms behind his back and breathes deeply. His shift started at 11 and there are 10 more hours to go. If a Code 3 comes in tonight, he'll share the lead with squadron commander McLaughlin, who's staff physician for the shift.

Nearby, Air Force Capt. Charles Freeman, a registered nurse certified in emergency nursing, fills out paperwork on one of the non-Code 3 patients.

McLaughlin paces the floor, checking with residents, nurses and technicians at various stations. He's pumped and ready for action. They all are. It's why they're here. To act. To learn.

To be prepared.

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