Out of Harm's Way

A GROUP OF MEDICS stands assembled beside about a dozen empty gurneys. This is patient receiving, also known as 12 Alpha. Within minutes, the gurneys will be loaded with wounded and ill men and women - America's best and bravest - flown in overnight from Iraq.

Autumn has come to Landstuhl, Germany. A chill hangs in the morning air as the medics quietly converse, passing the time. Then comes the familiar rattle and grind of an approaching school bus. It rounds the corner, into sight, a medically equipped Blue Bird - dark blue with a white box and red crosses painted on the sides and back. Inside this ambulance bus - "ambus," for short - some patients lie on litters hooked to stanchions. Others, though wounded, are able to stand.

All talk evaporates as the bus backs up to the entrance. Eight corpsmen surround the rear doors. In fluid and well-practiced motions, they carefully lift each litter off the bus and onto the gurneys. Some patients are barely awake. Their hands are soon clasped, and they hear their names, one by one.

"I'm Chaplain Pettigrew." The voice belongs to a man with a bright orange vest over his BDUs. He smiles gently. "You're at Landstuhl hospital in Germany. I'm here to let you know you're safe and that we're going to take good care of you. God's blessings to you."
Thirteen patients are offloaded in about that many minutes. A passenger van brings 11 others, the walking wounded.

Six years into the global war on terrorism, life at Landstuhl revolves around these daily arrivals from the battlefield. Twice a day, on average, a transport plane lands at neighboring Ramstein Air Base, carrying anywhere from a dozen to more than 50 patients at a time. Roughly a quarter of the cases are combat-related - IED blasts, gunshot wounds and the like. The rest are normal health problems that require medical attention outside the war theater: hernia, infected gall bladder, ruptured appendix, knee injuries.

"I've seen as many as four flights come in a day, and they come in at any hour of the day," says Capt. Jeffrey McCune, a Navy reservist from Wichita, Kan. As executive officer of the Deployed Warrior Medical Management Center (DWMMC), a patient-monitoring organization established in March 2002 to handle the influx of war casualties, he tracks every patient coming from "down range," and their injuries, so medical teams can prepare to receive them. "We get up to 900 patients a month," McCune says. "This hospital is probably the busiest military medical facility in the world, because every single patient, every one of them, comes through here. We're the funnel."

As McCune speaks, he directs a DWMMC mission team to prepare for another ambus. A second flight's due to touch down at Ramstein in a half hour, this one from Bagram Air Base in Afghanistan. Seven patients on litters, two ambulatory.

LANDSTUHL REGIONAL MEDICAL CENTER, or LRMC, is the largest American hospital outside the United States. Its grounds were once destined to become a Hitler Youth School, started in 1938 but never completed. During World War II, the site was used to manufacture aluminum parts for V-2 rockets. When American troops liberated the city of Landstuhl on March 19, 1945, they established a presence there that continues today as part of the wider Kaiserslautern U.S. military community.

Constructed in the early 1950s, LRMC - renamed in 1994 after the 2nd General Hospital was deactivated - sits atop a forested hill. From above, its intersecting white buildings resemble a curved spine. This is where injured personnel were treated following the aborted 1980 rescue attempt of American hostages in Iran and the terrorist bombing of Marine Corps barracks in Beirut in 1983. Casualties from the 1986 Berlin La Belle disco bombing, Somalia in 1993, the Khobar Towers bombing in 1996, the U.S. embassy bombing in Kenya in 1998, the attack on the USS Cole in 2000 - all were evacuated here.

"Landstuhl has been, and is, a pivotal place in the war on terror," says Dr. Brian Lein, an Army colonel who took over as LRMC commander last July. "As the only inpatient facility to receive casualties from Central Command, Africa Command, Pacific Command and Europe Command, we have a geographic distribution like no other hospital anywhere in the world."

The wars in Iraq and Afghanistan have strained the medical center, which also provides primary and tertiary care, hospitalization and treatment for about 100,000 U.S. military personnel and their families, along with specialized care for the larger European theater, consisting of about 250,000 servicemembers and their families. The increase in patients since 9/11 has been nothing short of a deluge, accounting for about 60 percent of Landstuhl's current workload.
As of Jan. 7, the hospital had treated 6,334 patients from Operation Enduring Freedom in Afghanistan - 4,666 outpatients, 1,668 inpatients. Operation Iraqi Freedom has delivered 38,816 for treatment - 26,288 outpatients, 12,528 inpatients. Among the 45,150 patients treated at Landstuhl at that time, 9,569 had battle injuries.

Recognizing Landstuhl's key role in a conflict that some Pentagon officials expect will last another 25 to 30 years, the U.S. government has committed to upgrading the aging hospital - and talks continue about eventually replacing it with a tower-like structure. As it is, doctors and nurses must traverse three miles of corridors connecting 14 buildings. A budget and a timeline for a new hospital have yet, however, to be established. The Army's Health Planning Facility Agency presented a proposal to the surgeon general's office only last month.

"My first impression when I saw Landstuhl was that I was going to be doing a lot of walking," says Lt. Col. Thomas Hines, LRMC's chief of logistics, who came to the hospital in 2006. "It's an older medical center, which requires a lot of maintenance and upkeep. But we're putting more money into the facility to make it state of the art." Last year, that included $12 million on equipment and $23 million on renovations. In October, LRMC opened new outpatient quarters for those wounded in the war on terror, eliminating the need for a 20-minute bus ride from the old barracks in Kaiserslautern. The emergency room is nearly refurbished, and has a new overhang to shield incoming patients from harsh weather. Last April, a remodeled ambulatory procedure unit opened as the first step in expanding the intensive-care unit. After two years of work, the entire facility now has air conditioning. Upgrades to the sprinkler systems are ongoing. And a $1.5 million USO center, called the Warrior Lounge, is on track to open in May.

In a war with multiple fronts and an uncertain future, the United States is expected to rely on this hospital more than ever, for a long time to come.

"If not Landstuhl, then where?" Lein says. "We're a critical asset no matter how you look at it. We have a major medical warehouse 20 minutes out the back gate and a major airfield 20 minutes out the front gate. We couldn't be better situated than we are right now, with total support from the Air Force in bringing casualties in and evacuating casualties out."

AMONG THE PATIENTS ADMITTED on this particular October morning are Army Spcs. Chase Fluhman, 21, of Mills, N.M., and Grayling DeBlanc, 26, of Slidell, La. By afternoon, the two young men are seen by their doctors, are sharing a room, and starting to tell their stories.
Fluhman points to the red marks covering his torso. "I took some shrapnel," he says. "They figured one piece went into my abdomen cavity, so they went in and tried to find it. I guess they pulled it out. I'm not too sure."

A Bradley driver for a major, Fluhman was checking the vehicle's oil when he heard two loud booms. Ordered to get down, he hit the ground and within seconds noticed little holes in his uniform, "like I'd been shot with a pellet gun." Blood began to soak through them.

Fluhman remembers medevac birds landing on the soccer field just south of the Joint Coordination Center, or JCC. His buddy Thomas sat in front of him on the flight to Balad Air Base, with a large blood stain on his own uniform. He'd been hit with shrapnel behind the ear and on the arm.

Once his staples are out, in about a week, Fluhman will probably go back to his unit in Iraq's Diyala province. But he's not worried about himself; he wants to know what happened to his friend. The last time he saw him was before Fluhman underwent surgery in the field hospital, and he thought then that Thomas didn't look too good.

It's time for Fluhman to call his father. "He's probably flipping out," he says, managing a weak smile.

DeBlanc faces a longer recovery. He and his squadron came under attack while patrolling Baghdad in a Stryker vehicle. DeBlanc was trying to identify the source of the gunfire when he was shot in the neck. At the time, he felt only a stinging sensation. He got off two shots with his .50-caliber before collapsing to the ground, yelling for a medic.

"I just kept thinking, ‘I can't believe I've been hit,' he recalls. "I didn't think it would ever happen to me." It was DeBlanc's fourth time in Iraq; he's been there twice as a Marine and twice with the Army.

In a strained voice, he describes how a medical team stabilized him for transport to Forward Operating Base Blackhawk, where he stayed for eight hours before they moved him to Balad. "That's where I met up with him," DeBlanc says, nodding at Fluhman.

"Right now, they think I'll be up and about in a little over a month. The way I was shot pierced one of my lungs. They want to make sure the blood is completely out before they remove the tubes. After that, it's just a matter of healing. I've got a couple of broken ribs that will heal with time, too."

Does he really want a fifth go-around in Iraq? "Yes, I'll be back out there. But it feels good to know these people are here and ready to take care of us."

LANDSTUHL HAS A STAFF of about 3,000, making Lein's job as CO "like trying to steer a battleship with an oar." But at the center of every management decision, every surgery, every act of care, is the facility's motto, "Selfless Service." Lein reminds hospital workers that their patients are not customers; they had to come to Landstuhl.

"It's not like a soldier in flight from Iraq or Afghanistan has a choice," he says. "The health-care provider's relationship with the patient is almost as sacred as priest and parishioner. It's a privilege to take care of them."

Given the option, an injured soldier would likely choose Landstuhl anyway. Years of experience in treating the unique wounds of this war - most related to IED blasts or explosively formed penetrators, or EFPs - have given military doctors the knowledge to save limbs and lives that even 10 years ago wouldn't have had a chance. Also, many of LRMC's staff have served down range at some time or another, and they're used to seeing casualty volume that would overwhelm an ordinary emergency room in the United States.

Landstuhl doctors were among the first to identify the war's signature wound: traumatic brain injury, or TBI. More U.S. troops are surviving bomb and rocket attacks thanks to sophisticated body armor, but the resulting shock wave can violently jolt the brain inside the skull and damage the tissue. TBIs range from moderate to severe, and some may not surface until weeks or months after the explosion. Every patient coming to Landstuhl from Iraq or Afghanistan - military or DoD civilian - is screened for TBI. Those with significant injuries are diverted to one of eight Defense and Veterans Brain Injury Centers in the United States. Landstuhl's achievements in identifying and treating TBI were recognized last fall when the American College of Surgeons designated the hospital a Level II trauma center - the only facility of that stature outside the United States.

IN JUNE, LANDSTUHL stood up a Warrior Transition Unit, or WTU, for soldiers undergoing a medical evaluation board or requiring medical care for longer than six months. Under the Army Medical Action Plan, each is assigned a primary care manager, a case manager and a squad leader to facilitate medical needs. LRMC oversees the program for soldiers stationed at Baumholder, Kleber, Landstuhl, Wiesbaden, Vicenza, Italy, and Supreme Headquarters Allied Powers Europe. WTUs provide high-quality living conditions, prevent unnecessary procedural delays, and determine when a "warrior in transition" meets or will meet Army retention standards, or is able to return to civilian life with dignity and compassion.

The Army Medical Action Plan also engages the Department of Veterans Affairs in a partnership to provide a "continuum of care and benefits."

LRMC faces uniquely challenging security issues. Following last September's discovery that a terror plot was aimed at striking U.S. military installations in Germany, the hospital ramped up its security, closely scrutinizing all bags and vehicles passing onto the post and conducting numerous precautionary exercices.

Like the war itself, Landstuhl is a fully integrated multiple-branch military endeavor. More than 100 Air Force personnel are assigned to casualty transport to and from Ramstein, and a rotating crew of nearly 400 Navy reservists is employed everywhere from the hospital's medical wards to pastoral services.

One of those Navy reservists, Cmdr. Gail Crutcher, will leave soon to return to his job as director of physical therapy at Condell Medical Center in Libertyville, Ill. But on this particular October morning, Crutcher is helping a 21-year-old Marine navigate the hospital's hallway. The young man arrived a day earlier, and this is his first time out of bed.

"You're doing good," Crutcher, 55, assures him. "Just remember, you don't go without someone with you, and you're not in a hurry."

The patient was overcome by toxic fumes while pumping oil and hydraulic fuel out of a pit in Iraq. He's still disoriented, unable to recall phone numbers, his Social Security number, his daughter's birth date. "I was working with hazardous materials and started throwing up," he says. "That's all I remember."

Crutcher realizes immediately that recovery will be tough for the Marine. "We don't understand right now the extent of the damage," Crutcher admits. Like most patients with serious health problems, he will stay at Landstuhl for three or four days before going to a military treatment facility in the United States, probably Bethesda.

Crutcher, a physical therapist, says the assignment in Germany has spoiled him. "When I go back to my civilian practice, I'm not going to have this," he says, sighing. "I'm looking at some of these patients, thinking, ‘They don't really want to walk,' but I learn real quick that they do. They find a way."

Chaplain (Lt. Cmdr.) Ronald Pettigrew - one of the first faces patients see after arriving at Landstuhl - says he considers his year-long deployment particularly rewarding. The Bettendorf, Iowa, minister has counseled LRMC staff through the stress of daily treating casualties, and he's watched many patients fight to exceed doctors' most optimistic expectations.

"Being there for people is not discouraging," Pettigrew says. "It's encouraging. I get empowered when I see these guys make the most of bad situations."

His eyes fill with tears as he describes a paraplegic patient in the ICU who needed the chaplain's help communicating with his wife over the phone. The man had a respirator in his mouth and couldn't speak clearly. "I'm sorry," he was trying to tell his wife. "I love you."

After the couple hung up, Pettigrew brought over a message board so he could understand what the patient said next. Seeing him point to R, then I, then N and finally G, Pettigrew suddenly realized what the man was asking for.

"More than anything, he wanted his wedding ring," he says. "It had apparently been taken off for surgery and all that stuff. That became my mission that day, to call down range and do everything I could to get this guy his wedding ring back. I was able to find it and get it back to him.

"I called my wife later that night and cried, because I saw how much we take life for granted."

The chaplain's thoughts invariably return to his daily mission, back to the patients he greets every day outside 12 Alpha. He holds the hands of every one. He knows that he, like the hospital, symbolizes something deeply relieving to the wounded and sick.

"We represent to them that they aren't in a war zone anymore, that they're safe. It's an honor to be there."

Matt Grills is an associate editor at The American Legion Magazine.


On the frontier of combat care

Landstuhl’s chief surgeon helps guide new understanding of TBI, battlefield survivability.

DR. STEPHEN FLAHERTY, 46, has spent most of his war time at the front of modern combat medicine. Prior to joining the staff of Landstuhl Regional Medical Center as chief of surgery, the Army colonel worked for eight months as director of U.S. Central Command's Joint Theater Trauma System, overseeing trauma care in Iraq and Afghanistan. During that time, he visited nearly every medical and surgical facility there, gaining intimate knowledge of the young Americans fighting in the global war on terrorism and the nature of their injuries and wounds.

A graduate of Tufts University in Boston, Flaherty is closely monitoring the high number of soldiers arriving at Landstuhl with signs of moderate to severe traumatic brain injury, often described as the "signature wound" of the war. In November, Stars and Stripes reported that up to 30 percent of Iraq and Afghanistan veterans suffer from some degree of TBI. As a result, hospital officials are proposing the creation of a brain injury center at Landstuhl to focus on finding better ways to diagnose, treat and screen for TBI. Flaherty spoke with The American Legion Magazine.

Q: Landstuhl played a key role in diagnosing traumatic brain injury in returning soldiers. When was it first recognized?
A: The concerns about traumatic brain injury began probably back in early 2005, if not before. Surgical teams here were seeing patients and realized the soldiers were not acting normally. Despite all their other injuries, there also seemed to be something else going on. That made them start to look for the possibility of concussions or concussive syndromes, because many were reporting they had been near an IED explosion. With that information, they began to ask other people about mild traumatic brain injury and post-concussive syndromes. The Defensive Veterans Brain Injury Center provided some education and resources, and the team here decided to start screening in a formal way.

Q: In terms of combat medicine, what have we learned?
A: I think what we've learned is that controlling blood loss is the most important thing for saving lives and improving function as the result of injuries. Some of the factors are as old as the Civil War - you need to use tourniquets, and our ability to overcome the bias against using them has been very important. I'm telling you, tourniquets are out there saving lives on the battlefield every day.
Other things we've learned about stopping bleeding come from our ability to look at large numbers of casualties and see what their injuries have been and why they died or why their healing process has been delayed. What we've found is that using products like Recombinant Factor VIIa probably do improve survivability. That's a new drug not used before this war that we have fielded as a result of our assessment of the data gathered during this conflict.
Another dramatic improvement has been the way that we use blood products. Some parts of blood carry oxygen to the tissues; other parts of blood help us stop bleeding. In routine trauma patients, it's typical to use one bag of blood-clotting component for every four bags of oxygen-carrying component. What we've learned here from this war is that we need to use more bags of blood-clotting component. We have to have more bags available, and we have to have it available quicker because it is frozen.

Q: You've spent time at most of the Army's combat support hospitals in Iraq and Afghanistan. Describe their atmosphere.
A: It is very chaotic in the emergency room forward because it's noisy - helicopters are landing; oftentimes jets are flying nearby. It's very austere; you're often in tents or, at best, plywood buildings. Casualties come in large numbers, and you know they are always trying to die when they come. So there's a tremendous pressure. You have a limited amount of time to make sure that there isn't something that is going to kill them in the next five minutes, whether it's that they can't breathe or their bleeding is so great. And there's often no way of knowing who they belong to; they're covered with blood and dirt and their clothes have been cut off.

Q: How much life saving happens at Landstuhl?
A: The emergency rooms are in Iraq and Afghanistan. That's where the immediate life-saving interventions are made. By the time they reach us here, their chance of survival is probably 98, 99 percent because of what has been done forward. What we do here is refine that care to make sure that infections are minimized and that their opportunity for the best possible functional outcome is maximized.

Q: How great is the survival rate for today's war casualties?
A: We've been able to increase that survival rate, but it's not a big percentage. A lot of people die who we have no chance to change that medically. The anatomic wound is so devastating right at the instant of the injury that we're never going to save that life. So when we look at potentially savable combat casualties, the number's probably pretty small. It's certainly a very small percentage out of all the people killed on the battlefield.


‘Nothing could compare'

Landstuhl's head intensive-care nurse motivated by treating heroes.

FEW ARE ACQUAINTED with the physical cost of war like Army Lt. Col. Dawn Garcia. As chief nurse of Landstuhl Regional Medical Center’s intensive-care unit, she daily sees the worst of the damage: paralysis, loss of limbs, head trauma, and many other life-altering battle injuries.

This posting, her second at Landstuhl since 1999, came after an intense year of serving as head nurse in an Army combat support hospital – CSH, or “cash” – in Iraq. There, the 40-year-old Texas mother held the hands of soldiers and Marines as they died, and promised not to leave their sides. She helped stabilize thousands more patients for medical evacuation to Germany.

Now Garcia is on the other end of the flight, receiving the wounded at Landstuhl with the care and concern of a mother. Overseeing a staff of about 75 nurses and their aides, she can only be described as profoundly kind, even bubbly, and, without question, deeply in love with her work.

Q: How long have you been in the Army?
A: About 18 years. I came in right after school. My family had moved to Texas, and I needed in-state tuition. The only way to do that was to sign my name on the dotted line, so I ended up in the Army. I got my bachelor’s degree from the University of Texas and my master’s from Baylor University. I wasn’t expecting to stay forever, but here I am, 20 years later.

Q: Considering the high demand and pay for nurses in the United States, is there a temptation to leave military nursing?
A: I really haven’t thought about it yet. I don’t know what I’m going to do. The other day I was thinking I might even go to VA. I don’t know that I’m ready to give this up.
There’s no experience clinically that gives nurses more purpose than taking care of these guys. They’re our heroes; nothing could compare. After Iraq, I went back to the United States and worked for a while in an office at Brooke Army Medical Center. Then the Army called and asked me to come here. Absolutely! To work with these guys again, and to work with the nurses caring for them ... there’s nothing else I’d want to do.

Q: You spent most of 2004 down range. What was it like?
A: I was the head nurse, so I was the extra set of hands or the person getting somebody ready for something. Often, I was the one who would care for the dying. Sometimes there was nothing we could do because of the nature of their injuries, but they came to us if they were still alive. So I was there to hold their hands until they died. And I did that frequently.
I also wrote notes for their families and put them in their personal things. I don’t know if those notes ever reached them, but I felt their families needed to know they weren’t alone – that Army nurses were there with them.

Q: How quickly does an injured soldier get critical care?
A: From the battlefield to the combat support hospital, we try to get within that “miracle hour.” They come by helicopter, SUV, Bradley, tank – whatever will get the patient to the CSH. So they’ll come very quickly sometimes, depending on where they’ve been injured. We do surgery if that’s what they need; most often they do. We then stabilize them and probably within 24 to 48 hours they’re on their way out to Balad Air Base, where they pick up what they call a Critical Care Air Transport mission, CCAT, or an aerovac mission, depending on what they need. And then they’ll come to us at Landstuhl. They have an entire ICU team in flight with all the equipment. They’ll stay here another 24, 48 or 72 hours depending on their condition.

Q: How has the war strained the hospital’s ICU?
A: The population here, pre-war, was normally three to four patients at a time. I had 14 today. I have equipment to carry the unit up to 24. But when I expand I take an entire hallway, plus another unit. We take whatever space we can get.

Q: What’s the emotional toll of caring for these patients?
A: I have a tendency to get pretty attached, but I’m able to still separate myself. You’ve got to protect your own psyche, because sometimes you put yourself in their place too much. We do have a problem sometimes with compassion fatigue, so a whole team has been set up to help the nursing staff with that. We try to teach them skills to take care of themselves, like exercise and eating right. It can weigh heavily on you when you see people around you get upset by what can appear to be little things, so we want to make sure that when they go home they can readjust.

Q: Do you personally struggle with compassion fatigue?
A: Not as much as I did when in Iraq. What I did a lot was exercise, and I still do that a lot. I’d be up at 4:30 running in the gym and then go do my 12-hour shift, but there I didn’t have my second job of my family. I have a husband and two daughters here with me in Germany. I still exercise, but it’s so important to me to be involved and to care for these guys, to make sure they have the smartest people at their bedside and that the nurses have the resources they need.