British trauma nurse goes to a small town in Germany and compares notes with the largest American military hospital outside the USA
Published: 22 July 2009
Captain Suzie Robinson visited Landstuhl Regional Medical Centre in Germany in her capacity as a Trauma Nurse Co-ordinator. Here's what she learned.
The majority of people in the UK will be unfamiliar with Landstuhl. I had certainly never heard of it until I took up post at the Royal Centre for Defence Medicine (RCDM) in Birmingham.
Landstuhl is a small town located in the Rheinland-Pfalz region and at first glance it is the same as any other German town. However, if you take a closer look, you will notice many American influences throughout the shops, restaurants and local businesses, and realise that pretty much everyone speaks English.
The reason for this is that at the top of the forested hills above the town is Landstuhl Regional Medical Center (LRMC). This is a permanent US military installation and represents the largest American military hospital outside of the US. It is classified as a Level II Trauma Center through verification by the American College of Surgeons Committee on Trauma, and the Verification Review Committee.
While the hospital provides care for some 500,000 US troops and their families stationed in Europe, combat casualties account for by far the majority of service admissions.
LRMC opened its doors in 1953, but rumour has it that it was built by Hitler, allegedly designed in such a way as to ensure if one building was bombed, the rest of the hospital would remain unaffected. This is best demonstrated in the aerial view (above), as from above the structure looks like a curved spine, with a central hallway 1.6 miles long connecting 14 individual buildings.
Optimise patients for returning home
Most US soldiers injured in operational theatres are evacuated back to LRMC within 36 to 48 hours from time of injury, with inbound flights arriving on an almost daily basis. Once at LRMC they undergo additional surgeries as required prior to transfer back to military medical facilities in the continental US (CONUS).
The aim is to optimise patients for an uneventful evacuation to the United States where they will have definitive care and family support. The average length of stay at LRMC is three days.
By comparison, a UK soldier injured in operational theatres will also be evacuated as soon as possible after injury, usually in under 24 hours if critically ill. However, they will then stay in Birmingham throughout the duration of their care (unless requiring specialist care elsewhere) and until such time as they are fit for discharge home or into a rehabilitation facility.
Therefore the length of stay can be anywhere from a few days to months, depending on the injuries and treatment required.
Imagine dealing with a 'major incident' a day
During my visit I was fortunate enough to be able to experience firsthand the entire patient pathway, witnessing the incredible daily turnover of patients. Inbound flights from Iraq and Afghanistan arrive four times a week, sometimes more, each bringing around 30 patients on them.
They are transported to LRMC from neighbouring Ramstein Air Base by specially adapted buses capable of carrying stretcher patients and are then met by teams of health care workers gathered outside the Emergency Room to take them to the appropriate part of the hospital.
In effect this constitutes a "major incident" each morning as "manpower" is called to receive this large number of patients (up to 50 on occasion). In addition, there is a Contingency Aeromedical Staging Facility, which holds patients overnight if they are being seen as outpatients, or going straight through to CONUS without requirement for hospital treatment.
The individual departments are too numerous to mention here, but essentially there are three main receiving wards, all mixed specialty, and the Intensive Care Unit (ITU). I understand there is the capability to increase capacity should the need arise.
ITU ward rounds
ITU is a large department encompassing a high dependency area too and that is one of the busiest areas in the hospital. I spent one morning on the unit observing the daily ward round, which is an extremely detailed analysis of each patient's history, diagnosis and management to date by body system presented by a medical student.
This was well attended by all disciplines, including the attending and resident intensivists, trauma surgeons, general surgeons, physicians, an infectious disease specialist, a pharmacist and a dietician.
In addition to these personnel, the Theater (note the US spelling!) Validating Flight Surgeon attends all ITU ward rounds to identify any potential issues regarding the transport of patients. It was this officer who was kind enough to invite me to accompany him on to the flight line to observe the Aeromed departure the following day.
Getting there is half the battle ...
Having managed to persuade someone to drive me the short distance to Ramstein Air Base, the simple matter of finding the building proved to be considerably more challenging than at first thought as the place was huge! It was like a small city with what seemed like endless convoluted road systems and traffic lights.
To my amusement this included roundabouts, which apparently Americans are not used to - as my driver demonstrated. After a slight detour, several phone calls and a close look at a map in a random office, we finally made it to the right building and were quite impressed to find a small welcoming committee, although it turned out to be for a visiting VIP rather than for us ... shame!
Flight line
As an Army nurse I have never been anywhere near a flight line (unless you count boarding a plane to go somewhere hot and sandy) so it was a great privilege to be able to observe the crews pre flight briefing and then go to the aircraft.
Unless there is a critically ill patient to be transported (with a doctor-led specialist team), the Aeromed personnel will be under the command of a senior nurse. Therefore, as there was no Critical Care Air Transport Team (CCATT) on this flight, it was this nurse who conducted the briefing, including every aspect of the flight from patient allocation and emergency procedures to toilet breaks.
When we reached the flight line the C17 was fully kitted out to cater for the number of patients being carried and it seemed to be waiting like some kind of beast with its jaws wide open. Three buses then arrived and backed up to the back of the aircraft.
The stretcher patients are all given a flight brief in the buses by the crew and are then taken to the aircraft first. With these outbound flights leaving three times a week, and up to 40 patients on board, it is not surprising that the loading procedure is so slick and well rehearsed.
Priority boarding - and cookies for the trip!
The crews line up either side of the aircraft with a team of four to load each stretcher upon receipt of a complicated set of hand signals and directions from the waiting medical crew. The stretchers can be stacked three high, but generally only two are used, given the difficulties of getting in and out.
The mobile patients are then loaded, along with any escorts they may have, and take their seats down the side of the aircraft.
This process takes the best part of an hour and gives the impression of organised chaos as the crew busy themselves in preparing for the transatlantic flight. The patients are all provided with bottles of water and several civilian women were speaking to each patient, and giving them cookies and good wishes for the flight. I later found out that these were officers' wives and, together with one of the chaplains, they are present at the departure of each flight.
A special relationship
My time at LRMC was fantastic and despite the constant stares at my very different uniform, everyone was so accommodating and willing to take time to speak to me - although I think there was a slight novelty value in having a British Army Officer visiting. For example, on one occasion an entire room fell silent as soon as I began to speak. Apparently they all loved my English accent, but it was very disconcerting at times!
I was even able to experience the weekly video conference between LRMC, operational theatres and CONUS Role 5 hospitals. This is considerably more protracted than the UK version, owing to the larger numbers and many echelons of care that an individual patient passes through. I am glad we don't use the video though, as it was quite difficult to find a seat that was out of the way of the camera!
Overall, it was an incredible opportunity to gain an insight into the US process of combat casualty evacuation from point of wounding to definitive care, and to compare and contrast that with the UK process.
Mutual understanding and appreciation
While many aspects are similar between the two nations, such as the methods and timeframes for evacuation from operational theatres, it was evident that there are vast differences too. These were primarily in the short length of stay at LRMC, the predominantly military environment and differing clinical practices.
With the two nations continuing to work together it is imperative that we have an understanding and appreciation of each other's approaches so that we can achieve sustained and productive working relationships.