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Preparing for trauma of war - Lessons learned from front line surgery

by David Scott

doctor in e.r.

It’s one of the only times doctors don’t want to see healthy patients: when training surgeons to perform in a war zone.

“You can’t maintain your competence if all you’re doing is dealing with a healthy population,” says Dr. D. Ross Brown, BSc’77 (MD, McMaster, MA, Royal Roads), co-founder and Medical Director of the Canadian Forces Trauma Training Centre in Vancouver.

Brown should know.

Aside from being a trauma and general surgeon at Vancouver General Hospital (VGH) and clinical professor in the department of surgery at the University of British Columbia (UBC), he has spent 25 years with the Canadian Forces in various ranks and roles, and done tours of duty in Bosnia and Afghanistan.

“In those early days when I deployed, I was there with people who came out of a clinic or people whose O.R. experience was doing hemorrhoids and hernias.”

When the medical team arrived in Afghanistan for Brown’s 2003 tour, the logistics were setting up and organizing the camp and initially dealing with lots of medical ailments. Then there was the inevitable wait for casualties, an intimidating experience for anyone.

“As the tour went on, our troops were deploying a little further. There were deaths. There were mine strikes as they call it. We had casualties. So, it did bring a different level of awareness.”

Dr. Brown said the surgical unit was still doing a lot of “on standby” for missions. “But the intensity that was in Kabul increased. Then by the time we went down south to Kandahar, that was full-on war all around us.”

In a kidding way, the surgeon says his three tours in Afghanistan were a bit like the Three Little Pigs where he went from a tent on a Canadian base with just his Canadian team to eventually the ‘brick house’ hospital.

The Straw House - or Tent
“That was one surgeon, one anesthetist, and all the support around. That was an O.R. nurse, small diagnostic imaging contingent, some primary care doctors and physician assistants and medics. And of course an ambulance group with our armoured ambulance, who would go out and pick up casualties as required. I think the number in total would have been about 50 – not that big.”

The Stick House - or “Plywood Hospital”
Then, Brown’s team moved down to Kandahar, Canada’s responsibility as the lead nation for the multinational medical facility at the Kandahar airfield. “That was a huge responsibility for Canada. In those early days, we had some fantastic leadership amongst our military commanders. They lived there and ran that organization for a year.”

Then the Canadians were combined mainly with medical colleagues from the Netherlands and Denmark as the core group.

Canada did that for about five years and then handed leadership over to the Americans. “While we were in command, that was the ‘plywood hospital.’ We went from canvas to plywood. That’s the hospital the TV program ‘Combat Hospital’ was based on, with Canadian leadership, primarily Canadian contingents, not only clinicians but the headquarters component as well.”

As Brown relates, Canada had not taken on a military/medical commitment of those proportions in an international conflict since the Korean War.

The Brick House – or Brick Hospital

“And then finally when we handed it over to the Americans, we moved into a brick hospital. By then, there would have been between 110 to 150 medical staff in that building. A large Emergency department, 12 resuscitation bays, five full resuscitation teams, that was the core group. There were two or three general surgeons; orthopaedic surgery, neurosurgery, ENT, oromaxillary. So, we had quite a large surgical group. Of course a big component of nurses, med techs, O.R. techs. And diagnostic imaging – we had two CT scans.”

The facility was actually accredited through the American College of Surgeons as a Trauma Centre.

“That was an important milestone for them. That was sort of the transition and that still exists. Now it’s American-run.” Canada is now in a mentoring role. “One of our colleagues in London, Dr. Vivian McAlister (Western professor), has been over there working very hard in a mentoring leadership role, now back in Kabul helping with their surgical education program for Afghanistan at the University of Kabul.”

Brown admits the experience that the medical and surgical teams picked up around Kandahar was “truly war surgery.” Those were lessons of trauma surgery he could bring back and share not only with the military but with VGH Trauma Services and UBC.

Most large hospitals today in Canada have constant competition for resources – from those trying to do emergency surgery, to those planning oncology surgery, to thosedoing elective surgery.

“That challenge of resource in North America, where we are so rich and have so much, is very different to when you’re in an emergency field hospital just waiting for the casualties to come in. Of course you never say no. You always receive.”

Things not considered in the civilian medical world include how to deal with the “evacuation chain” of returning coalition troops back to their home country if they are too injured to continue fighting – and what to do with local nationals? In the case of Kandahar, the Afghan army and the Afghan national police.

As any viewer of evening news knows, civilians unfortunately are also victims of war. How does a foreign army medical unit deal with civilians and release them safely? “There are ethical challenges dealing with care in a war zone where our own resources are limited to an extent and you’re always thinking of the cases ahead,” says Brown.

“How do we manage our non-combatants and how do you manage ‘peoples of interest,’ or perhaps Prisoners of War (POWs)? Again, those were great lessons to bring back and share with our colleagues here.”

Canadian Forces Trauma Training Centre

It was in the 1990s when Dr. Brown had the opportunity to meet the founding members of what was then called the Joint Trauma Training Centre in the U.S.

“I’d been to Taub in Texas (Ben Taub General Hospital, Houston). The military on both sides of the border recognized in the early to mid 1990s that in order to maintain the competence of our medical personnel, to enable them to deploy into war zones, conflict zones, high risk zones, they needed to maintain their skills in a rich environment.”

What that meant in the U.S. was taking their military medical teams that were about to deploy and put these 30 or 40 people into an inner-city hospital in a big city, in the “shooting gallery” where they could get firsthand experience with penetrating trauma. (That’s a nice term for gunshot, bullet and stabbing wounds).

Brown returned and put a proposal together for the Canadian Forces, offering tostay in Vancouver where he could learn more and solidify his skills.

“The military didn’t quite know how to do that because nobody had done that before. “So then I looked at that Ben Taub model that the Americans were doing and the Joint Trauma Training Centre and I just proposed it to the military… I said this is working for me. We need to do this for others. We need to create a training program.”

It was years in the making but the Canadian Forces Trauma Training Centre, cofounded by Brown, officially opened in May 2001, just months before 9/11.

“And at 9/11, we had a group of students here in the building, learning and maintaining skills and being ready to deploy. But it was quite timely for those early 2000s and the problems and challenges the military had or that Canada had and our commitment into Afghanistan after that.”

Dr. Brown has ventured where other Western University-affiliated doctors have served in foreign war zones. He has encountered and worked with professor and surgeon Dr. Vivian McAlister and Dr. Raymond Kao, recently named the Group Captain G. Edward Hall Chair in Military Critical Care Research, named after Western’s former Dean of Medicine and longest-serving president.

Order of Military Merit
Cmdr. Ross Brown received the insignia of Officer of the Order of Military Merit from Her Excellency, Michaelle Jean, Governor General and Commander in Chief of Canada at a ceremony in Rideau Hall on Nov. 9, 2007. “For the military, that’s a real highlight award. To be recognized in that way is very rewarding ... It means a lot.” The Order of Military Merit was created in 1972, to recognize meritorious service and devotion by members of the Canadian Forces. The Order has three levels, Commander, Officer and Member and is next in precedence to the Order of Canada.

This article appeared in the Alumni Gazette
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