Healing the Burn
The burn center at Brooke Army Medical Center at Fort Sam Houston in Texas serves as the sole burn center for the entire Department of Defense, providing multi-disciplinary specialized care for all severe burn injuries, inhalation injuries and complex soft tissues injuries for warfighters worldwide.
By Michael Burnett
The center of all for burn wounds is the burn center at Brooke Army Medical Center.
The burn center at Brooke Army Medical Center at Fort Sam Houston in Texas serves as the sole burn center for the entire Department of Defense, providing multi-disciplinary specialized care for all severe burn injuries, inhalation injuries and complex soft tissues injuries for warfighters worldwide.
The center also treats servicemembers’ beneficiaries from time to time as well as civilians in its capacity as the only national burn center in south Texas, Army Lieutenant Colonel Evan Renz, burn center director, told Military Medical Technology.
“The skin is the largest organ system. It affects all of the other systems of the body. It has been recognized throughout the world that the most efficient and effective way to treat burn wounds is at a special life center. There are regional burn centers stood up throughout the world. It’s not unique to the military to have a specialty center. Rather, we serve as that center for the military,” Renz explained.
DoD called the burn center into action at the beginning of Operation Iraqi Freedom, stationing a rotating member of its surgical staff at the Army field hospital Balad Airbase in Baghdad. As of press time, the burn center has treated more than 700 warfighters suffering from severe burns since the beginning of the conflict. Historically, about 5-10 percent of all combat casualties sustain severe burns, which require burn center care, Renz revealed. That overall percentage has not increased during operations in Iraq.
“We have not had a higher overall percentage of burn care victims, but the difference is an increase in the survival of the more severe injuries. The overall mortality from burns at our center since the war began is right around 6 percent, which is very low,” Renz observed.
Technological Advances
Renz attributes that decrease in burn mortality rates to significant advancements in technology and techniques.
“There have been many improvements in technology and techniques since the 1970s in terms of critical care. A burn center oftentimes focuses on the critical care aspect, there have been numerous advances made in terms of ventilator management, supportive measures, renal or kidney support mechanisms, improvements in antibiotics, improvements in wound dressings, and wound care devices such as a negative pressure wound dressings and silver nylon dressings. Our understanding of severe lung injuries has improved as well as our ability to support them,” Renz described.
In addition, while the basic processes and technology of skin grafting have remained the same for many years, the burn center now has the capability to grow cultured cells in a lab and cover the skin of burn patients with the resulting tissue. Skin substitutes like Integra skin regenerative materials, manufactured by Integra Lifesciences Corp., also provide a temporary dermal layer for patients whose skin is healing.
Other devices also have greatly improved skin care for burn victims. The Versajet hydrosurgery system, manufactured by U.K. company Smith & Nephew, has increased the burn center’s ability to debride wounds to better prepare patients for skin closure. Kinetic Concepts Inc. markets a negative pressure wound dressing that also has proved invaluable in skin treatment.
“We use silver-impregnated nylon dressings, which provide anti-microbial treatment, and we are able to use those to provide very easily applied and maintained effective wound dressings,” Renz added.
The burn center is part of the Army Institute of Surgical Research (ISR), which is a subordinate command to the U.S. Army Medical Research and Materiel Command. It is housed in the Brooke Army Medical Center as a part of ISR.
The genius of the relationship between ISR and the burn center has been responsible for spurring technological advances in the care of burn patients, Renz declared. As part of ISR, the burn center has been able to collect data from patients who provide permission and conduct research on their care to apply new techniques to the next generation of warfighters.
An example of a significant leap forward in burn care was the development of the Special Medical Emergency Equipment Device (SMEED), which carries commercial off-the-shelf monitors, pumps, ventilators and additional equipment that provide treatment to burn patients as they are transported in medical litters from theater to the burn center.
“That device was designed and built by the ISR Burn Center personnel, identifying the need many years ago. That’s a piece of technology that came out of the burn center’s flight team mission. Now it’s used worldwide. It’s commercially marketed now,” Renz noted.
Another technological leap will spring from resuscitation devices being developed now by the burn center, Renz predicted, as they may well become part of the standard process for treating burn patients.
“We use what’s called digital urimetry,” Renz elaborated. “We use devices to measure urine output in a detailed manner and record that to help us to assist in resuscitation process. We took that readily available technology, worked with companies to improve it for mobility so that we could use it in the field to allow us to help victims earlier, and then we tie that in with lighter, better, more capable equipment that we can use during a long-range evacuation process.”
That advancement gets warfighters to a higher level of care faster and then enables their transport to the burn center from anywhere in the world, despite critical injuries.
Burn Flight Team
Many of the innovations in military burn care have come in augmenting the capabilities of the burn flight team, which transports patients out of theater and back to the ISR Burn Center. The team has transported hundreds of critically injured patients out of Iraq over the duration of the conflict there.
A patient injured in Baghdad, for example, would likely go to the field hospital at Balad, where the burn center surgeon, known as the theater burn consultant, would determine their status. If the patient must be evacuated, the Army would usually send them to Landstuhl Regional Medical Center in Germany. If necessary, the burn flight team will travel from San Antonio to Germany to retrieve the patient.
“Many times, the only time we are not at their side is from that flight from Balad to Landstuhl. We try to get involved with their care as soon as possible if they have a severe injury,” Renz said.
Severe burn patients go to the center from all over the world, regardless of whether they are injured in combat or somewhere else as a military servicemember.
“Whether it’s a ship accident in Guam or a soldier injured in Italy—anywhere in the world—that request comes here for them to transfer here,” Renz said. “We have treated just over 700 combat casualties with burns since the war began. We also have treated an additional number of patients who weren’t necessarily injured in combat.”
Once injured warfighters arrive at the burn center, their care becomes very similar to that of civilians with severe burns.
“The difference between military and civilian often lies in the nature of the injury—the fact that military injuries are usually related to an explosion,” Renz explained. “They are very dirty, they are contaminated, and they oftentimes have fairly significant large soft tissue injuries associated with them.
“We work closely with our orthopedic colleagues. They are often frustrated by the fact that there may be a fracture, but then with that fracture there are open wounds and no soft tissues to cover the fracture. So you have these complex soft tissue wounds that include burns. That complicates everybody’s work. We don’t see a lot of that in a civilian patient,” he added.
The need for teamwork across disciplines really distinguishes the ISR Burn Center from other facilities around the world. Renz, who has served at the burn center for five years, recently became director after service as the assistant director of the center. In that time, he has witnessed the multiple disciplines of the burn center come together to effectively treat complex burns with additional injuries, providing a level of total care unavailable at other facilities.
The ISR Burn Center is the only center certified by the American Burn Association for the DoD, but it also is one of the few in the nation that is combined with a Level 1 trauma center, boosting its capabilities to care for complex injuries.
“We have trauma critical care surgeons combined with critical care nurses, and our own staff of respiratory therapists, anesthesiologists, occupational therapists, and physical therapists. We have every specialty in our center,” Renz proclaimed.
“Our patients get multi-disciplinary care continuously. That’s the key advantage of a burn center. You don’t have to go someplace else. We work as a team. The team approach to care makes the biggest difference.” ♦