Management of Dismounted Complex Blast Injury Patients at a Role V Military Treatment Facility: Special Considerations

  • John S. Oh
  • Ashley E. Humphries


Since 2001, the Walter Reed Army Medical Center in Washington, DC, and the National Naval Medical Center in Bethesda, Maryland, served as military Role V hospitals in the National Capital Area and in 2011 combined to form the Walter Reed National Military Medical Center (WRNMMC). Throughout this time, dismounted complex blast injury patients received comprehensive care at these facilities. This included a team of surgeons, subspecialty consultants, case managers, rehabilitation specialists, medics, corpsmen, and technicians. A dedicated trauma service oversaw the management of all those wounded in combat. This trauma service established a system of quality assurance, safety, performance improvement, and research with the complex surgical patient at the center. The American College of Surgeons verified WRNMMC as a trauma center based upon the institutional successes of the trauma program. The lessons learned from this historic program are presented here.


Dismounted complex blast injury Trauma program Combat wounded Rehabilitation Polytrauma Traumatic brain injury 


  1. 1.
    Dismounted Complex Blast Injury: Report of the Army Dismounted Complex Blast Injury Task Force. 18 June 2011. Accessed 17 July 2017.
  2. 2.
    Lewandowski LR, Weintrob AC, Tribble DR, Rodriguez CJ, Petfield J, Lloyd BA, Murray CK, Stinner D, Aggarwal D, Shaikh F, Potter BK, The IDCRP Outcomes Study Group. Early complications and outcomes in combat injury related invasive fungal wound infections: a case-control analysis. J Orthop Trauma. 2016 March;30(3):e92–9.CrossRefGoogle Scholar
  3. 3.
    Polytrauma/TBI System of Care. U.S. Department of Veterans Affairs. Retrieved from Accessed 27 Dec 2016.
  4. 4.
    Gironda RJ, Clark ME, Ruff RL, Chait S, Craine M, Walker R, Scholten J. Traumatic brain injury, polytrauma, and pain: challenges and treatment strategies for the polytrauma rehabilitation. Rehabil Psychol. 2009;54(3):247–58.CrossRefGoogle Scholar
  5. 5.
    Uomoto JM, Williams RM. Post-acute polytrauma rehabilitation and integrated care of returning veterans: toward a holistic approach. Rehabil Psychol. 2009;54(3):259–69.CrossRefGoogle Scholar
  6. 6.
    Stojadinovic A, Auton A, Peoples GE, McKnight GM, Shields C, Croll SM, Bleckner LL, Winkley J, Maniscalco-Theberge ME, Buckenmaier CC. Responding to challenges in modern combat casualty care: innovative use of advanced regional anesthesia. Pain Med. 2006;7(4):330–8.CrossRefGoogle Scholar
  7. 7.
    Rodriguez CJ, Weintrob AC, Shah J, Malone D, Dunne JR, Weisbrod AB, Lloyd BA, Warkentien TE, Murray CK, Wilkins K, Shaikh F, Carson ML, Aggarwal D, Tribble DR, Infectious Disease Clinical Research Program Trauma Infectious Disease Outcomes Study Group. Risk factors associated with invasive fungal infections in combat trauma. Surg Infect. 2014;15(5):521–6.CrossRefGoogle Scholar
  8. 8.
    Tribble DR, Rodriguez CJ. Combat-related invasive fungal wound infections. Curr Fungal Infect Rep. 2014;8(4):277–86.CrossRefGoogle Scholar
  9. 9.
    Weintrob AC, Weisbrod AB, Dunne JR, Rodriguez CJ, Malone D, Lloyd BA, Warkentien TE, Wells J, Murray CK, Bradley W, Shaikh F, Shah J, Aggrawal D, Carson ML, Tribble DR, The IDCRP TIDOS Study Group. Combat trauma-associated invasive fungal wound infections: epidemiology and clinical classification. Epidemiol Infect. 2015;143(1):214–24.CrossRefGoogle Scholar
  10. 10.
    Rodriguez CJ, Weintrob AC, Dunne JR, Weisbrod AB, Lloye B, Warkentien T, Malone D, Wells J, Murray CK, Shaikh BW, Shah J, Carson ML, Aggarwal D, Tribble DR, The IDCRP TIDOs Study Team. Clinical relevance of mold culture positivity with and without recurrent wound necrosis following combat-related injuries. J Trauma Acute Care Surg. 2014;77(5):769–73.CrossRefGoogle Scholar
  11. 11.
    Rodriguez, Tribble, Murray, Jessie, Khan, Fleming, Potter, Gordon, Shackelford. “Invasive Fungal Infection in War Wounds”. Joint Trauma System Clinical Practice Guideline. August 2016, published online. . Accessed 6/26/2017.
  12. 12.
    Lewandowski L, Purcell R, Fleming M, Gordon W. The use of dilute Dakin’s solution fo the treatment of Angioinvasive fungal infection in the combat wounded: a case series. Mil Med. 2013;178(4):e503–7.CrossRefGoogle Scholar
  13. 13.
    Elke G, van Zanten A, Lemieux M, McCall M, Jeejeebhoy K, Kott M, Jiang X, Day A, Heyland D. Enteral versus parenteral nutrition in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials. Crit Care. 2016;20:117. Published online 2016 Apr 29.CrossRefGoogle Scholar
  14. 14.
    Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feedings: techniques, problems, and solutions. World J Gastroenerol. 2014;20(26):8505–24.CrossRefGoogle Scholar
  15. 15.
    Practice Guidelines for Preoperative Fasting and the Use of Phamacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495–511.Google Scholar
  16. 16.
    Fang R. Venous thromobembolism among military combat casualties. Current Trauma Rep. 2016;2(1):48–53.CrossRefGoogle Scholar
  17. 17.
    Holley AB, Petteys S, Mitchell JD, Holley PR, Collen JF. Thromboprophylaxis and VTE rates in soldiers wounded in operation enduring freedom and operation Iraqi freedom. Chest. 2013;144(3):966–73.CrossRefGoogle Scholar
  18. 18.
    Caruso JD, Elster EA, Rodriguez CJ. Epidural placement does not result in an increased incidence of venous thromboembolism in combat-wounded patients. J Trauma Acute Care Surg. 2014;77(1):61–6.CrossRefGoogle Scholar
  19. 19.
    Grabo, Seery, Bradley, Zakaluzny, Kearns, Fernandez, Tadlock. “The Prevention of Deep Venous Thrombosis- Inferior Vena Cava Filter”: Joint Clinical Practice Guidelines published online. Accessed 3 July 2017.
  20. 20.
    Lucas DJ, Dunne JR, Rodriguez CJ, Curry KM, Elster E, Vicente D, Malone DL. Dedicated tracking of patients with retrievable IVC filters improves retrieval rates. Am Surg. 2012 Aug;78(8):870–4.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Surgery, Division of TraumaMilton S. Hershey Medical CenterHersheyUSA
  2. 2.Department of General SurgeryWalter Reed National Military Medical CenterBethesdaUSA

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