Dr. Jonathan Woodson fielded e-mails in his Pentagon office last April from nervous colleagues in Boston.
His fellow vascular surgeons there wanted to know if more attacks were coming in the Marathon bombings. "When you work at the Pentagon, everyone thinks you have total situational awareness," said Dr. Woodson, assistant secretary of defense for health affairs.
Dr. Jonathan Woodson
His former colleagues, however, also wanted tips on how to care for bombing victims, and knew that military surgeons like Dr. Woodson had answers. Before President Obama tapped him in 2010 to become the military’s top doctor and oversee the Pentagon’s $50 billion-plus medical budget, he’d scrubbed in on battlefield cases in Kosovo, Iraq, and Afghanistan, in addition to performing his vascular surgery and administrative duties at Boston University and Boston Medical Center.
"We’ve been dealing with [improvised explosive device] injuries for over a decade," said Dr. Woodson, a brigadier general in the U.S. Army Reserve.
"The good news is, I had trained some of the folks who worked" on the bombing victims, and "they knew what my techniques were." Still, there were discussions about particular fixes; hypertrophic bone growths, infections, and other wound complications; and ways to help young people recover from devastating injuries. Many of the lessons came from Dr. Woodson’s military service.
The back-and-forth about the Boston attacks highlights how important it is for military and civilian physicians to cross-pollinate. In the past, "there’s always been a cadre of usually academic surgeons and physicians who maintain contact with the military. I think [it] is very important to formalize these connections. One of my strategic imperatives is to make sure we invest in partnerships [with] academic medical centers and key professional organizations" so that war innovations make it into civilian practice, and, in turn, are remembered for future conflicts.
"There’s the potential for this expertise to be lost," said Dr. Woodson, who was finishing a paper with two colleagues on the history of military medical innovations (Semin. Vasc. Surg. 2010;23:235-42) when he was nominated to serve as the secretary of defense’s principal adviser on health issues.
There’ve been many innovations in recent years, including the recognition that extensive fasciotomies can save badly damaged limbs.
At the start of Operation Iraqi Freedom in 2003, Dr. Woodson was in northern Kuwait running a makeshift U.S. military hospital out of a commandeered Kuwaiti facility. "As the troops went over the berm, we were taking the first wave of casualties," performing surgery in full chemical-attack gear. "Luckily," the incoming Scud missiles weren’t very accurate. It was a humbling experience," he said.
A young soldier was helicoptered in with a crushed leg after a hit to his armored vehicle. "We did an interposition graft to repair the popliteal artery," and, because of severe swelling, extensive fasciotomies to prevent compartment syndrome; the soldier still had his leg when he was airlifted out. Although not standard practice at the time, that case and others like it quickly demonstrated "the benefit of doing four-compartment fasciotomies early on to preserve limbs. Fasciotomies are now [used routinely] to address these injuries," Dr. Woodson said.
Tourniquets – which "prior to this conflict had a very bad reputation" – have proved their worth in recent battles as well, a lesson that helped save lives in Boston. Likewise, the military has learned the value of temporary vascular shunts, narrow tubing – most often Argyle carotid artery shunts – to bypass tears or reconnect severed vessels when there’s no time for a definitive repair. "We [also] came to understand very early on the need for aggressive blood replacement. Previously, protocols called for lactated Ringer’s or saline infusions, but we realized they just lead to massive soft tissue edema, increased lung water," and other problems, he said.
Currently, Dr. Woodson and his military colleagues are helping coach the rehabilitation of the Boston bombing victims. Rehab has seen "major advances in the military that are now finding their way into civilian practice," including improved prosthetics; better understanding of rehabilitation psychology; and recognition of subtle traumatic brain, eye, ear, and other injuries that can derail recovery efforts, he said.
"Because soldiers were athletes before [their injury], they often have aggressive goals in mind. Some want to return to swimming, surfing, or skiing. We try to meet those goals ... to get them fully reincorporated into the lives they want to lead"; adaptive sports programs help, among other things. It’s a very appropriate strategy for the Boston bombing survivors, since many were athletes, he said.