REPORT ON THE OBSERVER TRAINING AT BROOKE ARMY MEDICAL CENTER IN SAN ANTONIO, TEXAS, USA

In the period between June 27 and August 26, 2016, I had the opportunity to visit the well-known Brooke Army Medical Center (BAMC) situated in San Antonio, Texas, USA and its Burn Center and Plastic Surgery Department. During a two-month long observation, I was primarily interested in reconstructive surgery after disfiguring injuries and burns, and I was able to attend a five-day microvascular course. The rest of the time I observed interesting surgeries in plastic surgery operating rooms in order to compare techniques and methods of treatment in the U.S. and the Czech Republic.

I was able to participate in this Observer Training thanks to the International Military Education and Training (IMET) program. According to the United States State Department, the IMET program provides training and education to students from allied and friendly nations. The program is funded by the U.S. government, and its main goal is to improve reciprocal understanding and defense cooperation between the U.S. and foreign allied countries. IMET provides more than 4,000 courses focused on the enhancement of cooperation skills during collective military operations. These courses are taught at approximately 150 military schools, installations, and military hospitals, ¹ including the BAMC.

BAMC is the largest U.S. military healthcare organization with approximately 8,500 staff members, including military personnel as well as civilian employees. At the heart of BAMC is the San Antonio Military Medical Center (SAMMC), which provides care for up to 425 military and civilian inpatients and more than 2,000 outpatients each day². SAMMC is situated in Fort Sam Houston, a U.S. Military installation in San Antonio, Texas. From the World War II to the present days, the BAMC has had a long history of burn care and research development. The famous Brooke formula, the formula for initial 24-hour fluid resuscitation of the severely burned patient, was developed here. BAMC serves as the only U.S. military Burn Center and cares for combat burn casualties as well as civilian emergencies.

The Burn Center itself uses 40 beds including twelve ICU boxes heated to human body temperature and two operating rooms. It is the top-class burn center providing cutting-edge treatment. The system of care is based on physician assistants (PAs) and nurses. PAs are healthcare professionals who usually have master’s degrees, and they help doctors with uncomplicated activities such as taking patient history, performing examinations, and prescribing medications. Some PAs run inpatient wards and some are allowed to attend surgical procedures in order to assist the surgeons. There are several types of nurses in the U.S. and some of them are authorized to work more independently than nurses in the Czech Republic. Compared to the number of patients, there are more nurses in the U.S. than in the Czech Republic, and many of them are men. For example, at ICU the nurses are in charge of routine dressing changes without any supervision by the physicians. Besides the inpatient part of the center, there is also an outpatient department called the Burn Clinic, where long term follow up and dressing changes take place. Most of the follow-ups are carried out without direct physician presence by physician assistants only. The above mentioned differences are the main reasons why significantly fewer physicians are needed in the U.S. than in the Czech Republic.

For the majority of the time at SAMMC, I observed the work of Dr. Rodney K. Chan, the reconstructive plastic surgeon assigned to the Burn Center. The wide range of his work consisted of reconstructive surgery after serious burns, amputated extremities, and also of soft tissue defects after open fractures. At SAMMC I had a chance to see many burn patients with scar contractures, patients with abdominal wall defects after open abdominal surgery, or large reconstructive cases of defects with exposed bone/tendon/ligament, as well as a self-inflicted gunshot injury to the face following a suicide attempt. Dr. Chan is an internationally known reconstructive plastic surgeon and skilled microsurgeon. He has contributed to more than 50 publications on various plastic surgery topics, and he was also a member of Dr. Pomahač’s team during the first full face transplantation in the U.S.

During my stay, I was happy to attend the BAMC Microvascular Course organized under the supervision of Dr. Peter Ch. Rhee, the Chief of Hand and Microvascular Surgery. The course focused on the training of microsurgical techniques on rats under microscope control in a live animal laboratory. The course was limited to only six residents, with four surgical microscopes to work with, providing each participant significant hands-on experience and staff guidance. During the five days in the live animal lab, we practiced not only end-to-end femoral artery and vein anastomoses, but also end-to-side femoral vein to artery anastomosis and even interposition of superficial epigastric vein graft into the femoral artery. These vessels, just 1mm in diameter or less, challenged the surgical skills of all participants. It was a rewarding experience because microsurgical skills are becoming more and more essential to the cutting-edge plastic surgeon.

Besides the time spent at the Burn Center and at the microvascular course, I also observed numerous interesting procedures in other operating rooms. I spent most of the time at Plastic Surgery Department, but several times I went to observe surgeries at the Ear, Nose, Throat operating room. I was surprised that their specialists did a lot of reconstructions after tumor resections by themselves without any assistance of plastic surgeons. For instance, twice I saw an impressive hemiglossectomy with immediate reconstruction utilizing a radial forearm free flap. In Plastic Surgery operating rooms (apart from the aesthetic procedures), I had the opportunity to follow cutting-edge breast reconstruction surgeries, fat grafting and multiple stage tissue expander procedures which were, little by little, supposed to remove a giant congenital pigmented nevus or a large skin grafted area. I also appreciated that I was able to become familiar with a wide range of modern technologies such as the Venous Coupler Doppler (a Doppler probe incorporated into a venous coupling device in order to monitor a free flap postoperatively), the ViOptix Tissue Oximeter (a system of near infrared spectroscopy for the monitoring of a free flap), and a fluorescence imaging system (SPY Elite) that enables surgeons to intraoperatively visualize microvascular blood flow and perfusion in tissue and therefore avoid ischemic complications. Although these technologies are currently too expensive to be used widely in plastic surgery departments in the Czech Republic, this will hopefully change over the course of the time.

Unfortunately, the U.S. law system does not recognize any foreign country university school of medicine, therefore I was not allowed to take part in a process of treating patients, and I could not even scrub into the surgeries. Nevertheless, I consider my observations a great experience, and I think I have learned a lot. During the time spent in and out of the operating rooms, I had the opportunity to discuss various topics of reconstructive and plastic surgery with Dr. Chan and other attending surgeons assigned to the Plastic Surgery department. With great interest, we discussed and compared procedures and methods used in the U.S. and the Czech Republic. I noted that the training of residents is much more systematic and sophisticated in the U.S. and I personally consider it to be far better than the Czech style. The system motivates tutors to share their experience and knowledge with their residents. This is demonstrated especially in the operating rooms where residents actively participate in majority of the surgical procedures.

In conclusion, the entire observation took place in a very pleasant and friendly atmosphere, and I would like to thank Dr. Chan, his resident Dr. True, and the other staff from the Burn Center and Plastic Surgery Clinic for their interest and helpfulness which enabled me to gain considerable knowledge and experience. Last but not least, I would also like to thank all staff from the International Military Students Office at Fort Sam for their support and hospitality, without which none of this would have been possible.

Corresponding author:

Adam Bajus, M.D.

Division of Plastic Reconstructive Surgery and Burns Treatment

Department of Surgery, University Hospital

Sokolská 581

CZ – 500 05 Hradec Králové,

Czech Republic

E-mail adam.bajus@fnhk.cz