Taste of Combat at County-USC

The young man wheeled into the emergency room at Los Angeles County-USC Medical Center had been stabbed below the collarbone almost to his back, as if he had been speared with a bayonet. A separate, twisting thrust through his belly injured several organs.

“They call it ‘the juke.’ It’s a move patented by gangs,” said surgeon John Newman. “His wounds were as devastating as anything you would see in a war.”

It was just the sort of injury the 36-year-old Navy surgeon had come to Los Angeles to learn to treat. He was training for war.

As the U.S. prepares for a possible war with Iraq, teams of Navy doctors, nurses and other medical personnel are spending monthlong stints at County-USC, treating injured patients alongside the hospital’s seasoned trauma staff.

The victims of shootings, stabbings, accidents and other traumas that the county sends to the massive hospital would resemble what military medical teams might see in battle, the Navy reasoned when it opened its Trauma Training Center in September.

“It’s a shame that Los Angeles has so much violence,” Lt. Cmdr. Newman said, “but from a training standpoint -- fantastic.”

The military has not always learned from civilian hospitals. Once, the reverse was true: Doctors learned from the battlefield.

But since Vietnam, there have been “no big wars except in our cities, where AK-47s and M-16s were being used increasingly by drug dealers and gang members,” said Dale Smith, who chairs the medical military history department at the Uniformed Services University in Bethesda, Md.

“Now,” Smith said, “the inner-city trauma room has much more trauma experience than the military hospital.”

Decades without a sustained conflict have left the military with a severe shortage of nurses and doctors with battlefield experience. For the most part, those now being deployed are family practitioners, pediatricians, gynecologists, general surgeons and other specialists with little experience in treating catastrophic wounds.

To respond to that shortage, the Navy, Army and Air Force have been training medical teams at civilian trauma centers. So far, 75 Navy men and women have gone through the program at County-USC, working in the emergency room, operating room and intensive-care unit.

One of them, surgeon Robert Izenberg, 45, said the County-USC emergency room at its busiest is “as close as you’ll get to a combat situation, except you’re not hearing gunfire or bombs going off. You have all the urgency and all the hectic nature of a mass-casualty situation.”

Cmdr. Izenberg, who left a successful practice in Newport Beach to join the Navy after the Sept. 11 terrorist attacks, was sent overseas from Camp Pendleton after his stint at County-USC.

More than 7,000 patients a year go through County-USC’s emergency room. More than 2,000 of them arrive with “penetrating trauma,” usually gunshot or knife wounds. Their arrival is sometimes announced by a public “panic button” just outside, usually punched by a gang member dropping off a wounded comrade.

“The first night I took calls here, it was unbelievable,” said Navy Cmdr. Peter Rhee, director of the Trauma Training Center. “We ended up opening five chests; we had 10 people shot in the chest. We were operating all night long. It was truly as bad as any kind of wartime experience you could have.”

The training is suddenly crucial, Rhee said. The entire Navy has only seven trauma surgeons and “can’t afford a learning curve.” In peacetime, most Navy medical personnel are more likely to treat colds, sports injuries, diabetes or retirees’ geriatric problems. Even today’s corpsmen, those charged in wartime with accompanying troops to the front and keeping the wounded alive while they are moved to mobile hospitals, lack training in trauma treatment, officials said.

“In what civilian sector would you allow your brother to go to a non-trauma hospital and be managed by and operated on by a urologist for a traumatic injury?” Rhee asked. “And yet we put able-bodied MDs in harm’s way and send them to war and expect them to take care of our brothers and sisters and children.”

Even after 22 years in the Navy, Chief Corpsman Jess Fender said he had seen only three gunshot wounds. “Unless you come to a hospital like this, you just won’t see it,” said Fender, who supervises corpsmen training at County-USC.

“I think those who benefit most are the family practice doctors [and others] who just do sick calls, stuff like that. Trauma is not their forte. And then the Navy says, ‘You go.’ Now they’re part of a trauma team.”

It was on a Wednesday afternoon that Navy and hospital staff tried to save the young man brought in with the grievous “juke” wound. His attacker had severed a main artery and injured several organs. The man had lost a lot of blood and, by the time the gurney hit the ER’s doors, his heart had stopped.

The trauma team worked frantically, intubating him, giving him IVs to stay ahead of the bleeding, clamping his aorta to route blood to his ravaged upper body. Within five minutes, they got a pulse and rushed him to the operating room.

There, corpsmen who had worked on the patient in the emergency room lingered, wanting to see the outcome, Newman recalled. Hours after surgery, the patient died. But Newman said the experience offered valuable lessons.

“The way I see it, this was the first time in history that this fleet surgical team worked together to help a combat casualty -- just on the eve of going to the Persian Gulf for war,” he said. “I’d never seen my team work under pressure -- and someone dying on you is pretty big pressure. I learned a lot. They’re a lot tougher than I thought.”

After the Gulf War, the federal government’s General Accounting Office issued a report citing inadequate preparedness for wartime among the military’s medical corps. Most of their training, the report said, consisted of classroom instruction, drills and other field exercises.

A subsequent GAO report noted a case in which “a slot for an Army thoracic surgeon was filled by a gynecologist who admitted that he was not qualified for the position because he had never opened a human chest cavity.”

In 1996, Congress passed a law requiring the Defense Department to create programs that would provide appropriate training at civilian hospitals.

The Army partnered with Jackson Memorial Hospital in Miami. Last year, the Air Force began training at R.A. Crowley Shock Trauma Center in Baltimore. Although doctors have trained sporadically at civilian hospitals before, these were the first permanent programs.

The Navy selected County-USC from among 64 trauma hospitals that expressed interest.

The Navy chose the hospital primarily for the reputation of its trauma staff and the sheer volume of patients. But the fact that County-USC doesn’t deal exclusively with trauma is also an advantage in training, Navy officials say.

Every day, workers confront rowdy or mentally ill patients; police and deputies ferry prisoners from the ER to the hospital’s jail ward; the poorest of the poor arrive seeking treatment for ailments; and a variety of foreign languages is heard.

“In war, you have to treat prisoners of war, refugees, injured civilians -- not just your own soldiers,” said Theresa Gee, an ER nursing coordinator for the program. “We got the best deal when we got County-USC. War is not all trauma. You have to help the indigent. Sometimes you embark on humanitarian operations. You get the whole experience here.”

The program works to the hospital’s benefit too.

“We get a permanent team of 12 Navy people for free, as well as a lot of other free personnel,” said Dr. Demetrios Demetriades, trauma chief at County-USC. “It’s extremely helpful for us. For instance, we can run extra operating rooms.

“For somebody who hasn’t seen a lot of trauma before, the emergency room, especially on a Friday or Saturday night, is simply overwhelming,” Demetriades said. “But it’s something you need to learn. You can’t simulate this. You really need to see the blood. They need to become accustomed to people dying. They need to become accustomed to people with multiple injuries, with a lot of confusion -- a real war situation.”