The Unreal World: ‘Combat Hospital’ on ABC

‘Combat Hospital’

10 p.m. Aug. 9, ABC

Episode: “On the Brink”

The premise: “Combat Hospital” is set at a military hospital in Kandahar, Afghanistan, where doctors and nurses from the International Security Assistance Force (Canada, U.S., Britain, Australia, Germany and other allied countries) take care of those injured in the war. In this episode, a military driver crashes into a bus with civilians, which catches fire. A severely burned young woman is among those brought to the hospital. Trauma team leader Dr. Bobby Trang (Terry Chen) uses a technique called the “rule of nines” to determine that 45% of her body is burned and therefore that she can be saved. But nursing chief Will Royal (Arnold Pinnock) believes that the patient’s wounds are much more extensive and that she will require many hours of nursing care to treat the wounds as well as multiple surgeries to excise the burns and graft new skin on them — and ultimately will die anyway. He says the patient should be allowed to die or be transferred to a civilian hospital. Trang proceeds anyway. The patient, who is having trouble breathing and is in shock from loss of fluids through the burns, is placed on a respirator and treated with fluids. She undergoes escharotomies — multiple incisions cut through the dead tissue of the burn to make sure that its thick hardness doesn’t compress and damage tissue underneath it. Trang says she needs to be watched for infection (for which she is placed on antibiotics) and rhabdomyolysis (muscle breakdown). She develops rhabdo and he treats her by cooling her off and administering a muscle relaxant, more fluids and sodium bicarbonate to “flush out the myoglobin” from the damaged muscle. In spite of all this, the patient goes into cardiac arrest and dies.

The medical questions: What is the rule of nines, and how accurate is it? Is there a point where a patient with severe burns is beyond hope? Would such a patient be transferred to a civilian hospital? Are fluid resuscitation, antibiotics, escharotomies and repeated surgeries to excise and graft the burns the correct approach? Is rhabdomyolysis a common cause of death in this setting and was it treated appropriately?

The reality: The rule of nines is a widely used method to estimate the percentage of body that has been burned, says Dr. Martin A. Schreiber, a lieutenant colonel who is chief of trauma, critical care and acute care surgery at Oregon Health & Science University in Portland and former joint theater trauma systems director for the U.S. Army in Afghanistan. Each large body area is considered 9% of the entire body or multiples thereof: The head is 9%, each leg 18%, each arm 9% and the trunk 36% (the area around the groin is the final 1%). This estimation is then used to determine how much fluid is needed to replenish the amount that is lost through the burned skin. Half is given in the first eight hours and the rest is given over the next 16 hours. The rule of nines is considered to be a valuable and accurate tool.

There is a point when burns are so severe that health teams do not try to save a patient, Schreiber says, but 45% is far from that point (it would occur when a large majority of skin was covered with third-degree burns). Death following burns is determined by three factors, adds Dr. Demetrios Demetriades, director of trauma, emergency surgery and surgical critical care at Los Angeles County-USC Medical Center: the extent of burns, age of victim and inhalation injuries.

The fire occurred in a bus, Demetriades points out. This would mean inhalation of toxic fumes in addition to burns, increasing mortality significantly. He says this should have been mentioned on the show and that patients should have been evaluated by bronchoscopy.

A patient would not be considered for transfer, as the show suggests, unless there were a nearby burn center. “When we are responsible for injuring the civilians, we would take responsibility for treating them,” Schreiber says.

When burns go all the way around the trunk or extremities they can form a tight band and prevent people from breathing or blood from reaching the extremities, Schreiber says. The cuts of escharotomies open up these bands and allow the wounds to decompress. Repeated surgeries to excise dead tissue and graft new skin are crucial in burn care. But administering antibiotics without evidence of infection hasn’t been proved helpful.

Rhabdomyolysis is a breakdown of muscle fibers that causes release of the muscle protein myoglobin into the blood. It can occur if the burn involves muscle tissue but only if escharotomies are not done early enough, Demetriades says. Rhabdomyolysis can injure the kidneys and it is treated by giving fluid to flush the organs. Bicarbonate is typically given to treat the acid that accumulates in blood following muscle death but has not been shown to prevent kidney failure.

Siegel is an associate professor of medicine at New York University Langone Medical Center. His new book is “The Inner Pulse: Unlocking the Secret Code of Sickness and Health.”

marc@doctorsiegel.com