Joining Forces and the ACS: Dr. Holcomb dedicates career to improving trauma care for soldiers and civilians

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Dr. Holcomb with his daughter Ryan Alexandra during a trauma prevention visit for her third-grade class.

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Dr. Holcomb on board an Army helicopter during a 2003 trauma consulting visit to Iraq

Editor’s note: As David Hoyt, MD, FACS, Executive Director of the American College of Surgeons (ACS), explained in his March 2012 “Looking forward” column, the College is participating in a national program known as Joining Forces. Through its participation, the ACS is partnering with a number of other health care organizations to help ensure that the veterans returning from the wars in Iraq and Afghanistan receive the compassionate care they need and deserve.

As part of this effort, the Bulletin will be running occasional profiles of ACS Fellows and other individuals who are actively involved in Joining Forces for purposes of helping other surgeons learn what they can do to help, and what initiatives they might consider implementing in their institutions. This article profiles John B. Holcomb, MD, FACS, director of the Center for Translational Injury Research; chief of the division of acute care surgery; vice-chair, department of surgery; and Jack H. Mayfield, MD, Chair in Surgery at the University of Texas Medical School, Texas Medical Center, Houston.

Retired U.S. Army Col. John B. Holcomb, MD, FACS, developed a passion for ensuring that military service people receive the best possible care on and off the battlefield in 1993, during his deployment to the east coast of Somalia, Africa. He operated on many of the U.S. casualties of the Battle of Mogadishu, perhaps the most violent episode in that conflict. One of those soldiers bled to death in Dr. Holcomb’s hands—an experience that would profoundly affect his decision to center his career on trauma surgery and research.

“Somalia was a pretty short episode. It’s interesting. People say, ‘Well, it didn’t last very long,’ but while it lasted, it was just as violent as any episode in this war,” he observed. “People talk about low-intensity conflicts. That’s a real oxymoron. Any time you have a conflict, it’s high intensity.”

Joining Forces

Dr. Holcomb subsequently deployed overseas on multiple occasions before retiring three and one-half years ago after completing more than 23 years of military service. Six of those tours of duty were for purposes of providing care to the troops in Iraq. So, it is perhaps no great surprise that he has become a proponent of the College’s involvement in the Joining Forces program. “Throughout my career as a trauma surgeon, I’ve had the opportunity to take care of many casualties, so I have sort of a personal interest in this,” he said.

Presently, Dr. Holcomb is particularly concerned about the long-term effects of the wars in the Middle East. The U.S. has been fighting in Iraq and Afghanistan for more than a decade, and nearly 2.3 million troops have been deployed. “That’s a large chunk of the population. How that number will change the United States is unclear at this point, but I think there’s no question that it will change the United States. Vietnam changed the United States; World War II changed the United States; the Korean War changed the United States at all levels; and this conflict will as well,” Dr. Holcomb noted.
The White House, the U.S. Department of Defense, Veterans Affairs, and all of the organizations participating in Joining Forces have designed the program “to anticipate, rather than to react to, those changes,” Dr. Holcomb said. More pointedly, Joining Forces is a far-reaching effort to ensure that returning troops and their families have access to education, jobs, housing, and health care.

TMC activities

The Texas Medical Center (TMC)—which includes the University of Texas (UT) School of Medicine and the Center for Translational Injury Research, where Dr. Holcomb practices, teaches, and studies trauma care—had been strategizing to implement programs that would support returning veterans before anyone at the institution had even heard of Joining Forces.

“What’s interesting is that, along with James “Red” Duke, Jr., MD, FACS, we had launched a local effort at the TMC to hire veterans, and that effort is expanding across the TMC and its 50 institutions,” Dr. Holcomb said. “Over the last couple of months, some of the institutions have hired more veterans than they would have, and then, at the same time, this [Joining Forces] effort came along, and we jumped at the opportunity to participate.”

UT’s health care-related activities are closely tied to a directive from the Association of American Medical Colleges (AAMC) and the American Association of Colleges of Osteopathic Medicine (AACOM). “What the AAMC and the AACOM have asked the medical schools to do is to raise awareness—to make sure that veterans’ issues are identified and discussed within the curriculum of the medical schools,” he said. Some key issues that Joining Forces encourages health care providers to address include traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). An estimated one in six veterans of the Iraq and Afghanistan conflicts is experiencing the life-altering effects of one or both of these conditions.

“We’ve met and discussed this with our curriculum committee, which I’m on. We’ve discussed the TBI and PTSD concepts already in our curriculum, but not in the context of veterans,” Dr. Holcomb said. He anticipates making changes in the medical school program specific to veterans’ issue starting with next year’s class.

“One of the big things that we’re going to do locally is to develop a military trauma scenario for our problem-based learning portion of the second year schedule, which will allow us to go through all the phases of trauma, including anticipation, explosion, injury, TBI, physics, evacuation, infection, rehabilitation, all the way through to PTSD,” Dr. Holcomb, who serves on the ACS Committee on Trauma, said. The curriculum will also explore the psychosocial issues associated with these conditions, their effects on veterans’ families, including children, and so on. “It will be a significant portion of the education block,” he added.

Not all institutions need to follow this model to prepare medical students for the challenges they may face when providing care to veterans. “What I like about what the Joining Forces folks have done is that they’ve said, ‘We’re not going to tell you how to do it, but we think you should do something.’ So, each school will have different ways of raising awareness of veterans’ issues, which I think is a great way to do this,” Dr. Holcomb said. “They’ve also created a website where we can share these different solutions to a common problem, so that everyone can adapt different solutions to their local institutions.”

The medical and surgical communities should be able to readily adapt to training people to deal with the effects of wartime trauma, Dr. Holcomb observed. “Certainly within the surgical community, there are a lot of veterans. Eight percent of our department of surgery is either on active duty or reservist or retired,” he noted.

Veteran surgeons at UT also try to educate surgeons who have not had military experience through their daily interactions, as well as in more formal settings.“We have grand rounds every week, and two to three grand rounds [at UT] every year are devoted to military issues. We also have the required disaster committees, which have a strong military presence,” Dr. Holcomb said.

Silver lining

Furthermore, the Center for Translational Injury Research’s efforts often focus on such issues as bleeding and resuscitation that are commonly seen on the battlefield, and their correlation to civilian patients. “A lot of the lessons learned in the military are spreading throughout the civilian trauma community,” Dr. Holcomb said. “A study we did in San Antonio showed that the PTSD rates between civilian and military burn victims were both very high. One of the things that’s under-acknowledged about civilian trauma patients is how high their PTSD rate is. One of the silver linings, I think, of the war [in Iraq and Afghanistan] will be not only a heightened awareness about veterans’ issues, which was very much lacking after the Vietnam War, but also a heightened awareness of the nonvisible injuries of civilian trauma patients.”

Furthermore, Dr. Holcomb said, “The [current] war has generated interest and funding for trauma studies. These studies are ongoing, and we anticipate great improvements in the care of trauma patients. And in the next war, which will inevitably come along at some point, we’ll have data-driven, rather than tradition-driven, treatment options and protocols.”

ACS activities

In addition to leading efforts to fulfill Joining Forces’ objectives at UT, Dr. Holcomb is playing an active role in the College’s activities in this arena. He will be participating in a panel discussion at the 2012 Clinical Congress, titled Joining Forces: How We Can Help Our Returning Vets (see sidebar for details). His portion of the program will compare and contrast military surgery with civilian practice.
Dr. Holcomb is impressed with the level of support members of the College and both the public and private sectors have shown for the Joining Forces initiative. “Everyone is really joining in to support this effort. It gives me goosebumps,” he said. “It is the right thing to do for veterans. Veterans have followed the orders from their Commander-in-Chief. They make every organization better, and we should do everything we can to help them.”

Mark your calendar:  2012 Clinical Congress session on Joining Forces

The American College of Surgeons will present Joining Forces: How We Can Help Our Returning Vets during the 2012 Clinical Congress in Chicago, IL. The session is designed to provide an overview of the Joining Forces program and to help surgeons become aware of the unique challenges facing the nation’s returning veterans and to offer insights into how to refer them to appropriate care. Following are the details that were available at press time regarding the session.

Time:     9:45–11:15 a.m
Date:     Tuesday, October 2
Location:     McCormick Place, room TBD
Moderator:     A. Brent Eastman, MD, FACS, ACS President-Elect
Co-Moderator:     Michael F. Rotondo, MD, FACS, Chair, ACS Committee on Trauma

Topics and speakers:
Joining Forces: The Structure and Goal of the Program   
Capt. Bradley Cooper, U.S. Navy, executive director of Joining Forces

The Scope and Impact of the Problem   
Jonathan Woodson, MD, FACS, Boston Medical Center, MA

Military Service versus Work in the Civilian Community 
Dr. Holcomb

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