University of Cincinnati, Department of Surgery
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Research

UC Institute for Military Medicine

Certain major advances in the science of surgery have stemmed directly from experiences with medical care provided during prior military conflicts. Every military conflict, including those currently engaged, has presented unique challenges requiring unique innovative solutions. Invariably these solutions have regularly translated to improving civilian medical and surgical care. Our Department of Surgery has been fortunate to partner with the military to educate military medical service providers, and to better understand how to successfully treat the injured soldier. We have made substantial progress in this area and see the potential for even greater progress. To facilitate our mutual progress, we have recently partnered with other University of Cincinnati colleges and departments to establish the UC Institute for Military Medicine. We aim to further advance the state-of-the-art of military medicine through cutting-edge educational programs and research advances here at the University of Cincinnati. The specific missions of this institute are: (1) to provide state-of-the-art training for those caring for our wounded soldiers; (2) to discover new knowledge to develop improved and innovative treatment approaches for the acutely injured patient; (3) to prepare and train the next generation of surgical leaders; and (4) to advance the care of the acutely injured patient.

State-of-the-Art Training

The UC Institute for Military Medicine serves as one of three nationally recognized U.S. Air Force Centers for the Sustainment of Trauma and Readiness Skills (C-STARS) training. This unique collaborative program provides specialized training to members of the Air Force’s elite Critical Care Air Transport Teams (CCATT), who care for and transport severely injured soldiers around the world. The University of Cincinnati C-STARS program has garnered significant national recognition for the achievement of quality and efficiency in this most complex educational process. Faculty members have personally committed to the program, with five having been previously deployed to the combat support hospital at Balad Air Base, Iraq. These include Dr. Jay Johannigman, Director of the Division of Trauma and Critical Care, Dr. Warren Dorlac, former Director of C-STARS Cincinnati and Dr. Michael Petro, current Director of C-STARS Cincinnati.

Since the C-STARS program began in 2004, more than 300 medics and ancillary staff have been trained at the C-STARS Cincinnati facility at University Hospital, the only verified Adult Level 1 Trauma Center in the region, serving Southwestern Ohio, Northern Kentucky and Southeastern Indiana.

With the support and cooperation of our University Hospital, the C-STARS team has developed a one-of-a-kind, high-fidelity simulation training center which incorporates two adult simulator mannequins positioned in a flight cabin. The center is capable of generating physiologic signs such as respiration, peripheral pulses and cardiac arrhythmias in the mannequins, while at the same simulating the in-flight environment. The mannequins have been programmed to mimic the medical conditions encountered during the evacuation of combat casualties. In addition, the physical environment of the simulation center mimics the low-light and high noise environment encountered when moving injured soldiers from a combat zone. The University of Cincinnati C-STARS program has received letters from deployed CCATT students who have credited their experience in the Cincinnati C-STARS simulation center with being responsible for improving care and saving many soldiers’ lives.

Improving Treatment Approaches with New Knowledge

The UC Institute for Military Medicine fosters synergistic collaborations from a variety of expert specialty and scientific disciplines, all focused on determining how traumatic injuries lead to disruptive changes at the clinical, organ, tissue, cellular and molecular levels. We have learned that this knowledge leads to a better understanding of those factors that contribute to increased rates of infection, multiple organ failure and death. The organization of this research group provides a unique interdisciplinary approach that advances a “battlefield to bench to bedside” mission of understanding and discovery. Current projects conducted by our research team are funded by the Department of Defense, United States Air Force, Office of Naval Research, the National Aeronautics and Space Administration (NASA) and the National Institutes of Health. Currently active research projects include:

• Development of a closed-loop inspired oxygen controller for critically injured patients requiring mechanical ventilation. This system has the potential to revolutionize military patient care by providing sophisticated respiratory support in remote and austere environments. The unit being developed is completely automated and does not require the usual personnel to maintain conventional ventilators. In addition, this system delivers oxygen more efficiently than its conventional counterpart and therefore will conserve this most critical resource in times of resuscitation on the battlefield and during aero-medical transport.

• Development of oxygen concentrators for use at high altitudes and/or space. Missions conducted during aeromedical evacuation of the injured require supplemental oxygen delivery. Carrying oxygen stores during aero-medical evacuation constitutes a cargo problem as well as an increased risk of fire. Development of oxygen concentrators has the potential to reduce both the amount of stored oxygen needed and the associated fire hazard.

• Elucidating the effects of altitude on injured soldiers during aero-medical evacuation. Severely wounded soldiers in Iraq and Afghanistan are stabilized in theater and then rapidly transported by plane to hospitals in Germany and the United States (usually within the first 24 hours after wounding). It is vitally important to understand if the aeromedical evacuation has an effect on existing injuries. This project models an injury in animals and tests the effects of high altitude on the ultimate recovery and resolution of these injuries. The ultimate goals are to determine the biological mechanism by which high altitude affects existing injuries and, secondly, to determine the best time after severe injury for aero-medical evacuation.

• Monitoring of intra-cranial pressure response in patient with traumatic brain injury. Increased intra-cranial pressure following traumatic brain injury adversely impacts the likelihood of recovery and worsens the brain injury. Monitoring and control of the pressure inside the head is critical to recovery. The research group at the UC Institute for Military Medicine has designed a novel data logging device which allows for the continuous recording of the pressure within the head of an injured patient. This monitor has been used in preliminary studies to examine the effects of aero-medical transport and will be utilized in a civilian setting to monitor patient response to promising novel treatment approaches.

• Evaluation of resuscitation strategies for hemorrhagic shock. Massive blood loss is a leading cause of death amongst wounded soldiers. Different fluid replacement strategies for resuscitation have been proposed. The Institute is actively engaged with leading research teams in assessing the efficacy of different fluid replacement strategies, with emphasis on how these strategies ultimately affect organ function and host survival.

• Repair of burn injury with autologous engineered skin substitutes. Burn injury is a major cause of combat-related morbidity and mortality. Our institution has pioneered the development and application of autologous engineered skin substitutes for the treatment of severe burn injury. These substitutes are derived from the patient’s own skin and therefore are not rejected. This project will further develop the use of these skin substitutes such that they have improved blood supply and pigmentation which will increase graft success.

Training Future Leaders to Advance the Care of the Acutely Injured

The Department of Surgery is home to a basic research training program funded by the National Institutes of Health. This program provides surgical residents and research scientists with focused training at the cellular and molecular levels in defining the host response to traumatic injury. This program is unique in that it is tightly coupled to the research activities of the UC Institute of Military Medicine. We are training the next generation of surgeon scientists who will apply their knowledge to addressing problems associated with the types of injuries sustained during military conflict. The program funds surgical residents and post-doctoral research fellows for a period of 2-3 years to conduct research on topics related to injury biology. Examples of current trainee projects include physiologic and pathologic responses and survival as a result of different fluid resuscitation strategies for hemorrhagic shock, and determining the effects of traumatic brain injury on the systemic inflammatory response. This training program is in its 16th year and to date has trained over 30 individuals.

One of the past trainees in this program is Dr. Timothy Pritts, Associate Professor of Surgery, Division of Trauma and Critical Care, and former Director of the Residency Training Program in General Surgery.Dr. Pritts is an integral member of the Institute who has both clinical and research expertise. His current research involves the molecular mechanisms by which burn injury results in systemic inflammation and organ dysfunction.

The Department of Surgery has been fortunate to work with United States Air Force residents based at Wright-Patterson AFB as they collaborate with surgeon/scientists in the laboratory on scientific projects related to organ, tissue, cellular and molecular changes caused by trauma. Residents participate for a one-year rotation, focusing on assignments that concentrate on improving care for the wounded warrior. In addition, the department accepts undergraduate cadets with an interest in medicine and science from the United States Air Force Academy. These five to six week rotations give them the opportunity to learn basic science at the laboratory bench.

The University of Cincinnati's surgical residency program has also expanded its simulation curriculum to allow the acquisition and refinement of skills and techniques in a safe environment. Our goal is to better prepare and train our surgeons in patient care before they ever perform an invasive procedure. The enhanced program, which has been implemented in the new Woliver Laboratory for Simulation and Education in Surgery, was made possible by a gracious donation from retired surgeon and 1939 UC College of Medicine alumnus Edward Woliver, MD. Located on the second floor of the College of Medicine's Medical Sciences Building, the Woliver Lab includes an array of simulation equipment designed to allow surgical residents to practice new skills outside of the operating room in a safe, faculty-mentored environment. The Woliver Lab has both low- and high-fidelity simulation equipment including simple models to simulate suturing vessels and intestine, as well as extremely sophisticated devices, such as the Simbionix Lap Mentor II laparoscopic virtual reality simulator, which incorporates haptics (sense of touch) and tracks a surgeon's performance during a training session in minimally invasive surgical procedures.

Summary

The UC Institute for Military Medicine develops and applies innovations in clinical care, research and education to real-world surgical treatment of civilians and soldiers. This mission of discovery and transformation is being accomplished through innovative collaborations with related disciplines at the University of Cincinnati, industry, the government and military, as well as our partners in the community. These innovations play a crucial part in the Institute’s mission to:

• provide state-of-the-art clinical and research training for those caring for our wounded soldiers and civilians;

• discover the scientific basis of severe injury and utilize this knowledge to develop new technology to advance treatment of the acutely injured patient;

• train the next generation of surgeon leaders; and

• advance the treatment of the acutely injured patient.

For more details about the program or a list of partnership opportunities, please contact Alex B. Lentsch, Ph.D., Director, Institute for Military Medicine,at 513-558-8674 or by e-mail at Alex.Lentsch@uc.edu.