Monday, November 28, 2016


       Earlier in 2016, COL Robert B. Lim, MD, U.S. Army, edited a landmark text Surgery during natural disasters, combat, terrorist attacks, and crisis situation. I had the opportunity to chat with Dr. Lim about his text. Having been deployed numerous times into the zone of combat, I believe he can be considered an expert in this area. Several chapters peaked my interest (especially the one on unexplored ordinances), but the chapter written by Seon Jones and Gordon Wisbach on "Trauma in an Austere Environment: Trauma and Emergency Surgery in Unusual situation" interested me most due to the details provided on trauma teamwork in the combat environment. Trauma teamwork is difficult enough under normal circumstances, but just imagine managing a team in remote or hostile environments.

           In their chapter Jones and Wisbach reinforce the need for strict organization and planning. There is no room for error. They reiterate that success starts with Mass Casualty Planning and Rehearsal. After arrival to the operational area the team should discuss and rehearse the casualty plan. Preparation includes memorizing the layout of the trauma area, the facility as well as the outlying areas. Defined team positions and roles are key to avoid confusion and delays. In spite of the appearance of redundancy, prior to each incoming casualty, stating names and roles avoids confusion. Continued repetition focuses the team and reminds the team about potentially forgotten measures (PPE, civil closed loop communication). Team member names should be readily visible on each member to assure communication is clear and avoid distractions. Supplies and equipment need to be in standardized placement close to the immediate resuscitation area to avoid excess noise in asking or searching for supplies.  Each team member has an assigned checklist posted at their work station (detailed summary of those checklists noted in their chapter). The trauma team leader (TTL) should stand in a routine position where they have continued observation of the team (i.e. Foot of bed). One examiner is then on one side of the patient and the other examiner or RN on the other. Anesthesia should be at the head of the bed. Prior to patient arrival, each member needs to confirm their checklist has been reviewed. Team review should remind the team that only the TTL should be providing resuscitation instructions thereby avoiding the confusion that results from too many members instructing the team. A hierarchal structure helps to maintain the TTL's situational awareness. The TTL needs to remember to take a pause for summarization prior to and after critical steps in the resuscitation process- preintubation, post-BP stabilization- to avoid missing crucial details. The authors remind us that in spite of combat casualties occurring in austere environments, following standard clinical practice guidelines (CPG's) is vital- just because you may be remote, standard evidence-based protocols avoid conflict and improve team dynamics. Several other reminders of TTL roles are highlighted in this chapter.

              Finally the authors remind us of three vital team leadership roles- 1. watch for and control team stress and conflict 2. Be cognizant of Bruce Tuckman's revised stages of group development (forming, storming, norming, performing, and adjourning) to assure your team is developing appropriately 3. Morale retention and support from "compassion fatigue" is necessary to survive the arduous often primitive conditions. 

I immediately had a few questions for the authors and when I met up with Gordon Wisbach at the Excelsior meeting in advance of the ACS Clinical congress he agreed to discuss these.

1.      I constantly hear from surgeons that checklists and teamwork principles have no place in emergency or life-threatening situations.  When we discuss following the WHO and checklist principles, frequently heard complaints are: "the patient is dying! following these recommendations simply wastes valuable time and is not necessary".  I hear the complete opposite in your assessment of how to manage a team in life-threatening poorly supplied environments. Have you had success in
promoting these principles in civilian arenas? If yes, how do you convince others that moving fast without direction and rehearsal may slow you down?

Part of the reason for the usual resistance against check lists: Long, detailed, rigid, generic, all-inclusive checklist are arduous to follow and meaningless in some locations.  Checklist for emergency/life-threatening situations/crises should be developed differently than those designed to be implemented in a controlled, mindful setting.  A good analogy is a checklist prior to take off of a plane where you should take your time and focus on not missing key safety measures versus checklist that pilots and crew take during in-flight emergencies where seconds matter.  Even in the second scenario, they run through a checklist efficiently and effectively without error even though most medical personnel would think that it would slow the pilot down and the plane would crash before he even opens up the checklist.  

The reason the emergency checklist works is because they practice and drill the list so that ALL of the important steps are taken in a specific sequence without fail.  This is the principle we are very resistant to apply for major trauma resuscitations.  What we don't realize is that, as medical professionals, we already subscribe to the checklist principle whenever we take ACLS and BLS courses or do ACLS drills.  We practice those drills with the algorithms printed out on cards as cognitive aids, but we know the important first steps of that checklist by heart: 1. Open the airway, 2. Give breaths, 3. If no pulse, start compressions, 4. When the AED or crash cart arrives, check rhythm, 5. Shock or give drugs, etc.

The emergency checklists should be designed considering the frame of mind of someone who is in the emergency situation, traumatic injuries in our case.  After developing the list, it should be drilled and tested.  The actual emergency situation should not be the first time a team or an individual goes through the checklist.  It should be deliberately practiced and drilled.  Also, in this process, you may discover that some steps in your checklist are not appropriate (not practical, not useful, counterproductive, etc.)

In regard to, in your words, convincing others that moving fast without direction and rehearsal may actually be counterproductive, those others should try to remember those times when they just jumped into doing a procedure without all the necessary equipment, supplies, and set up.  They may have been all gowned up and gloved, but the patient was not prepped, yet, the chest tube was not in the room, there were no drapes, no scalpel, no hemostats, no drugs for sedation and the patient is moving too much, etc.  The patient received paralytics, but you didn't get the laryngoscope, didn't check the light was or was not working, now you're bagging him, but the O2 tank is empty, who checked the O2 tank? Ok, now the laryngoscope is here, but you can't see cords, oops we didn't plan for a difficult airway, no fiberoptics, no bougie, no LMA, need a surgical airway, stat? where is the scalpel, where is the crich tube or the 4-0 endotracheal tube, etc.

2.      When you first went into action, what preconceived notions were instantly proven false?

The preconceived notion that only the medical providers were essential personnel is false.  In a resource and personnel scarce environment, everyone is vital to running an ongoing casualty receiving area.  For optimal throughput, all the steps from restocking supplies, preparing the room for a resuscitation, litter bearing, and cleaning to be ready for the next casualty are important steps.  Nothing conveys the importance of these details than actually carrying out these tasks yourself when you can.  It's like pre-flighting your trauma bay/ED/OR like a pilot pre-flights or looks over the aircraft he is about to fly.

3.      When you arrived at a designation, was there anything that totally caught you by surprise?

In retrospect, it is incredibly rare to see the type of multi-dimensional injuries of blast casualties in any civilian setting.  The only similar situations I can recall off the top of my head are the Boston Marathon bombing, the Oklahoma bombing, and may be 9/11.  It would be much simpler in comparison to have straight forward gunshot wounds or blunt trauma from a fall or MVC.  The war time casualties come with the myriad of unique injuries characterized by blast injuries.

4.      Describe the most remote, austere operating environment you faced? Any take homes from that experience?

One room OR with two OR tables in an old Soviet Era hardened structure.  Take home points: Forget about sterility expected in a US hospital OR, the casualties have wounds that likely more contaminated than an un-sterilized instrument in the OR.  Of course, we still followed the surgical principles and used sterile procedures and equipment.  In these austere settings, advanced, expensive, cumbersome medical technology is not as good as your/your team's knowledge and training and you/your team are the patient's best chance of survival.  The other basic necessities are lights, headlights (nothing fancy), electricity, sterilizer, basic general surgery, thoracic, vascular, and orthopedic sets, IV fluids, blood, and transfer facilities.

The overall take home point I would say is to take the time to read the lessons learned from the prior team if you are fortunate enough to have that resource.  There is no pride in delivering sub-optimal care while trying to reinvent the wheel.  Also as important, continue to learn from each experience, record it, and pass on your wisdom to the next team.  And wish them success.

5.      Was there any aspect of team leadership you predetermined you would be adept at but found needed improvement, or a total rehaul?

Coming from a busy trauma center, running a casualty resuscitation was second nature, but what I needed to do more of is team-building and preventing compassion fatigue.

6.      Any leadership aspect you had not considered or discounted that you found you had to learn on the fly?

What would have been useful is de-escalation techniques during confrontations, whether as a third party observer or directly involved.  Deployed individuals are stressed, fatigued, and prone to respond poorly to perceived slights or confrontation.  Leaders should stay vigilant of this tendency in themselves and others and respond with compassion and de-escalate the situation.

7.      When the teams form initially, do the members automatically register this concise preformed process or does the process not always work as well as you wished?

In general, when teams form, they naturally follow the model and do great without any catastrophes.  Viewing the evolution of team formation with this objectivity would help you see the bigger picture, anticipate likely scenarios, and to plan ahead.  In general, being social animals, people do well as a team.  It is only rarely that a member of the team may be maladjusted sociopaths who could sabotage your team.  These individuals should be removed from the team early if possible.  I see no other solution.

8.      How do you quiet the room when the commotion becomes distracting? Paul Lucha told me he just keeps turning his voice decibels quieter and quieter until everyone has calmed down (Paul Lucha, MD, FAC, CAPT, MC, USN, Retired; Department Head, Department  Surgery Navy Medical Center Portsmouth, VA.).

This aspect of commanding the room goes back to practicing drills and getting used to running actual resuscitations so that the team members associate the voice as the Trauma Team Leader.  Likely, there will be more than one TTL; we had several.  In this instance, a quick pre-brief that includes the team member's rolls should also clearly identify who the TTL will be and establish this hierarchy for a given casualty.  During the training, drilling, and coaching of a TTL candidate, they should be taught and reminded to assume the "command voice" which is not necessarily loud, but loud enough for most situations for all to hear and listen.  More importantly, it should be confident, precise, and succinct.  Deeper male voices seem to help, but I have seen many small female surgical residents assume this voice quite effectively, leading difficult resuscitations with authority.

One other technique is to "reboot" the room by reviewing the primary survey and current status of the patient to get everyone on the same wavelength to focus on the most important tasks at hand.

In addition, the other team members in the room should be empowered to practice crowd control - less people in the room equals less extraneous noise.  People talking about other topics besides the casualty or joking around should cease or be excused from the vicinity of the trauma bay.

9.      If a team member attempts to take control but is clearly wrong, how do you redirect them?

If the action is not life-threatening, then it can be discussed afterwards during the debrief and later during peer-review.  It may even be a learning point for all the team members and can be incorporated into didactic training.

If the wrong action will lead to harm for the patient, it must be stopped and corrected immediately.  The interaction and apologies for hurt egos can be discussed afterwards during the debrief.

10.     Any particular lesson learned about combat care you did not expect but sticks with you today? 

Having had a few sudden deaths in patients that appeared fairly stable when they were physiologically compensating, I still worry particularly about patients who on the surface seems to be doing unusually well despite severe injuries or mechanism of injury.

11.     Have you arrived at a treatment facility and just did not have time for orientation and rehearsals?

Fortunately, I have not had that experience.  Our team had time to work out the kinks with drills and had time to set up.  You would just have to trust that the training works and the team members you work with are also well trained.  If things are so rapid and chaotic, more communication among team members would be needed including their identification and role during the resuscitation.  If there are few minutes to spare prior to the arrival of the casualty, the pre-brief is useful to establish roles, ensure personal safety, review the basic steps through primary survey, secondary survey, and disposition plans.  Immediately debrief the team if time allows before the next casualty.

12.     Have you missed something that in looking back was obvious?

Allowing the team to decompress and hangout together is one major pillar that maintained a functional team.

13.     Did you ever receive a godsend help when you were praying for it that arrived from a source you least expected it?

An excellent CRNA who was able to place an IV on an infant in hemorrhagic shock when all IO's failed and I could not place a central line. 

14.     When you first started, what technique worked best for you in controlling your anxiety? What about controlling another's anxiety? Or maybe you never had a situation that did not pose a threat and therefore was not anxiety provoking?

Keeping physically fit kept me resilient to anxiety, but what exponentially helped that resilience was meditation.  It really works.  I would recommend it, just not the pseudoscience of some types of meditation trends.  As for anxiety in others, developing a strong emotional IQ to detect and ameliorate the others' anxiety would be my only advice.

15.     When you encounter a patient who has no chance for survival but clearly has their mental faculties totally intact what does one say to them?

If he has family and friends, they should be with them without me monopolizing the little time he has.  If there is no one, I would be there to listen to his requests, keep him comfortable, allay his fears, and not abandon him.

Thank you so much for your questions.  I enjoyed responding to them.  Please let us know if you have further questions.

Seon Jones, LCDR MC USNR

Kenneth A. Lipshy, MD, FACS

Gordon Wisbach, MD, CDR, MC, USN, Staff Surgeon, General Surgery Department

Lim RB. Surgery during natural disasters, combat, terrorist attacks, and crisis situations. New York. springer. 2016.

Tuesday, November 22, 2016



Washington DC March 30 1981, 2:27 pm:

       On March 30 1981, 2:27 pm, John Hinckley Jr shot President Ronald Reagan, White House Press Secretary James Brady, Secret Service agent Tim McCarthy and Washington D.C. police officer Thomas Delahanty using his R√∂hm RG-14 .22 cal blue steel revolver loaded with six "Devastator" brand cartridges (each with small aluminum and lead azide explosive charges designed to explode on contact). Hinckley fired six shots in 1.7 seconds, first hitting Jamey Brady in the head and then officer Delahanty in the neck. As Special Agent Jerry Parr pushed President Reagan into the limousine, a fourth shot hit Secret Service agent Tim McCarthy in the abdomen. The sixth bullet ricocheted off the armored side of the limousine and hit the president.

         It was initially assumed that The President was uninjured. Thinking he was uninjured, they initially planned to take the President to the White House. Until he coughed up blood, President Reagan assumed the pain in his left chest was due to rib fractures from being pushed into the limousine. Special Agent Parr thought otherwise and directed the motorcade to George Washington University Hospital. Upon arrival the President walked into the Emergency Department unassisted but immediately collapsed. At the insistence of The Physician to the President, Daniel Ruge, the ED team was instructed to treat the President as any other trauma victim. The President was in shock and the Trauma team quickly discovered a bullet entrance wound in his left axilla. Within 30 minutes, he was stabilized and transported to the Operating Room where, with the assistance of Joseph M. Giordano, Chief Thoracic Surgery Benjamin L. Aaron, performed a thoracotomy. Wikipedia, NY TImes

           An interview a few weeks later revealed the anxiety control methods both surgeons utilized when they realized they were operating on the President:

Giordano: ''I looked at him and I could feel myself getting tense, which has happened to me occasionally when I do surgery. When that happens, I talk myself through it. I thought, 'O.K., calm yourself. You want this to go well. Concentrate, and do everything the way you always do it, if you expect to get good results.' But I could not divorce myself from the fact that he was the President and his wound could have been lethal.''

Aaron: “He assessed the seriousness of the President's wounds, and said he too would have had ‘heightened anxiety’ if he had not judged that Mr. Reagan's bleeding could be controlled. Although Dr. Aaron described himself as someone who ''doesn't get anxious about things,'' he acknowledged that he was ''on edge at times.'' ''When I couldn't feel that bullet, and I knew it should be there, I thought it might have embolized through the pulmonary veins, into the heart and gone someplace.'' …The bullet, it turned out, was flat. ''I just couldn't feel it in that spongy lung tissue,'' Dr. Aaron said. ''The X-ray settled me down because I realized that when I was feeling for the bullet it wasn't trapped in one place. It had room to move, and it just squirted away from my fingertips.” ''Then it was just a matter of hanging in there until I could find the blooming thing by passing a catheter along the bullet track. It took about five minutes of very concentrated tactile discrimination until I suddenly pinned it down and got it out.''


After Jon White revealed the heroic aspects of the team saving the Presidents life I had questions of Dr. Aaron:
1.       What leadership or crisis management experience /techniques did you discover worked well for you?
2.       What ones did you figure out quickly you had to improve upon.
3.       What preconceptions about your skill or your medical center staffs skill proved correct?
4.       What ones proved false?
5.       What lessons did you rehash with the residents and /or hospital staff in post scenario debriefings?

Dr. Aaron was kind to discuss this with me:

“Bear in mind that all this took place 35 years ago and that it is coming from an 83 year old brain.  Also, at the time, things were moving at a fast pace during which time there was not much time for reflection or organization, or to put it another way, much of the time we were "winging it" in dealing with the complexities imposed by the unique nature of the event. “

1.  Leadership or crisis management experience/techniques applied?
    The care in the ER was flawless as regards urgent processing, mobilization of staff and systematic application of appropriate care.  This was not an accident, but came about because of aggressive and thorough preparation and training of the ER staff and residents.  In order to take care of the President, James Brady and Tim McCarthy (SS), the area had to be cleared of patients, the ensuing crowd screened and managed, and assignments quickly defined.  No one consulted any manuals on procedures on techniques.  The key was preparation and training, professionally applied.

     I recall insisting, from the get-go, that everyone on my team regard the President first and foremost as a patient in trouble and to put aside any consideration of who he was or what might be swirling around beyond our perimeter of care.  This kept us focused on the task at hand and help quell nervousness.  You might call this the principle of putting first things first.  I did not note it at the time, but have been told since that as the team leader, my calm demeanor, efficiency, decisiveness and apparent lack of nervousness did much to hold things together as this event moved along. (Jon White, MD noted that this was indeed the case- Dr. Aaron maintained a calm demeanor with no yelling and no screaming, which allowed flawless communication and the ability to resuscitate the President and rapidly transport him to the OR).

2.  Consideration of changes or alterations.
     One can be persuaded in such a situation that having additional professional experience at the table could be helpful and perhaps diffuse responsibility should things go wrong.  I had many offers of help from fellow surgeons, but quickly put this aside in favor of a three-person team composed of me, my chief Thoracic resident and a surgical intern (just as it would be if the patient came in off the street).  This seemed to me to be the simplest route to good decision making during the operation.  This might be termed good management versus too many "cooks" calling the shots.

     Because of the remote possibility that the bullet might have transited the dome of the left diaphragm, the ER General Surgeons strongly supported an abdominal paracentesis before opening the chest to rule out injury to the spleen, etc. I had seen no evidence of this and had reservations about taking the time to do the procedure (20 minutes or so), but as the President's condition was stable at the time, I agreed to move ahead on this even though had I found a hole in the diaphragm, I could easily have dealt with the problem through the chest.  This gets down to using clinical judgment (was it safe to take the additional time) to forestall a fuss with the General Surgery group.

     Putting the President, post-op, on the ICU was a management mistake, as his presence along with all of his SS entourage and visiting staff rendered the ICU unworkable.  We quickly evacuated a wing of the hospital, tailored it to all the requisites and had the patient moved in 6 hours.  My plan for post-op care was drastically and suddenly altered but I and my team quickly adapted to the new circumstances and moved on. Being flexible, prepared for contingencies, and able to move in different directions effectively is essential to completing the mission.

3.  How ready were we?
     Occasionally one hears that University medicine is "sterile", impersonal, isolates a patient from compassionate care and has poor inter-staff communication.  Some of this may be true, but what University Medical centers do provide is well credentialed and experienced staff and first rate facilities.  We were prepared for this challenge at every level of staff, management and resource availability and because of this, the event came off without a significant hitch.  It was a team effort in every regard from beginning to end and a wonderful thing to be a part of.

4.  What plans or preparations proved false?

     We were not prepared for the security requirements by the SS.  There was a SWAT team on the roof at all times during the eleven days he was present.  When he needed good quality x-rays (there was a portable machine in his suite), the halls had to be cleared and explosive sniffing dogs preceded his visit to the x-ray floor.  His food supply was carefully guarded. Bullet proof glass was installed in his room (despite the fact that he was on the 3rd floor of an interior court with a window free wall opposite).  ALL entrants to the 3rd floor had to undergo a SS check, each and every time they entered.  Medical folk, especially doctors, are not particularly patient people by nature, so with great restraint, and resolve, we managed to work it through to a successful conclusion.  The lesson here is to practice situational awareness and be willing to accept imposed restraints, always keeping the mission as our first goal.

5.  Post event debriefing.
     Post mortems are standard issue for any medical event.  We had many discussions after the fact, but almost all centered about things like conduct with the intrusive press (residents and especially interns, are full of false info and quite willing to share it).  To relive and relieve tensions. we produced a high quality 30-minute documentary utilizing all the primary participants (doctors and nurses, etc) plus actors as the presidential party.  This process brought out into the open the vital parts played by each participant and highlighted the importance of the synthesis of each performance in attaining a good outcome.  On almost every count, we were satisfied with how our medical center responded to each and every challenge and this was echoed by the AMA in their commendation of our efforts.

I hope that this insight into how our medical center and all it's integrated parts dealt with a most unusual and unexpected event will help you develop a useful syntax for your book.  If you have additional questions, fire them my way and I will field them as best as I can.

Sincere regards, Ben Aaron, MD

Special thanks to Dr. Jon White, Chief Surgery VAMC Washington DC for filling in the gaps.

Altman LK. THE DOCTORS WORLD. New York Times. April 21, 1981




Kenneth A. Lipshy, MD FACS

Friday, November 4, 2016



           On October 13 2016 Boston CBC reported "Tourniquet Credited With Saving Life Of Officer Wounded In Shootout". The night prior to that report, a Boston Police Officer was shot during an attempted arrest. In the midst of a gun battle, a tactical officer pulled him from harm’s way and applied a tourniquet, saving his life. Boston Police Commissioner William Evans reported that the officer who applied it had just had tourniquet training less than a week before. Commissioner Evans noted that, while tourniquets were credited with the survival of several victims of the Boston Bombing in 2013, the crude devices used during that situation were created and applied by citizens. Since that time Boston police have had ongoing training on the use of combat tourniquets. Earlier in the year a Boston officer saved his own life by applying a tourniquet after a potentially fatal gunshot wound.

          I found it interesting that I was reading this on October 17th, just immediately prior to our American College of Surgeons Committee on Trauma Business Meeting whereby Lenworth Jacobs, Jr MD MPH FACS presented the most recent information regarding the Hartford Consensus and American College of Surgeons ongoing efforts with the “STOP THE BLEED!” campaign {and presented the following day during the Excelsior Surgical Society/Edward D. Churchill Lecture "Strategies to Increase Survival in Active Shooter and Intentional Mass Casualty Events"}. My attention was captured as Dr. Jacobs clearly pointed out some disturbing news:

1. Major Shooting events are becoming alarmingly common.

2. Educational areas remain the second most common location for these events to occur- and these types of events are definitely increasing.

3. No environment seems immune!

4. While it is fortunate that most of these events are over within minutes, large volumes of ammunition have been expended during that short time frame injuring countless people.

5. First responders may not have access to victims for easily 30-45 minutes

6. Most life-threatening hemorrhage is terminal within 5 minutes without STOPPING THE BLEEDING!.

7. More than likely, the person next to you (your friends or strangers) will be the one who has the greatest opportunity to save your life.

8. After these events a Police officer is likely to be the person closest to the victim and capable of successfully applying a tourniquet, thereby saving a life.


         With this in mind I began to wonder

a. when did the military first implement the use of tourniquets in their Individual First Aid Kits (IFAK's),

b. Was Boston the first Police force to utilize these tourniquets.

c. are any other police forces carrying these.

d. What is the response of the folks in the field regarding their being requested to be trained in, carry and utilize these in the midst of potential dangerous situations, whereby theoretically it is diverting their focus

e. Are any communities posting these STOP THE BLEED KITS and using them yet?

Fortunately, I know some of the members of the Hartford Consensus Conference, so I contacted them for some answers.


         Frank Butler, MD (Credentials below) relayed to me that while select military units (SEALS, RANGERS, PJs..…) may have carried tourniquets and hemostatic dressings prior to 2005, widespread use in U.S. Military IFAK’s (Individual First Aid Kits) did not begin until 2006. CAPT Butler, the US Special Operations Command Surgeon at that time and COL John Holcomb, Commander of the US Army Institute of Surgical Research, spearheaded the Tactical Combat Casualty Care Transition Initiative (initiated in 2005) which was designed to ensure that all deploying Special Operations forces had the recommended TCCC equipment and were trained to use it. To quote from the 2015 Hartford Consensus Compendium:

       “The TCCC Transition Initiative was funded by the USSOCOM and conducted by the USAISR. This effort, led by Sergeant First Class Dom Greydanus, was basi­cally the medical equivalent of a rapid fielding initiative. It provided TCCC training and equipping to deploying special-operations units and incorporated methodology for determining the success or failure of the newly intro­duced TCCC measures. The TCCC Transition Initiative (and the U.S. Army) chose the C-A-T as the tourniquet to field.

        The TCCC Transition Initiative was a resounding suc­cess and documented 67 uses of tourniquets in special-operations units with good effect and with no loss of limbs to tourniquet ischemia. The first four-star en­dorsement of the TCCC and tourniquets occurred when General Doug Brown, Commander of the USSOCOM in 2005, mandated TCCC training and equipment for all deploying special-operations units. The U.S. Central Command, largely through the efforts of former Colo­nel Doug Robb, also mandated in 2005 that all indi­viduals deploying to that combat theater be equipped with tourniquets and hemostatic dressings.

       As awareness of the success of the TCCC Transition Ini­tiative and the U.S. Central Command directive spread throughout the military, conventional units began to adopt the TCCC, including tourniquets. In 2005 and 2006, tourniquet use expanded rapidly throughout the U.S. military. The beneficial impact of the battlefield use of commercially manufactured tourniquets was very well documented by an army orthopaedic surgeon, Col­onel John Kragh, during his time at a combat support hospital in Baghdad in 2006.”

          Dr. Butler explained that the first Hartford Consensus Conference in Jan 2013 concluded that “Life-threatening bleeding from extremity wounds is best controlled initially through use of tourniquets, while internal bleeding resulting from penetrating wounds to the chest and trunk is best addressed through expeditious transport to a hospital setting. Optimal response to the active shooter includes identifying and teaching skill sets appropriate to each level of responder without regard to law enforcement or fire/rescue/EMS affiliation.” By the time of the Jan 2016 Hartford Consensus IV, Dr. Eastman reported that 8 major cities had initiated Trauma Kit Preparedness protocols (NYPD, Washington, Edmonton, San Francisco, Honolulu, Vancouver, Phoenix and Raleigh). By 2015 over 400 readiness courses teaching close to 7000 LAW ENFORCEMENT students have been carried out. In Denver the Tactical Casualty Care for law enforcement first responders (TCC-LEFR) has been taught at over 125 courses and 2500 LEO’s and EMTs. Known data has revealed that five officers and r civilians have been saved thus far due to this training. Admittedly up to this point clear data has been difficult at best to collect and report, but a data base for LEO TECC use nationally is in progress. During the Hartford conference, John Holcolmb reported on data from Houston whereby 105 trauma patients were treated with a PREHOSPITAL tourniquet resulting in a 3.2% mortality rate compared to 17% treated with an ED applied tourniquet.


          In an effort to learn more regarding the use of these kits in the police and civilian arena, I contacted Alex Eastman, MD and Lenworth Jacobs, MD (Credentials below). Dr. Jacobs and Dr. Eastman relayed that efforts to initiate use in the field of personal equipment including a tourniquet began some time back in police service. Alex Eastman stated that he has been a member of the Dallas Police Department since 2004 and has served as the Medical Advisor for the Major Police Chiefs Association since 2011.  Dr. Eastman said they have had a version of the combat kits in their specialized units since 2006. In the Dallas Police service, 3700 sworn officers and 400 civilian employees have been trained.  By now Parkland Hospital has taught 1000 civilians and is currently working with businesses to move this out even further into the private sector. Dr. Jacobs relayed that in other police units implementation was likely via police staff with prior military experience (Special Forces, Medics, etc).  Use of tourniquets was likely met with some hesitancy to accept officially because the Police clearly have more pressing priorities during a Police action.  By now, there is no hesitancy to support this with policy and training.


        The Dallas Police Department Kits contain the following Equipment: Quick clot ($35roll), SOFTT-W tourniquet (25 each), Wide gauze and gloves. Their Carrying cases are typically donated.
Courtesy Alex Eastman


         I was curious how much resistance the group met when this was proposed several years ago. Dr. Jacobs explained that initially there were some challenges in asking police staff to take on the training but through a series of collaborating events the vision became reality (NOT IN DALLAS THOUGH as Dr. Eastman relayed). “You need to keep in mind that Police have the primary responsibility of ending the violence and providing a safe scene for other first responders. Having said that, the police realize that they are there on the scene and able to first respond when the paramedics are likely to be delayed.”

         Daniel Linskey, (Boston Chief of Police during the Boston Marathon Bombing) explained the tourniquet implementation process in Boston to me: “We did urban shield exercises which used amputees moulaged up as if they had just lost a limb. We identified tourniquets as a gap. Dr. Rickey Kurt took over as our assistant medical director at Boston EMS. He began to train our teams on tactical EMS getting into our stack. He taught hemorrhage control to our special ops guys and many started carry tourniquets. After the marathon we got tourniquet training and quick clot for all our officers before the July 4th event 2013.  I have been explaining the need for tourniquets around the country with law enforcement. I was at a third presentation in North Carolina when an officer approached and said he saw my earlier presentation tapped his tourniquet that he got for himself and the officers he worked with. He then went on to tell me of an officer who crashed his car and they then used a tourniquet to save his life. I've spoken to dozens of groups and hundreds of departments. Just spoke to 150 officers from 30 plus agencies today in St LOUIS every one said their guys carry tourniquets on their patrol officers’ duty belts some kept extra in their glove box.

             So if that was a challenge, I could only imagine the challenge in obtaining citizen group buy in. Dr. Jacobs explained that, “the Boy and Girl scouts already are trained on first aid so it is a natural pathway to teach.” To save live citizens simply have to be trained. Communities must have policies in place to assure citizens and first responders are trained to give permission to those who are the first responders. We need to empower the responder to help. Expectedly, the initial reaction to attempts at implementation of policy were very hesitant but the events that occurred over the years, especially in Washington, prompt a positive response. The credibility of these programs continues to grow as people realize that these “rare events that will not happen in our community” are happening at an alarming rate. Add to that the non-rarity of police and citizen events in everyday trauma where there may be one person with one chance to save a life.  People are slowly realizing that the further away from care that you reside, the more reinforcement of this training is necessary.  It has been proven that waiting to get the patient to the ED to stop the bleeding is not good practice.  “When our soldiers know better how to treat exsanguination than our doctors, we have a bad situation on hand but we need to train the medical students and residents!”  People are taking this seriously now. We need surgeons to take the leadership in their community and empower them to train the citizens.

        So what does any of this have to do with working in a small, especially rural hospital? That turns out to be similar to the questions others ask: “we never have to deal with exsanguinating hemorrhage from penetrating trauma! We are a small town, small hospital. We don’t have penetrating trauma.” At first that seems like a worthy question and conclusion. However when one listens to Dr. Jacobs and others explain the realm of this problem, it becomes clear that in some situations you may be the first with an opportunity to provide this life saving care. It is certainly not inconceivable that an injury on or adjacent to the property could result in profuse hemorrhage that could be controlled by trained personnel. It takes minutes to train, little money to support and saves lives.

Kenneth A. Lipshy, MD, FACS



CAPT Frank K. Butler, Jr., MD Member of Hartford Consensus Conference. USN Retired US Navy, diving medical Officer, Director of Biomedical Research for the Naval Special Warfare Command. Platoon commander Navy Underwater Demolition and SEAL (Sea/Air/Land commando) teams. Diving Medical Research Officer, Navy Experimental Diving Unit. Chief of Ophthalmology - Naval Hospital Pensacola. Naval Special Warfare Command. Ophthalmic consultant to the Divers Alert Network.  Chairman, Committee on Tactical Combat Casualty Care, Department of Defense, Joint Trauma Systems (Feb 2015).


Alexander L. Eastman, MD, MPH, FACS, DABEMS Member of Hartford Consensus Conference Lieutenant and Deputy Medical Director Dallas Police Department (SWAT), Interim Medical Director, The Trauma Center at Parkland (UT Southwestern Medical Center). Medical advisor to the Major Cities Chiefs Association.


Lenworth M. Jacobs, Jr., MD, FACS, Trauma Surgeon Hartford Con., American College of Surgeons (ACS) Regent and Chairman of the Hartford Consensus.


Chief Daniel Linskey, Boston Chief of Police during the Boston Marathon Bombing.


Joint Committee to Create a National Policy to Enhance Survivability From Mass Casualty Shooting Events

Lenworth M. Jacobs, MD, MPH, FACS Hartford Hospital, American College of Surgeons (ACS) Board of Regents

Norman McSwain, MD, FACS Medical Director, Prehospital Trauma Life Support

Michael Rotondo, MD, FACS Chair, ACS Committee on Trauma

David S. Wade, MD, FACS Chief Medical Officer, Federal Bureau of Investigation (FBI)

William P. Fabbri, MD, FACEP Medical Director, Emergency Medical Support Program, FBI

Alexander Eastman, MD, MPH, FACS Major Cities Chiefs Association (Lt. Dallas Police Department)

Frank K. Butler, MD Chairman, Committee on Tactical Combat Casualty Care

John Sinclair International Director and Immediate Past-Chair, International Association of Fire Chiefs-EMS Section (Fire Chief, Kittitas Valley Fire and Rescue)



Tuesday, November 1, 2016

Daniel Kuhn Interview: surgeons, PTSD, Stress and Comfort zones

Daniel Kuhn Interview: surgeons, PTSD, Stress and Comfort zones:
          General Surgery News recently published a piece titled “When a Stressful Event Sticks Traumatic Stress Disorders Can Plague Surgeons; Psychiatrist Describes Technique Helpful in Erasing Ill Effects “ (an interview with Daniel Kuhn, psychiatrist) The topic meshes well with other discussion I have had on physician/surgeon resiliency (
       In this editorial Dr. Kuhn, a Psychiatrist in New York city, N.Y. developed a method that reportedly can readily clear PTSD and traumatic stress in one to two sessions in most cases.  He reports that when the Yom Kippur war erupted in Israel he returned home to serve as a physician in the Israeli Army. It was in this role that he detected a pattern amongst those who suffered from mental trauma in the battlefield and consequently developed his technique which allowed the patient to erase the charge of the recording of a traumatic event.
          He realized that the negatively charged image of a traumatic experience is stuck like a splinter in one's memory and continues to interfere and even overpower the individual, dictating attitudes, emotions and actions which are derived from the reality of the traumatic experience. The individual is transfixed to and  hypnotized by the traumatic experience. It induce intrusive recollections, bad dreams, avoidant anxiety etc. which  compromise his function, judgment and wellbeing.
Dr. Kuhn describes his technique as deconditioning which erases the charge of the traumatic memory by repeating many times verbal commands or using visualization technique. It is a new paradigm for treating PTSD, that by-passes the need for medications and regular psychotherapy. It is a form of a guided self therapy. It usually produces immediate release and lasting results.
He notes that as a cellist he was looking to enhance his own (as well as other's) performance level and found out that the Kuhn Technique helps to recover, improve and sustain peak professional performance level.
               Dr. Kuhn states that he has helped numerous Surgeons who suffer from a post traumatic stress. He notes that he has treated surgeons who experienced moments of acute stress  and overwhelm while  facing life endangering situations in surgery i.e. like laceration of a major blood vessel in a laparoscopic surgery, or who reacted negatively to being invalidated, humiliated or bullied professionally during residency training.
               Surgeons face stressful conditions and unpredictability on a frequent basis. In his book Forgive and Remember, Bosk, describes the difficulties in a Surgeon’s professional life in handling failure. Essentially our patients and peers (and us) expect surgery to be a quick fix compared to medical therapy of disease. When the outcome is not perfect doubt begins to creep in. If the surgeon does not elicit help or find a solution to break the cycle, then inevitably, performance will be negatively affected. At the ACS NSQIP conference (see Oct 2016Bulletin ACS), Peter Angelos is reported as stating "healing cannot occur without actions that would be illegal in any other context. It is an intensely physical relationship." This intensity likely makes failure extremely difficult to face if one is either not equipped to do so or they are becoming less resilient. At this same conference, Julie Freischlag presented a keynote address on resilience and noted that "despite our best efforts, someone is going to return to the hospital and as a surgeon, you need to generate ways to bounce up".  Diminished resiliency inevitably results in burnout.
             Several recent studies have highlighted the risk for PTSD in Trauma Surgeons and Surgical trainees (Journal of Trauma and Acute Care Surgery 2014;77:148-154;  Surgeon 2015. pii: S1479-666X[15]00099-2). Surgical trainees have been shown to have higher rates of psychological distress than the general population (10% reported PTSD symptoms lasting more than one month). In the Journal of Trauma and Acute Care Surgery Study  40% of trauma surgeons relayed symptoms of PTSD (15% met the diagnostic criteria for PTSD). This risk was increased with the following factors:
.Male trauma surgeons operating on more than 15 cases per month
.more than seven call duties per month
.less than four hours of relaxation per day

       Back in Dec 2015 Carol-Ann Moulton and I discussed a paper their Toronto group published in the Annals of Surgery on Comfort Zones and Risk Taking in Surgery (Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone. Ann Surg. 2015); Details of that conversation are at In our discussion of the interviews which led to their publication it appeared that even the boldest appearing surgeons probably have a breaking point.  It is likely that every surgeon has a perception of where their boundary is; the place where they no longer feel comfortable.  Self-assessment literature seems to indicate that we frequently do not openly acknowledge that we have a comfort zone (or may not accept that personally). It may be that the temperamental and angry affect we see in some surgeons is actually a reflection of anxiety. It is unlikely that anyone is immune, but we simply do not discuss it.
                 I was fortunate to speak with Dan Kuhn about this process- why is it we have a risk of becoming too hesitant, too risk aversive, and in some cases frightened to operate as many surgeons have related?

How much a risk do Surgeons face for developing what you equate to PTSD?              
           “Most surgeons think their stress is related to a recent trauma, but in actuality it begins much earlier in life. Most of us apparently have a traumatic event early in training- a death, a difficult encounter with a mentor, colleague, training program…. A lot has to do with how we are trained- our education. Punitive drilling, like the Marine Corps, destroys your identity and can shatter you. Degradation and invalidation does not build the frame for one’s own identity. You don’t want to break your children’s spirit. You cannot traumatize them.  You cannot invalidate people into performing. “
       “Surgeons work under a considerable level of pressure and often face unpredictable crises. A Surgeon must be well informed, well trained, and must be alert and analytical at all times during surgical procedures. When faced with unpredictable emergencies like sudden uncontrolled bleeding, patient's unexpected death, operating errors or consequential malpractice suits, etc., such experiences may have a lasting traumatic impact on them, leaving them with a negative experience and conclusions that can become morbid and destructive.
  It is not always possible to shield oneself from such an exposure and when traumatized, it is quite harder to erase the effect of trauma on one's life and health. Furthermore, earlier similar experiences tend to compound the traumatic effect. After having developed chronic anxiety and significant work related stress following exposure to a single or recurrent mental trauma, some surgeons may opt for early retirement or limit their activity.
  A traumatic fixation occurs following an unexpected, overwhelming and life threatening event which impinges on one's performance and composure, i.e. accidents, injury, or high randomness and loss of mental control. At that moment the analytical mind is momentarily frozen as the neo-cortex is overpowered by the Limbic system (the reptile brain's survival mode). facing danger one can go into a hyper-focus and a fight mode, and find a solution to the danger, but another one will frozen by fear, alarmed and disconnect - being in a momentary dissociative state (confusion, disorientation and a state of discontinuity.) The highly charged image of the traumatic experience is then fixated in memory and becomes the seed of a post traumatic condition.    
           Even if a solution was found a moment later, a traumatic experience has already being lodged in one's memory and starts to impinge on the individual; the charged emotions and negative identities within that image will surface from now on in situation reminding one of s traumatic event(s), hitting the individual with a hypnotic force. It will distract  and upset the individual and interfere with his ability to function.
        The post traumatic reactions comes from the 'reptile brain' within us, from the limbic system of the brain, which reacting to a perceived danger in an attempt to protect the organism from a survival threat and a perceived danger.
         The trauma has a hypnotic effect on the individual who is in a state of trance, where his attention is divided between the present time and the past incident. The individual is engulfed and trapped in the traumatic experience like a fish in a fish ball with perception of a way out. Alcohol and psychotropic medications may have a temporary, limited symptomatic relief but do not erase the fixated experience or change the course of the condition that tends often to worsen and become chronic. In most cases psychotherapy is not able to release the trauma fixation and resolve the condition.
     An individual is more prone to develop PTSD if he operates on an unfamiliar territory, lacking a real understanding and mastery of the necessary skills or techniques necessary to solve problems. An opera singer who does not master her voice will be more anxious and prone to traumatic stress regarding her performance. A misinformed or untrained surgeon may be more susceptible to it too. Furthermore, being hungry, tired, and jetlagged or overworked while operating, or being preoccupied with other problems in life such as litigations, divorce or fear of loss of loved ones.
                In addition, similar experiences earlier in one's life are most likely to be stirred up and energize the more recent trauma, a compounding effect that makes the individual more prone to dissociate and develop a post traumatic stress disorder."

How do you know if you have this PTSD syndrome?
“when you have PTSD you know you have PTSD. You recognize you are not the same. Your personality has changed. You become reticent. You are not liking to do things you used to enjoy. You avoid them and get anxiety. Some people dissociate. It is a dissociative condition- you are overwhelmed. BUT you can take control, but that moment is forever a part of your memory. Some result to alcohol, drugs,… For example, look at musicians. They start in music because they enjoyed it. Soon something causes them to not feel enjoyment anymore. Then they start drinking.

Can you do anything?          
 “You cannot get rid of those emotions easily, but you can. You must use visualization and images to reform that memory. I use the Kuhn Technique - A Trauma Deconditioning Paradigm. I can use three questions to get to the right specific incident. You have go to the original event. It could be at a very early age and have nothing to do with surgery. It could be at age 3. You were fixated on it and now trigger the trap later on.” “The treatment aims at locating the moment of traumatic impact and then to repeat verbally repetitive commands to erase the trauma and its negative component (identities) like the angry, fearful, overwhelmed, anxious, avoidant ones.
          It is important to go first to the first traumatic incident, evoke it and then discharge it's with repetitive commands.
         There is a similarity between erasing a mental trauma and erasing a computer file by a command with the key difference being that while the information and recollection of the incident stays the negative charge around it is dissipated. The discharging experience feels similar to deflating a pressured balloon.
              There is a wide spectrum of severity in PTSD cases; many normally functioning individuals experience chronic symptoms of PTSD and are able to function while having negative symptoms of it.
         In summary The Kuhn Technique is a form of self therapy which readily produces distinct results in most cases if correctly applied. Supervision by an experienced person is strongly recommended for better results. Its benefits are lasting and no negative effects have been observed over many years of applications on many hundreds of cases. The Effectiveness of the Technique comes from the observation that repetitive commands erase the recording of charged negative experiences.  Usually it takes one to two sessions to release a condition in most cases. The technique is also very helpful before going on stage to perform or when facing stressful situations. The number of repetitive commands can shift dramatically from one condition to another, and range from very few ones to many dozens of them. A specific process ends usually with a sense of mental release; breathing become deeper and attention becomes free.

What is the trigger?
“Typically, you have a traumatic event and either you feel invalidated and humiliated or others invalidate you or humiliate you. You may deal with life threatening problems daily and handle them all well. Maybe you failed and a patient died. Maybe someone was not nice in their response to your failure. Their comments can seem innocuous to them, but to you this could be a major incident. For example, when I gave a talk, someone will blatantly be rude and argumentative. Someone can call you a charlatan.  Maybe the incident that triggered it really did not seem that significant but it triggered an early memory.“

Why are doctors at such a high risk?
“Doctors are at high risk due to their identification as a Doctor. Their identity is so rigid; they cannot allow it to be broken… like the tin-man. If you are very rigid and do not feel anything, emotionless, with no empathy, mechanical, indifferent- you are actually using a defense mechanism – a type of dissociation.
If you keep your core being and are empathetic and can be connected, you can typically respond adaptively. You have to have “beingness”. Others move to an area where they don’t have to deal with people, patients. Others avoid the emotional aspect. They don’t worry about the supratentorial aspects of patient care. “
“if you have good technique, good knowledge and are sure of it, you are protected. But if you are not sure, you are susceptible. The army can work with you to assure you are not dissociated. You must send people to battle with personal ammunition. Betrayal can have an extremely negative effect. A bad atmosphere can cause a very negative emotional response. If you sense that someone is just waiting for you to make a mistake. For whatever reason, this is traumatic. If you know someone does not like you, the sense of betrayal is always prevalent. You are overly cautious. If you are confident and have not been betrayed, it will sharpen your career.“

Are any of us beyond hope?
“no! I can work with you for 20 minutes. I handled casualties in Israel and traumatic memories in soldiers and restore their faith. I can find the trigger and eliminate the fearfulness. Whatever is scaring you, it can be erased.“

Is there any familial risk?
 “Some people are more prone than others. Some are more histrionic. That can be biological. The real question is if you can control it. “

Daniel Kuhn, M.D., Board Certified Psychiatrist, 200 West 57th Street, Suite 1205.  New York, N.Y. 10019 Phone: (212) 315-1755; Cell: (646) 645-1755

Bosk CL. Forgive and Remember: Managing Medical Failure. 2nd ed. Chicago, IL: University of Chicago Press; 2003
Zilbert NR, Murnaghan L, Gallinger S, Regehr G, Moulton C. Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone. Ann Surg. 2015; 262(2):253-259.

Kenneth A. Lipshy, MD, FACS