Lessons Learned
What can we learn from the Iraq War about fighting COVID-19? One thing is that we are bad at learning.
A lot of what I am about to say is not going to come as a shock. We are a few weeks into quarantining from COVID-19. In the US, Dr. Anthony Fauci the Director of the National Institute of Allergy and Infectious Diseases, has appeared on T.V. more than a few times to spell out his message:
“Practice social distancing.”
“Wash your hands.”
“There must be a partnership between the states and the federal government.”
According to the television and the internet this is news. Yet this is not news. Dr. Anthony Fauci’s message has appeared many times over before. But I think we have a problem with learning it. In fact, our problem with learning the message was identified in the same reports that gave us the message in the first place.
A few years ago
Walter Reed National Military Medical Center was facing a really weird crisis. It was, and still is to this day, one of the most renowned medical centers in the US, located just north of Washington DC in Bethesda, Maryland. Operation Iraqi Freedom had been going on for longer than expected. At that time, Walter Reed had to deal with a bacterium it had never seen before.
Soldiers returning from Iraq were infected with Acinetobacter baumanii. It was an entirely new, and was resistant to nearly every drug thrown at it. Just under 10% of medical staff returning from Iraq were testing positive. Shortly thereafter the bacteria was found in 3 surrounding hospitals.
Walter Reed had 2 major courses of action. The first: isolate all returning people from Iraq upon their arrival and screen them. Screening was critical. The second: Walter Reed revamped its efforts to make sure that all medical personnel were adequately washing their hands.
The CDC was able to create a 3-step method of controlling the bacteria following an investigation.
Step 1) Active surveillance of groin, axillary, and/or wound cultures for all patients;
Step 2) Use of personal protective equipment as precautions with infected patients;
Step 3) Increased availability of alcohol-based hand rubs.
Meanwhile in Iraq
It was 2004, and already Army Major, Dr. Mark Taylor was on his second deployment. He was a surgeon in Operation Iraqi Freedom and was stationed in Fallujah as part of the 782nd Main Support Battalion. In 1991 he received his pharmaceutical degree from UC-San Fransisco, and his medical degree from George Washington Medical School in 1995.
The war was starting to change and this made his job harder. The US Army had secured Fallujah and a number of other locations in Iraq. Before the fight had been short, intense battles. Mark Taylor mostly worked out of a mobile, emergency medical tent. Now the Army were building garrisons as the fighting became more of a war of attrition. Mark Taylor began working out of a building.
Buildings transformed into hospitals and immediately had a lot of work to do. Not just soldiers, but civilians started to flood the hospital beds. The hardest part was pediatrics. Mark Taylor was expecting soldiers, and did not anticipate treating children. US medical staff all over Iraq did not have the right personnel, nor the right equipment.
Requests were made, and denied. Medical equipment was deemed unnecessary and fewer medical professionals were going to Iraq. So the Army did what it could. About a third of the medical staff reported that they lacked medical supplies. The equipment they did receive did not function that way it was intended.
Urologists and cardiothoracic surgeons retrained to become general surgeons. Everyone learned how to be a triage nurse. And the doctors that were there stayed for longer. That is why Mark Taylor was there for a second deployment. If he left, there wouldn’t be anyone to take his place.
4 days before returning home, Mark Taylor was killed when a rocket hit his residence in Fallujah.
Lessons Learned
By 2011, all of the experiences and data collected by the US Army medical personnel was being analyzed and we started to learn lessons. In July 2010, a group of medical staff conducted 29 missions in the recently established Iraqi Army Headquarter Clinic. The first thing they list in the “Lessons Learned” section in their report is the importance of thorough patient assessment, better hand washing, and the organization of medical supplies.
In 2015 the Defense Health Board published a report titled, “Combat Trauma Lessons Learned from Military Operations 2001–2013.” You can summarize most of the recommendations into really just a few points. First of all, we need better records for patients and how doctors are treating them. In the 2011 report, David Lynn et al. say that the major issue for them were patient records. In the US we have an electronic health care system. They had to do everything on paper, over multiple languages, and a lot of the medical documentation that should have happened never really did.
The second major point is a unifying agency in charge of knowledge transfer. All of this documentation is important to get the right people trained up quickly to do the right care. There is no big system, yet there should be. Even today, US News obtained a breakdown of Army medical personnel. Allergists, pediatricians, pharmacologists were all labelled (not necessarily retrained) as general surgeons. That means they can be on the front lines, doing any sort of primary care. As the US News report put it: “Dermatologists could find themselves treating sexually transmitted diseases.”
This makes knowledge transfer important. The Defense Health Board report outlines the difficulty in this. It says how everyone must work together to make sure that all knowledge is passed along. It’s hard enough to learn what to do without the hassle.
Here is what they recommend:
Step 1) Create a senior level organization whose sole duty is to transfer knowledge between groups. This includes having funding, and at least some sort of common language that everyone can communicate across. A huge challenge was that medical personnel did not know Army jargon, and Army soldiers did not know medical terminology.
Step 2) Create some measure of making sure that people are learning the knowledge well and using it. The point of knowledge is to make sure that it is implemented well.
Step 3) Make it easy for everyone to share. At the time, many medical professionals going to the Army were coming from the civilian world. At the time it was nearly impossible for anyone within these two groups to communicate or share information easily.
Step 4) Have a plan that anyone can train from and that anyone can add to. As the war changed, ways of caring for patients also changed. There was a problem when the training people received was not for was not what they actually had to do.
Step 5) Keep a log of what is causing the biggest challenges. This helps people understand of what is known well, and what can still be fixed.
Dr. Anthony Fauci’s Message
I think there is a certain parallel to what we are going through today. We are facing an extreme medical crisis. NYC in particular is being hit the hardest by COVID 19. A friend of mine has not left her small studio apartment in Manhattan for weeks. Her groceries are delivered. In the rest of the state, as of April 2020, the daily death toll has finally dropped below 500.
That said, NYC is famously facing a respirator and ventilator shortage. The federal government is famously denying them the equipment. In a report from NPR, NYC has had to retrain medical professionals. Plastic surgeons and pediatricians are learning the ins and outs of ventilators. Pulmonologists used to be in charge of this. They are now supervisors who are tasked to train everyone else.
Knowledge transfer is important. Yet we keep relearning the same message. Walter Reed learned a lot from Acinetobacter baumanii. The Defense Health Board came up with a many recommendations to make knowledge transfer easy. A few years later we are back to where we started.
“Practice social distancing.”
“Wash your hands.”
“Work together.”
Notes
This article was inspired by the chapter “Casualties of War” from “Better” (Atul Gawande)
Acinetobacter baumanii description.
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5345a1.htm
Mark Taylor in memoriam biography.
https://www.latimes.com/archives/la-xpm-2004-mar-28-me-taylor28-story.html
Study on equipment and mental health of US Army Medical staff. It also outlines the training challenges faced in 2010.
https://www.ncbi.nlm.nih.gov/pubmed/22479913
2011 Report
“Advising and Assisting an Iraqi Army Medical Clinic: Observations of a U.S. Military Support Mission” Maj. David Lynn et. Al.
2015 Defense Health Board Report
“Combat Trauma Lessons Learned from Military Operations of 2001–2013” March 5, 2015
US News report on the planned 2020 reorganization of military medicine.
NPR Report on retraining doctors in NYC.
