Operation "NeuroTeam": rendering the absolute best care for the most deserving patients under the most difficult conditions

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  • 1 Department of Neurosurgery, Inova Neurosciences, Inova Fairfax Medical Campus, Falls Church, Virginia;
  • | 2 Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland;
  • | 3 Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland; and
  • | 4 Departments of Neurology, Neurosurgery, Anesthesia, & Critical Care, Johns Hopkins Medical Institutions, Baltimore, Maryland
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The tenets of neurosurgery worldwide, whether in the civilian or military sector, espouse vigilance, the ability to adapt, extreme ownership, and, of course, an innate drive for developing a unique set of technical skills. At a time in history when the complexity of battlefield neurotrauma climaxed coupled with a chronic shortage of military neurosurgeons, modernized solutions were mandated in order to deliver world-class neurological care to our servicemen and servicewomen. Complex blast injuries, as caused by an increased incidence of improvised explosive devices, yielded widespread systemic inflammatory responses with multiorgan damage. In response to these challenges, the "NeuroTeam," originally a unit of two neurosurgeons as deployed during Operation Desert Storm, was redesigned to instead pair a neurosurgeon with a neurointensivist and launched itself during two specialized missions in Operations Iraqi Freedom and Enduring Freedom. Representing a hybridized version of present-day neurocritical care teams, the purpose of this unit was to optimize neurosurgical care by focusing on interdisciplinary collaboration in an Echelon III combat support hospital. The NeuroTeam provided unique workflow capabilities never seen collectively on the battlefield: downrange neurosurgical capability by a board-certified neurological surgeon within 60 minutes from the point of injury paired with a neurocritical care–trained intensivist. This also set the stage for intraoperative telemedicine infrastructure for neurosurgery and optimized the ability to evaluate, triage, and stabilize patients prior to medical evacuation. This novel military partnership ultimately allowed the neurosurgeon to focus on the tenets of the craft and thereby the dynamic needs of the patient first and foremost.

Since the success of these missions, the NeuroTeam has evolved into a detachable unit, the "Head and Neck Team," comprising neurosurgeons, otolaryngologists, and ophthalmologists, supported by a postinjury hospital unit, which includes an embedded neurocritical care physician. The creation and evolution of the NeuroTeam, necessitated by a shortage of military neurosurgeons and the dangerous shift in military wartime tactics, best exemplifies multidisciplinary collaboration and military medicine agility. As neurocritical care continues to evolve into a highly complex, distinct specialty, the lessons learned by the NeuroTeam ultimately serve as a reminder for civilian and military physicians alike. Despite the conditions and despite one’s professional ego, patients with highly complex morbid neurological disease deserve expert, multidisciplinary management for survival.

ABBREVIATIONS

CSH = combat support hospital; ICP = intracranial pressure; IED = improvised explosive device; MNSU = mobile neurosurgical unit; OEF = Operation Enduring Freedom; OIF = Operation Iraqi Freedom; TBI = traumatic brain injury; TCD = transcranial Doppler.

The tenets of neurosurgery worldwide, whether in the civilian or military sector, espouse vigilance, the ability to adapt, extreme ownership, and, of course, an innate drive for developing a unique set of technical skills. At a time in history when the complexity of battlefield neurotrauma climaxed coupled with a chronic shortage of military neurosurgeons, modernized solutions were mandated in order to deliver world-class neurological care to our servicemen and servicewomen. Complex blast injuries, as caused by an increased incidence of improvised explosive devices, yielded widespread systemic inflammatory responses with multiorgan damage. In response to these challenges, the "NeuroTeam," originally a unit of two neurosurgeons as deployed during Operation Desert Storm, was redesigned to instead pair a neurosurgeon with a neurointensivist and launched itself during two specialized missions in Operations Iraqi Freedom and Enduring Freedom. Representing a hybridized version of present-day neurocritical care teams, the purpose of this unit was to optimize neurosurgical care by focusing on interdisciplinary collaboration in an Echelon III combat support hospital. The NeuroTeam provided unique workflow capabilities never seen collectively on the battlefield: downrange neurosurgical capability by a board-certified neurological surgeon within 60 minutes from the point of injury paired with a neurocritical care–trained intensivist. This also set the stage for intraoperative telemedicine infrastructure for neurosurgery and optimized the ability to evaluate, triage, and stabilize patients prior to medical evacuation. This novel military partnership ultimately allowed the neurosurgeon to focus on the tenets of the craft and thereby the dynamic needs of the patient first and foremost.

Since the success of these missions, the NeuroTeam has evolved into a detachable unit, the "Head and Neck Team," comprising neurosurgeons, otolaryngologists, and ophthalmologists, supported by a postinjury hospital unit, which includes an embedded neurocritical care physician. The creation and evolution of the NeuroTeam, necessitated by a shortage of military neurosurgeons and the dangerous shift in military wartime tactics, best exemplifies multidisciplinary collaboration and military medicine agility. As neurocritical care continues to evolve into a highly complex, distinct specialty, the lessons learned by the NeuroTeam ultimately serve as a reminder for civilian and military physicians alike. Despite the conditions and despite one’s professional ego, patients with highly complex morbid neurological disease deserve expert, multidisciplinary management for survival.

From Walter Dandy’s small postoperative neurosurgical ward at Johns Hopkins University in the 1930s to the Ibsen unit fighting the poliomyelitis epidemic in 1950s’ Copenhagen, the "neuro ICU" evolved to support these two distinct patient populations with complex neurological needs.1 A third population, patients with severe neurosurgical trauma, represented another midcentury impetus for the organization of neurocritical care. In conjunction with the Royal Canadian Air Force, veteran William Cone created one of the first helicopter transport services with onboard neurotrauma management at Montreal Neurological Institute, where patients were transported to the McGill University stadium yards away from an expert neurological team.2 Like Dandy, Ibsen, and many others, Cone recognized the critical need for improved access and proximity to specialized care to optimize patients’ recovery after complex neurological injuries and treatment. The significant advancements of neurosurgery and neuroanesthesia that followed further evoked the need for specialized monitoring units for patients undergoing modern neurosurgical procedures.1 Likewise, patients with nonoperative, acutely morbid neurological illness benefited greatly from a specialized, neuro-focused ward where neurologists and pulmonologists directed their care, thereby forming the basic template for the modern ICU.1,3

In 1955, Mayo Clinic was one of the first institutions to create a hybrid ICU where both patient populations were closely monitored in concert, an initiative driven by a team of skilled neuroscience-trained nurses.4 Yet, at that time, individual patient management remained under the direction of the responsible neurology or neurosurgery physicians with little need for collaboration. Intensivists were not a pivotal component in the care of these patients unless acute cardiopulmonary illness required intervention. By the 1980s, there was a growing interest in using these hybridized wards to treat a variety of serious neurological illnesses, and they were soon replete with patients having status epilepticus and stroke to subarachnoid hemorrhage and traumatic brain injury (TBI).1

By 2002, neurocritical care became recognized as a distinct specialty with the foundation of the Neurocritical Care Society.5 Despite an extensive mastery of multiple complex disciplines, the ultimate challenge of neurointensivists is to identify patients at risk for secondary injury, determine disease severity, adjudicate unclear prognoses, and distinguish treatment responders from nonresponders.6 These challenges require a swift, accurate interpretation of subtle changes on examination and dynamic decision-making. Furthermore, a careful balance must be struck between cerebral and systemic treatment priorities.5 The evolution and worldwide implementation of the neurosurgical ICU soon became a physical acknowledgment of the severity and complexity of modern-day neurological and neurosurgical illness, whether situated in a permanent civilian ward or in a tent near the battlefield.

Military Neurosurgery in the Modern War Era

The combat environment also drives neurocritical care. From the low-velocity injuries sustained during the Revolutionary through Civil Wars to the development of high-energy weaponry capable of more tissue damage, injuries sustained in war theater have evolved just as dramatically. This change was particularly abrupt during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). In comparison with previous conflicts, battlefield injuries were dominated by severe but survivable blast injuries.7 Despite a decline in isolated TBI mortality from 73.7% in the Crimean War to less than 14% in World War II, previous advances in battlefield medicine would not suffice for this new class of trauma.8,9

The preponderance of severe blast injuries added a new layer of complexity to patient care. Patients injured by improvised explosive devices (IEDs) were subjected to multiple different injury forces, including the primary injury from blast overpressure (i.e., barotrauma), secondary injury from device fragmentation (i.e., penetrating injury), tertiary injury from individuals being thrown by the blast wave, and quaternary injuries from other effects such as thermal energy, hypoxia, collapsing buildings, and possibly electromagnetic pulse.10,11 These injury patterns often resulted in a widespread systemic inflammatory response further complicating recovery.11 Finally, the increased velocities used in modern military-grade weaponry inflicted cavitary soft-tissue and cranial injuries with a more extensive degree of end-organ damage.9 The mean Injury Severity Score for patients during OIF/OEF was 24.4, nearly 10 points above that which designates polytrauma.7

Military improvements in protective armor, medical evacuation, and early "far-forward" advanced neurosurgical treatment allowed military personnel to survive injuries that would have previously been fatal.9 Aggressive ground and aeromedical evacuation policies and overwhelming air superiority allowed for the rapid evacuation of patients from the point of injury to centrally stationed hospitals with surgical subspecialists. Transport time from the battlefield to a neurosurgeon in an Echelon III medical facility decreased to 1 hour with these strategies.9 On arrival to the combat support hospital (CSH), the soldier could be immediately assessed by a specialist, undergo CT to delineate injury severity, receive lifesaving treatment, and be held for up to 72 hours to achieve stabilization prior to evacuation to a higher echelon of care. Despite these successes, it rapidly became apparent that the care of these critically ill patients required further refinement of team structure and neurosurgical workflow.

Evolution of the "NeuroTeam"

Lessons Learned From the Past

The inclusion of neurosurgeons in war theater proved variable throughout history. Each conflict reinforced the critical importance for expedited access to specialized care with many iterations of surgical care teams to encourage such progress. During World War II, dynamic enemy movement caused the war zone to move rapidly farther away from the hospital. Patients with neurological injuries were either untreated or operated on by other surgical specialties prior to evacuation. In response, Sir Hugh Cairns of the Royal Army Medical Core was the first to propose the use of mobile neurosurgical units (MNSUs).12 These units worked within casualty clearing stations close to the front line, which included ophthalmological and oral-maxillofacial surgical capabilities.13 One operating theater used by the MNSU during the 8th Army’s campaign on Tunisia was a retrofitted diesel motor coach with electric suction, cautery, and light from batteries recharged by running the vehicle. The neurosurgical team consisted of one neurosurgeon, three operating room staff, a ward sister, and one anesthetist shared by all surgical specialties.14 After surgical intervention and patient evacuation, the MNSU could progress forward with the battlefield.

The importance of specialized frontline care continued to be recognized during the Korean War, where a two-stage system consisting of immediate frontline care by autonomous neurosurgical units and evacuation to a hospital after stabilization greatly reduced infection rates and improved outcomes.15 These units enabled early neurosurgical intervention, tactical readiness, and the ability to provide both operative and specialized postoperative neurosurgical care. Personnel included a senior neurosurgeon, one or two assistant neurosurgeons with at least 2 years of residency training, four nurses, and ten enlisted surgical technicians.15

With a progressive improvement in access to specialized neurosurgical care and a reduction in infection and mortality, neurosurgeons became a coveted facet of battlefield medicine. By Operation Desert Storm, each team consisted of two neurosurgeons who commanded variable support staff and resources relevant to their supply needs, a unit colloquially referred to as the "NeuroTeam." Additionally, a large workforce of reserve neurosurgeons was deployed. However, the incidence of TBI was far lower than expected for US soldiers, and, as a result, the neurosurgical workforce was overresourced, a reality that contributed to the gradual reduction in active-duty assignments over the next decade. Support staff continued to include nursing and anesthesiology, yet neither personnel was guaranteed to have critical care specialization. NeuroTeams relied chiefly on the leadership of neurosurgeons with limited capacity for interdisciplinary collaboration or flexibility in patient care management.

An Unmet Need

With the rise in the volume and complexity of critically injured casualties during OEF/OIF, the strain on the military health system brought several neurosurgical issues to light.

The first concern was the method by which to provide 21st-century neurosurgical care to the most deserving patients, service members injured in battle, in a war theater. Over the previous decade, advances in neurosurgical technique and neurocritical care transformed clinical care of severely neurologically injured patients. The leading civilian academic centers were evolving into a multidisciplinary team approach with neurosurgeons, neuroanesthesiologists, neurointensivists, and specialized nursing working to improve clinical outcomes. However, at the dawn of the Global War on Terrorism, military medical doctrine remained fixed in the 1960s’ era of the Vietnam War, relying on a neurosurgeon to provide all types of neurological care. In the Bosnian conflict, for example, the senior author was assigned to create and train a team of support personnel to augment the medical resources present in theater. On call every day for more than a year, the neurosurgeon and his team carried deployment gear containing neurosurgical equipment for use in any field hospital.

The second and perhaps most glaring concern was the incongruent size and responsibility of the military neurosurgery community. During initial engagements in OIF and OEF, neurosurgeons were deployed as part of a surgical team attached to a hospital unit. While this team contained an ICU, it was often staffed by a noncritical care–trained anesthesiologist, medical physician, or, in their absence, a nurse without critical care experience. As the population of critically injured neurosurgical patients increased, neurosurgeons found themselves responsible not only for their operating room but also for postoperative care and expert consultation on a wide variety of nonoperative, yet critical neurological illnesses. Furthermore, the few military neurosurgeons required repeated rotations in and out of deployments far more frequently than ideal, which led to additional staffing burdens at the military medical centers and a further exodus of neurosurgeons from the military.

It soon became apparent that 1) quality of care would suffer through existing military doctrine, and 2) the sheer volume of operative and nonoperative critical care was too burdensome for a solitary neurosurgeon. Deploying multiple neurosurgeons to the same CSH was not sustainable due to the small cohort, the need for constant long-term neurosurgical coverage, and coordination challenges between the military service branches. Furthermore, the military’s usual strategy of increasing physician complement in a needed specialty was impractical given the 6- to 7-year duration of neurosurgical residency training.

As the blast-induced nature of these injuries led to medically complex multiorgan-injured patients, a need was ultimately recognized for a fully trained neurocritical care physician to staff the ICU. Furthermore, refinement in workflow was necessary to optimize the neurosurgeon’s unique skills and acumen to allow for greater focus on neurosurgical intervention without compromising efforts for multiorgan stabilization.

A Novel Redesign

By 2003, with the shortage of deployable active-duty neurosurgeons at a critical peak along with the increasing complexity of neurotrauma, the NeuroTeam was redesigned from its original paired-neurosurgeon concept. By OIF/OEF, there were not enough neurosurgeons to generate enough NeuroTeams, and an upcoming escalation in "op tempo" in Afghanistan required resourcefulness. The NeuroTeam became a rapidly deployable unit consisting of a neurosurgeon and neurocritical care–trained physician. Colonels James Ecklund and Geoffrey Ling composed this team in its infancy on two separate missions during OIF and OEF to test proof of concept in Afghanistan (2003), and then for a longer mission in Iraq (2005) (Figs. 1 and 2).

FIG. 1.
FIG. 1.

Photographs taken at the CSH in Kabul, Afghanistan (A, B, and D–F), and at Walter Reed National Military Medical Center in Washington, DC (C), in 2003, depicting the military medical environment during OEF in 2003. A and B: The Echelon III CSH incorporated CT imaging for urgent diagnostics (A) located in a network of tents downrange from the battlefield (B). C: Infrastructure was set up for intraoperative teleconferencing after OEF deployment and first tested between Colonel Ecklund at Walter Reed National Military Medical Center and a remote general surgeon in theater. D: A nurse tends to a postoperative pediatric patient in the neurosurgical ICU. E: Advancements in aeromedical evacuation via helicopter ensured efficient transport from point of injury to the hospital. F: Dangers of the environment included not only the active engagements between allied and hostile forces but also minefields remnant of conflicts past. © Geoffrey Ling, published with permission.

FIG. 2.
FIG. 2.

Photographs taken at the CSHs in Kabul, Afghanistan, in 2003 (B and E) and in Baghdad, Iraq, in 2005 (A, C, and D), depicting NeuroTeam deployments during OEF and OIF in 2003 and 2005, respectively. A: Colonels Ecklund and Ling work in parallel in the operating room performing a lifesaving craniotomy and deploying a central line for ongoing resuscitation. B: Colonel Ling (left) and Colonel Ecklund (right) pictured at the entrance to the CSH in Afghanistan at the inception of their first NeuroTeam mission. C: Bedside neurocritical care procedures were executed in collaboration in any setting in which they were indicated. D: Colonel Ling performs TCD ultrasonography on a patient to confirm the presence of cerebral blood flow prior to neurosurgical intervention. E: Colonel Ecklund rounds on a postoperative patient in the wards. © Geoffrey Ling, published with permission.

In Afghanistan, where no far-forward neurosurgeon was deployed, the pair instantly became ingrained into clinical workflow. On arrival, they were immediately requested to the bedside of an Afghan child with altered mental status and persistent gaze deviation. Their instant recognition of seizures led to swift antiepileptic administration, production of their own hypertonic saline solution, and subsequent treatment of a cerebral abscess, which had not been diagnosed by nonneurological medical staff. Opportunities for optimal collaboration were unrelenting. After 17 consults, 6 craniotomies, and several neurocritical care procedures in a span of 3.5 weeks, the military’s approach to neurocritical care in theater was revolutionized.

Apart from the administrative and leadership responsibilities inherent to senior military officers, daily tasks consisted of joint inpatient rounding, triaging new trauma patients, telemedicine consultations, critical care procedures, and emergency neurosurgical operations. During a 12-week mission to Baghdad during OIF, the NeuroTeam managed 159 inpatients, 180 consultations, 34 neurosurgical operations, and numerous critical care procedures. The operative experience included 22 craniotomies, 1 cervical spine corpectomy and fusion, 7 cranial and spinal wound irrigation and debridements, and several assists to nonneurosurgical surgical teams. Operative cranial trauma was extensive and spanned cerebrovascular blunt injuries, penetrating IED fragments, intracranial hemorrhage, cerebral ischemia, cerebral edema, skull base and calvarial fractures, dural defects, and complex degloving injuries (Fig. 3). The breakdown of specific operative interventions is displayed in Table 1. At least 8 patients (36.36%) required more than one surgical team performing simultaneous operations because of extensive polytrauma (Fig. 4). As a result of the close partnership with the intensivist, the neurosurgeon was readily available to assist other surgeons during particularly challenging cases, including a case of severe retroperitoneal hemorrhage due to avulsed lumbosacral vasculature and neck explorations for carotid artery injury. Overall operative neurosurgical morbidity included one progression to brain death and one postoperative death secondary to cardiopulmonary arrest. All other patients were successfully stabilized and either evacuated to an Echelon IV hospital or transferred to appropriate civilian facilities within 72 hours.

FIG. 3.
FIG. 3.

A collection of intraoperative photographs and radiographs taken at the CSH in Baghdad, Iraq, in 2005, demonstrating both the severity and diversity of neurotrauma managed by the NeuroTeam in OIF/OEF. A: Complex, stellate scalp laceration with open calvarial fracture. B: Standard trauma craniotomy. C: Anterior fossa destruction sustained after an IED blast requiring skull base reconstruction. D: Diffuse pneumocephalus with presumed basal skull fractures. E: Malignant cerebral edema with active herniation out of the craniectomy site. F: Thoracic spine gunshot wound with the retained bullet lodged in the lateral recess and facet joint. Photographs in panels A–C and E © Geoffrey Ling, published with permission.

TABLE 1.

Composition of neurosurgical cranial interventions (n = 22) performed by the NeuroTeam during OIF in decreasing order of frequency

Surgical InterventionNo. of Cases (%)
Duraplasty21 (95.45)
Decompressive craniectomy15 (68.18)
Foreign body removal &/or track debridement14 (63.64)
Subdural/epidural hematoma evacuation11 (50.00)
Complex scalp closure w/ or w/o rotational flaps or split-thickness skin grafts9 (40.91)
Calvarial reconstruction w/ or w/o titanium mesh7 (31.82)
Lobectomy5 (22.73)
Frontal sinus exenteration4 (18.18)
FIG. 4.
FIG. 4.

Scenes from the operating room at the CSH in Baghdad, Iraq, in 2005, where severe polytrauma often required simultaneous stabilization by multiple surgical teams as well as interdisciplinary collaboration. A: Colonel Ecklund prepares to assist the general surgery team during a neck exploration for carotid artery injury. B–D: A critically ill patient requires concurrent craniectomy, exploratory laparotomy, and thoracotomy. E: After the craniectomy is completed, Colonel Ecklund provides direct cardiac massage to assist the trauma surgeon. © Geoffrey Ling, published with permission.

Within the ICU, 29 intracranial pressure (ICP) monitors, 17 central lines, and 17 intubations were executed by the NeuroTeam. Additionally, 56 transcranial Doppler (TCD) ultrasonography studies were performed to triage injury severity, monitor recovery in the acute postoperative period, and manage cerebral vasospasm. This diagnostic skill, unique to neurocritical care training, provided an additional triage data point that was especially helpful when severe craniofacial trauma precluded a reliable pupillary examination. Nonoperative consultations were a mix of inpatient soldiers, civilians, and "curbside" requests by remote military personnel without access to critical care or neurosurgical resources, and pathology was equally as diverse, summarized in Table 2. Overall, 47.79% of the consultations were for injuries sustained outside of the central nervous system, including traumatic amputations, burns, abdominal barotrauma, and blast lung disease. Noncritical neurological illnesses such as stroke in a young patient, tremor, migraine, back pain, and neuropathy were effectively triaged and managed by the neurointensivist because of his foundational training in neurology. During mass casualty events where the neurosurgeon was serially operating day and night, the neurointensivist triaged casualties to determine the order of priority to the operating room. Patients treated by the NeuroTeam were not restricted by nationality or political allegiance.

TABLE 2.

Composition of neurosurgical and neurocritical care consultations (n = 118) requested of the NeuroTeam during OIF in decreasing order of frequency

Consultation TypeNo. of Cases (%)
Cranial pathology112 (62.22%)
Spinal pathology46 (25.55%)
Mixed cranial/spine14 (7.78%)
Peripheral nerve injuries5 (2.78%)
Pediatric trauma3 (1.67%)

Case Examples

The following case examples best exemplify the benefits of the NeuroTeam’s optimal collaborative workflow as well as the spirit of their endeavors.

Case 1: Optimizing the Neurosurgeon

A 30-year-old soldier with multiple skull base fractures, severe intracranial hemorrhage, and foreign body fragments in the posterior temporal lobe after an IED blast was brought urgently to the CSH. A cricothyroidotomy was evidently performed in the field because of airway loss from facial trauma; however, on arrival, the patient was severely hypoxemic. Neurological examination findings were significant for purposeful left-sided movements and a nonreactive left pupil. The neurointensivist immediately paralyzed and intubated the soldier to restore his oxygenation. After fluid resuscitation for hypotensive shock was administered, CT results revealed extensive globe injury, significant cerebral edema with 5 mm of midline shift, and effacement of the basal cisterns for which decompression was indicated (Fig. 5). Because the neurosurgeon was concurrently performing the critical steps for a trauma craniotomy with additional urgent cases to follow, the intensivist administered hypertonic saline solution for temporary ICP reduction while simultaneously coordinating transfer to another facility with an available team of two neurosurgeons. Relying on the triage capabilities and medical management of the neurointensivist allowed the neurosurgeon to maintain procedural focus while avoiding further delays of care for another deserving patient.

FIG. 5.
FIG. 5.

Case 1. Axial CT head images without contrast revealing retained IED fragments in the left posterior temporal lobe, multicompartmental intracranial hemorrhage, cerebral edema (A), severely comminuted orbital and skull base fractures (B), and a large retained IED fragment in the left temporal bone with comminuted, depressed calvarial fragments (C).

Case 2: Success in Teamwork

A young Army medic, struck unconscious by an IED on patrol, was evacuated to the CSH for immediate NeuroTeam assessment. The patient was extensor posturing with bilateral nonreactive, dilated pupils. The team quickly intubated, sedated, and paralyzed him prior to performing neuroimaging. Head CT findings were consistent with diffuse traumatic subarachnoid hemorrhage and parafalcine subdural hematoma, diffuse cerebral edema with fully effaced basal cisterns, and retained bihemispheric IED fragments (Fig. 6). While the neurosurgeon prepared to perform intraventricular catheterization for cerebrospinal fluid diversion and ICP control, the intensivist administered hypertonic and hyperosmolar therapies, adjusted ventilatory settings, and assisted with the neurosurgical procedure. Given the severity of injury, as well as a significant amount of brain matter evident at the entrance wound, TCD ultrasonography was performed to ascertain cerebral blood flow and the utility of neurosurgical intervention. Cerebral blood flow was compromised but preserved, prompting emergency bilateral hemicraniectomies. Initial workup further revealed blast lung disease and a small pneumopericardium for which the neurointensivist teleconferenced with a cardiothoracic surgeon for further guidance. After surgery, the patient was admitted to the ICU for close ICP monitoring and cardiopulmonary support. If the neurosurgeon’s expertise was required for a consult or in the operating room, the intensivist autonomously adjusted the ventriculostomy and medical therapies as needed. On postoperative day 1, the patient was successfully evacuated to a higher level of care without further decline or immediate complication. One year later, despite expected cognitive deficits, this patient was alive, functional, and able to interact with his children.

FIG. 6.
FIG. 6.

Case 2. Axial CT head images without contrast illustrating subgaleal hematoma, bihemispheric IED fragments, diffuse cerebral edema, traumatic convexity subarachnoid hemorrhage, and thick parafalcine subdural hematoma.

NeuroTeam Evolution

The NeuroTeam has since undergone several alterations to best support modern-day peace and wartime efforts, currently structured as the "Head and Neck Team," a surgical detachment containing one to two neurosurgeons, an otolaryngologist, and one ophthalmologist, along with additional operative support personnel. The neurocritical care physician has been attached back to the hospital unit, as postinjury critical care has almost become the standard for military injuries. The changes initially set in motion by the NeuroTeam have helped spur dramatic improvements for the severely neurologically injured. During OIF and OEF, total mortality was approximately 15%–20% lower than in the First Gulf War and, of those patients who survived their initial resuscitation, many achieved a good functional outcome.16,17 While the long-term functional outcomes of the specific 2003 and 2005 patient cohorts treated by this team are largely unknown due to lack of medical record access or confidentiality, approximately half of patients who survived OIF/OEF had a Glasgow Outcome Scale score greater than 3.18 In comparison with previous conflicts, like the Vietnam War, where blast injuries were also prominent and forward neurosurgical care available, yet without an intensivist, this metric appears to be maintained despite an escalating incidence of CNS injury and complexity of injury patterns.17,19 The addition of a neurocritical care–trained physician and emphasis on multidisciplinary "neuro-focused" teams is ultimately necessary to reduce CNS-related mortality and to optimize the potential for good functional neurological outcomes in an era of progressively complex weaponry and polytrauma. However, comparisons of long-term outcomes across wars ultimately merit caution because of significant differences in study methodologies, limited available data, and complexity and pattern of CNS injury relevant to each conflict, as well as lack of standardization of outcome measures.

Modern Neurocritical Care and the Future

The modernization of neurocritical care has been amplified by the creation of mobile stroke units and comprehensive stroke centers with neurointerventional capabilities, multimodal neurological monitoring, clinical practice guidelines, and clinical performance measures with a predominant focus on quality improvement.1 With more than two-thirds of patients with neurocritical care disorders now managed in a dedicated neurosurgical ICU, modern neurocritical care, in both military and civilian practice, relies heavily on interdisciplinary collaboration and diverse training pathways.20,21 Yet, debates regarding the optimal structure within this multidisciplinary team and their consultants persist.

The current concept of civilian neurocritical care includes dedicated neurointensive care units with in-house or remote intensivists. These units may be "closed," where the intensivist assumes total responsibility for clinical tasks and decisions; "open," where the intensivist acts as a consultant; or a hybrid model. Evidence thus far supports the implementation of closed neurosurgical ICUs because of cost reduction, improved patient outcomes, and a previously reported 94% reduction in mortality, yet neurosurgeons caution against strict delineations in physician roles that limit active patient management and decision-making abilities.1,22,23 Battlefield neurocritical care remains vastly different, where operational constraints, tactical environment, and resource availability further complicate patient care.24 The NeuroTeam represented the epitome of a hybridized adaptive neurocritical care unit, advocating for the optimal employment of each specialist’s unique skills with maximal collaboration.

Neurosurgeons have critical care ingrained into their training and practice, and while a focus on operative technique remains an obvious priority, maintaining general neurocritical care capabilities is also vital. During the recent COVID-19 pandemic, neurosurgeons were ideal candidates to assist in covering desperately needed critical care in areas where infection was surging and intensivists were understaffed. As part of a triservice effort, military neurosurgeons participated in and led multiple humanitarian missions within the United States.25 Much like the optimization of the neurosurgeon by neurocritical care during challenging patient care complexity and staffing shortages, neurosurgeons too can render the same support to their neurocritical care colleagues, thus once again assimilating into one NeuroTeam.

Conclusions

The continued evolution of neurocritical care as a distinct specialty along with a chronic shortage of military neurosurgeons launched a new NeuroTeam during the Global War on Terrorism. Consisting of a paired neurosurgeon and neurointensivist, this team best exemplified the important concept of multidisciplinary collaboration, which underscores the spirit of modern neurocritical care today: the tenet that the most deserving patients, whether civilian or military, require the highest level of expert care modern medicine can offer. The future of military neurosurgery success in and out of theater ultimately relies on its innovative and resourceful past.

Acknowledgments

We wish to acknowledge the many colleagues we have had the privilege to serve with and learn from, in addition to the many military neurosurgeons and physicians of previous conflicts who have documented their experience in the literature to help us all provide better care to our patients in the future.

Disclaimer

The views expressed herein are those of the authors and do not reflect the official policy or position of the United States Army, Navy, Air Force, Marines, Department of Defense, or the United States Government.

Disclosures

Dr. Ling: ownership in On Demand Pharmaceuticals and Phonetics 657.

Author Contributions

Conception and design: DD Dang, JV Dang, Ling, Ecklund. Acquisition of data: DD Dang, Ecklund. Analysis and interpretation of data: DD Dang, Boulter, JV Dang. Drafting the article: DD Dang, Boulter, Meister. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: DD Dang. Study supervision: Ling, Ecklund.

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    Larkin MB, Graves EKM, Boulter JH, et al. Two-year mortality and functional outcomes in combat-related penetrating brain injury: battlefield through rehabilitation. Neurosurg Focus. 2018; 45(6):E4.

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  • 18

    Bell RS, Vo AH, Neal CJ, et al. Military traumatic brain and spinal column injury: a 5-year study of the impact blast and other military grade weaponry on the central nervous system. J Trauma. 2009; 66(4 suppl):S104S111.

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  • 19

    Raymont V, Salazar AM, Krueger F, Grafman J. "Studying injured minds"—the Vietnam head injury study and 40 years of brain injury research. Front Neurol. 2011; 2:15.

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  • 20

    Suarez JI, Martin RH, Bauza C, et al. Worldwide organization of neurocritical care: results from the PRINCE study part 1. Neurocrit Care. 2020; 32(1):172179.

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    • Export Citation
  • 21

    Dhar R, Rajajee V, Finley Caulfield A, et al. The state of neurocritical care fellowship training and attitudes toward accreditation and certification: a survey of neurocritical care fellowship program directors. Front Neurol. 2017; 8(8):548.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002; 288(17):21512162.

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    • Export Citation
  • 23

    The impact of closed ICUs on neurosurgical practice. AANS Neurosurgeon. February 28, 2016. Accessed July 20, 2022. https://aansneurosurgeon.org/peer-reviewed-research/the-impact-of-closed-icus-on-neurosurgical-practice/

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  • 24

    Chalela JA, Britell PE. Tactical neurocritical care. Neurocrit Care. 2019; 30(2):253260.

  • 25

    Ravindra VM, Dunn GP, Belverud S, et al. U.S. neurosurgical response to COVID-19: Forging a path toward disaster preparedness. Mil Med. 2021; 186(5-6):549555.

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Captain Benny Brandvold stands "at the ready" outside of Dhahran, Saudi Arabia, during the early phase of Operation Desert Shield, fall of 1990. © Benny Brandvold, published with permission. See the article by Martin et al. (E16).

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    Photographs taken at the CSH in Kabul, Afghanistan (A, B, and D–F), and at Walter Reed National Military Medical Center in Washington, DC (C), in 2003, depicting the military medical environment during OEF in 2003. A and B: The Echelon III CSH incorporated CT imaging for urgent diagnostics (A) located in a network of tents downrange from the battlefield (B). C: Infrastructure was set up for intraoperative teleconferencing after OEF deployment and first tested between Colonel Ecklund at Walter Reed National Military Medical Center and a remote general surgeon in theater. D: A nurse tends to a postoperative pediatric patient in the neurosurgical ICU. E: Advancements in aeromedical evacuation via helicopter ensured efficient transport from point of injury to the hospital. F: Dangers of the environment included not only the active engagements between allied and hostile forces but also minefields remnant of conflicts past. © Geoffrey Ling, published with permission.

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    Photographs taken at the CSHs in Kabul, Afghanistan, in 2003 (B and E) and in Baghdad, Iraq, in 2005 (A, C, and D), depicting NeuroTeam deployments during OEF and OIF in 2003 and 2005, respectively. A: Colonels Ecklund and Ling work in parallel in the operating room performing a lifesaving craniotomy and deploying a central line for ongoing resuscitation. B: Colonel Ling (left) and Colonel Ecklund (right) pictured at the entrance to the CSH in Afghanistan at the inception of their first NeuroTeam mission. C: Bedside neurocritical care procedures were executed in collaboration in any setting in which they were indicated. D: Colonel Ling performs TCD ultrasonography on a patient to confirm the presence of cerebral blood flow prior to neurosurgical intervention. E: Colonel Ecklund rounds on a postoperative patient in the wards. © Geoffrey Ling, published with permission.

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    A collection of intraoperative photographs and radiographs taken at the CSH in Baghdad, Iraq, in 2005, demonstrating both the severity and diversity of neurotrauma managed by the NeuroTeam in OIF/OEF. A: Complex, stellate scalp laceration with open calvarial fracture. B: Standard trauma craniotomy. C: Anterior fossa destruction sustained after an IED blast requiring skull base reconstruction. D: Diffuse pneumocephalus with presumed basal skull fractures. E: Malignant cerebral edema with active herniation out of the craniectomy site. F: Thoracic spine gunshot wound with the retained bullet lodged in the lateral recess and facet joint. Photographs in panels A–C and E © Geoffrey Ling, published with permission.

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    Scenes from the operating room at the CSH in Baghdad, Iraq, in 2005, where severe polytrauma often required simultaneous stabilization by multiple surgical teams as well as interdisciplinary collaboration. A: Colonel Ecklund prepares to assist the general surgery team during a neck exploration for carotid artery injury. B–D: A critically ill patient requires concurrent craniectomy, exploratory laparotomy, and thoracotomy. E: After the craniectomy is completed, Colonel Ecklund provides direct cardiac massage to assist the trauma surgeon. © Geoffrey Ling, published with permission.

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    Case 1. Axial CT head images without contrast revealing retained IED fragments in the left posterior temporal lobe, multicompartmental intracranial hemorrhage, cerebral edema (A), severely comminuted orbital and skull base fractures (B), and a large retained IED fragment in the left temporal bone with comminuted, depressed calvarial fragments (C).

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    Case 2. Axial CT head images without contrast illustrating subgaleal hematoma, bihemispheric IED fragments, diffuse cerebral edema, traumatic convexity subarachnoid hemorrhage, and thick parafalcine subdural hematoma.

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  • 17

    Larkin MB, Graves EKM, Boulter JH, et al. Two-year mortality and functional outcomes in combat-related penetrating brain injury: battlefield through rehabilitation. Neurosurg Focus. 2018; 45(6):E4.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18

    Bell RS, Vo AH, Neal CJ, et al. Military traumatic brain and spinal column injury: a 5-year study of the impact blast and other military grade weaponry on the central nervous system. J Trauma. 2009; 66(4 suppl):S104S111.

    • Search Google Scholar
    • Export Citation
  • 19

    Raymont V, Salazar AM, Krueger F, Grafman J. "Studying injured minds"—the Vietnam head injury study and 40 years of brain injury research. Front Neurol. 2011; 2:15.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Suarez JI, Martin RH, Bauza C, et al. Worldwide organization of neurocritical care: results from the PRINCE study part 1. Neurocrit Care. 2020; 32(1):172179.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21

    Dhar R, Rajajee V, Finley Caulfield A, et al. The state of neurocritical care fellowship training and attitudes toward accreditation and certification: a survey of neurocritical care fellowship program directors. Front Neurol. 2017; 8(8):548.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002; 288(17):21512162.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    The impact of closed ICUs on neurosurgical practice. AANS Neurosurgeon. February 28, 2016. Accessed July 20, 2022. https://aansneurosurgeon.org/peer-reviewed-research/the-impact-of-closed-icus-on-neurosurgical-practice/

    • Search Google Scholar
    • Export Citation
  • 24

    Chalela JA, Britell PE. Tactical neurocritical care. Neurocrit Care. 2019; 30(2):253260.

  • 25

    Ravindra VM, Dunn GP, Belverud S, et al. U.S. neurosurgical response to COVID-19: Forging a path toward disaster preparedness. Mil Med. 2021; 186(5-6):549555.

    • Crossref
    • Search Google Scholar
    • Export Citation

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