By María Pinel/Joint Task Force-Bravo Public Affairs August 17, 2017 A team of U.S. Army medical personnel from Brooke Army Medical Center (BAMC) participated in a training exercise in Hospital Escuela and Hospital María in Tegucigalpa, Honduras, from July 19th – 27th. They performed complex trauma surgical procedures in a resource-limited environment with logistical support from Joint Task Force-Bravo (JTF-Bravo). The group of surgeons and combat medics split up into two teams to be able to simultaneously perform surgeries in both hospitals after receiving an orientation from Dr. Ricardo Aviles, JTF-Bravo medical liaison, who also introduced them to their Honduran counterparts. The teams then began to screen patients and scheduled surgeries of the most complex cases. “Many of the surgeries we are doing prepare us really well for what is seen as a result of dismounted complex blast injury,” said U.S. Army Lieutenant Colonel Steven Hudak, a staff urologist at BAMC, in Fort Sam Houston, Texas. “We don’t usually see that in civilians so we are able to come here and get a lot of important techniques that cross over into these complex injuries that are seen only on the battlefield.” The combat medics also had the opportunity to complete morning rotations through the emergency room at Hospital Escuela, a school hospital that works as the main center for public health care in Honduras. The teams also rotated to Hospital María, a public pediatric hospital where they performed pediatric urology surgeries. Both teams were joined by surgeons from the JTF-Bravo Medical Element Mobile Surgical Team (MST) who also participated actively. “JTF-Bravo doesn’t necessarily have the same exposure to these patients, so it gives them experience to see the abdominal type of injuries and gives them a broader understanding of all kinds of patients,” said U.S. Army Sergeant Major Richard Russell, the chief clinical NCO at BAMC. “JTF-Bravo and its MST become more efficient in trauma areas that they are not used to treating,” said Dr. Aviles. “A general surgeon is used to doing general surgeries and not urology or orthopedics, but once he is in the battlefield he is the only surgeon and has to be able to assist – so this is basically the concept behind the mission.” Multi-faceted mission The mission consisted of different components, such as female urology, male reconstructive surgeries, and pediatrics, with the intent of teaching the group of medical and surgical providers how to perform complex trauma surgeries in an austere environment in preparation for combat. “Most if not all of what we see in the clinic here is a direct result of trauma,” said U.S. Army Major Humberto Villarreal, a staff urologist at BAMC, who is participating in his third trauma mission to Honduras. “We are seeing blunt trauma, penetrating trauma – these are late manifestations of those injuries but we get to reconstruct urethra injuries, and that has a direct application to the patients that we care for back home,” said Maj. Villarreal. Historically, this mission has always been about urology, but is now expanding the concept to obtain combat readiness by incorporating prehospital training with the Honduran Red Cross through an exchange of best practices. “We get exposure to prehospital training and our surgeons develop skills from working in an austere environment –using equipment that they are not accustomed to– which allows them to think outside the box, as they would in a deployed environment,” said Lt. Col. Hudak. Evolving collaborations U.S. Army Lieutenant Coronel Thomas Novak, a BAMC urologist and officer-in-charge of the mission, has participated actively in the event since 2009. He spoke about how the mission is continuously expanding and the partnership formed with the Honduran urologists. “It was already a mission that was in place with a smaller footprint, but we’ve expanded the scope of our operations here,” said Lt. Col. Novak. “We went from being one surgical team to now three surgical teams using an additional site as well moving pediatric surgeries to Hospital María. A lot of what we are doing has significant trauma relevance even though we are not treating acutely injured patients. What we are trying to accomplish is to evolve it in terms of getting a trauma surgeon to actually see acutely injured patients.” Cases are selected and prioritized by their complexity with the help of Honduran medical counterparts to provide different learning opportunities to both U.S. and Honduran participants. “We have treated many medical issues that had an apparently difficult solution; but as an integrated team we have been able to solve them,” said Dr. Carlos García, a Honduran urologist at Hospital Escuela. “We can say that these are cases that provide us both with learning opportunities.” “I hope it will lead to a continued advancement of our own skills and readiness and I hope that it provides a continued chance for collaboration with our Honduran partners so we can continue to learn from them as much as we hope they are learning from us,” said Lt. Col. Novak. Surgical backlog Limited resources and urologists for adults and children cause a surgical backlog in Honduras, where most patients seen at hospital Escuela or María have to wait months if not years for surgery. Such is the case of Hector Sánchez, who patiently waits in the screening room prior to surgery at Hospital Escuela. Sánchez has waited 10 months to have his urethra repaired and his urinary catheter removed. Another patient, already in the operating room, is having a bullet removed from his urinary tract after a gunshot he received four years ago. If not for this mission, he and Sánchez as well as many others would be forced to use a catheter for life. “We hope that we continue every year because this is a learning experience that helps both countries and strengthens our relationships” said Dr. García. “You will always be welcome in Honduras, and on behalf of the people who have received your support, we thank you.” The surgical teams were able to see a total of 123 complex trauma surgical patients. They developed the way for future engagements involving pre-hospital training opportunities to practice many of their combat trauma skills with a focus on readiness and alleviating the surgical backlog for many Hondurans in need.