The face of the Army in Europe has been changing dramatically since the fall of communism nearly two decades ago. U.S. installations have closed as a result of the Department of Defense's continuing effort to downsize -- to save money and put resources where they're most needed.

In July 2005 DOD reported some 13 installations in southern Germany would close by the end of 2007. Landstuhl Regional Medical Center is one of the few military facilities in the region that has proven its relevance through some of the toughest recent times.

Since operations Enduring Freedom and Iraqi Freedom began, DOD's premier medical center in Europe “went from being a sleepy community hospital to an active, vibrant, turbulent medical center, with the number of people arriving and being air-evacuated to the States always changing,” said MAJ Kendra Whyatt, head nurse of the hospital's Orthopedic Ward.

As of September 2005 more than 27,000 patients had arrived from Iraq and Afghanistan. After the battle in Fallujah began on Nov. 8, 2004, as many as 455 patients arrived in a week's time, hospital officials said.

Before operations Enduring Freedom and Iraqi Freedom, LRMC's intensive-care unit could accommodate six patients, now it can handle 20. The number of operating rooms has doubled to eight. In fact, admissions climbed 56 percent, operating-room cases swelled by a staggering 100 percent and the number of pharmacy products leaped by 141 percent, said LRMC spokeswoman Marie Shaw.

Today, when the public-address system blares “wheels on the ground,” LRMC's doctors, nurses, psychiatrists, chaplains and members of the 77- member Deployed Warrior Medical Management Center spring into action.

To date, coalition troops from 38 nations have been cared for at LRMC, as have Soldiers, other service members, government civilians and contractors.

Chaplain (CPT) Billy Steen stood at the bedside of SPC Ryan Bowen of the Fort Stewart, Ga.-based 4th Brigade Combat Team, who was medevaced to LRMC after an improvised explosive device blew up his Abrams tank near Balad, Iraq.

Bowen had not only his own injuries to deal with -- a perforated liver and leg pierced by shrapnel and burns in 20 places -- he'd also witnessed the deaths of two of his buddies.

Time to Talk

“This is the first real stop for Soldiers who have been wounded in Iraq and Afghanistan,” said Steen. “We've heard how well chaplains have worked with wounded Soldiers at the aid stations downrange, but this is the Soldiers' first real chance to talk about what happened. And they say, ‘Thank you so much for listening.'

“Up until they come here, life has been a whirlwind for the wounded -- they've been quickly moved from the aid station to a combat support hospital to here. Many of the Soldiers who arrive at LRMC have lost comrades and they feel guilty about being out of the combat theater while their units remain in-theater,” Steen said. “Many ask themselves if they could have done something differently to prevent a buddy from dying.

“It's very important for them to recount what happened. They've rehearsed it in their minds time and again,” he added. “They think they need to get back to the fight, and they wonder how their injuries will affect their careers.”

Often they rationalize that they trained together, so they should return home together, Steen said. “When they don't come back with their units, they face one of the facets of their loss. We cry with those Soldiers. They need somebody to cry with them.”

“I've talked to a Soldier who had the first joint of an index finger amputated, and he just wanted to know what life holds in store for him,” said Whyatt. “Other Soldiers have had arms and legs amputated and just want to go back to the fight. I've seen grown men cry when they're told they're going to be air-evacuated to the States, because they didn't think their injuries were so bad.”

What makes one person cope and adapt more easily than another? Upbringing, level of responsibility, so many things enter into it, Whyatt said.

Getting Soldiers Well

The number-one mission for LRMC's medical staff is to help Soldiers get well.

Steen, who has done pastoral work for many years, has been dealing with the casualties of war for the first time in his career. He's among the first people patients see upon their arrival at LRMC. And he assures them that many people are praying for them.

“Seeing Soldiers all torn up is draining,” Steen said. “But this is hallowed ground, because it's the first real stop for men and women who have risked their lives in OEF and OIF and it's a privilege to be able to work with them.”

Preparing to Minister

Chaplains prepare themselves for ministering to combat casualties by attending the two-week Emergency Medical Ministry Course offered at Brooke Army Medical Center at Fort Sam Houston, Texas, and twice annually at LRMC. The course curriculum includes the Critical-Incident Stress- Management Course, which prepares chaplains to work with both patients and hospital staff to also combat compassion fatigue. [See accompanying box.]

Chain of Medical Care

Many more Soldiers survive combat wounds today than at any other time in history because of the more immediate care they receive. Those wounded in Iraq and Afghanistan are rushed to the closest treatment facility in the combat theater -- whether operated by the Army, one of the other services or even another of the coalition countries.

SSG Clifford McDaniel Jr.'s right leg was badly injured in a roadsidebomb explosion in Iraq. McDaniel, a Reservist with the 48th Brigade's 648th Engineer Battalion from Statesboro, Ga., said another Soldier who had been in his up-armored Humvee when it ran over a trip wire initially patched him up before a helicopter medevaced him to Baghdad Hospital, in the “Green Zone.” He was there for a day, then briefly someplace else in Iraq before his evacuation to Landstuhl.

“I couldn't have asked for better treatment,” McDaniel said. “Everyone who cared for me has every right to be proud of the work they've done.”

First-line Treatment

“The first line of treatment ‘downrange' is buddy aid,” said LTC Cathy Martin, head nurse of LRMC's intensive-care unit. That might mean the buddy applies a tourniquet to stop severe bleeding. A combat medic starts an intravenous line, and then a wounded Soldier is rushed to the nearest combat-support hospital to receive blood or undergo surgery.”

“Surgeons downrange are the key to the survivability of our patients,” Martin said. “Without them, wounded service members wouldn't get to us.”

All service members wounded in Afghanistan and Iraq arrive at LRMC via one of two evacuation sites in Afghanistan and four sites in Iraq, said Dr. (LTC) Ron Place, deputy commander for LRMC's eight outlying clinics and managed care facilities in Germany, Belgium and Italy. Twenty-three percent of the wounded are returned to duty in theater.

Critical-Care Air Transports

“We have Air Force critical-care air-transport teams assigned to us,” said Martin. “Three to four times a week these flying intensive-care units from nearby Ramstein Air Base pick up ICU patients and either bring them here or transport them from LRMC to the States. The CCAT teams do what we do in the ICU, but they do it in the austere environment of a military transport aircraft.”

Changes Sparked by War

Today, some 70 percent of Whyatt's staff on the Orthopedic Ward is composed of Reservists. And Reservists can be found supplementing active-duty hospital staff and civilians throughout the hospital.

The types of injuries hospital personnel are dealing with have changed, too. While Whyatt and her staff see typical orthopedic injuries, for example, “the mechanism of injury is what makes them different,” she said.

“We're dealing with breaks due to IED injuries, vehicle rollovers or vehicle rollovers onto IEDs, together with gunshot wounds,” she said. “So, we're not just taking care of broken bones, but soft-tissue injuries as well.”

Before OIF began, the ICU was staffed by some 20 medical professionals, Martin added. At the height of the war, there were between 85 and 93.

Other things have changed, too. Among the greatest improvement to patient care has been a medical tracking system called JPTA [see story on pg. 18] that provides the staff the patient's medical history before the patient arrives. It tracks a patient en route to LRMC, from the departure airfield to his arrival at Ramstein Air Base and during the drive to the hospital, Martin said.

The timely information helps medical teams properly prepare for the patient's arrival, covering every physical and emotional contingency by having the appropriate professionals on hand, Martin said.

During the first Gulf War it took about 28 days from the time a Soldier was wounded to the time he was evacuated to the States, Place said. The average length of time today is three to four days.

If a patient can be returned to the combat theater, he usually returns within two weeks, Martin added. If he needs long-term care, he's evacuated to the States, often to BAMC, Walter Reed Army Medical Center, in Washington, D.C., or a hospital near the Soldier's home station, Place said.

“There's no place in the world that's doing what we're doing now,” said Martin, a 20-year Army veteran who served with the 5th Mobile Area Support Hospital in the first Gulf War and has seen her share of trauma and burns.

“We may have seen burn patients in the past -- from house fires. But burns with blast are very different injuries resulting in head-to-toe trauma -- or ‘polytrauma,'” Martin said. Picture a car accident in which the car explodes and the passengers are burned.

“One reason a trauma patient dies is because something that should have been observed is missed,” Martin said. “That's why, for the past year, 15 to 20 people -- including an infectious- disease specialist, respiratory specialist and a nutritionist -- participate in daily rounds to evaluate the patient.”

Lessons learned have resulted in procedural changes downrange, too.

Medics are trained to leave wounds open; they no longer close amputations, because dirt can get into the wounds and cause infections, Place said. And patients with abdominal wounds are medevaced to LRMC with only bandages covering the wounds, allowing swelling inside the abdomen to decrease and reducing the possibility of kidney damage and renal failure.

The one-handed tourniquet, which Soldiers can administer to themselves to stop bleeding, has saved lives, as has the process of removing foreign material from wounds downrange and doing cultures on tissue from the wounds to determine what bacteria exists and how to combat it, Place added.

The protective equipment Soldiers wear today saves lives, but it leaves them with perforated ear drums and traumatic brain injury, Place said.

“Because some parts of their bodies are so well protected, the parts that aren't protected are injured. Today it takes a .50-caliber machine-gun round or rocket-propelled grenade to pierce the Soldier's body armor. And the most serious injuries are due to IEDs, RPGs and mines,” he said.

“The vast majority of injuries are soft-tissue injuries to extremities, broken bones and injuries to major vessels. Roughly four to five percent of OEF/OIF patients undergo amputations,” Place said.

Thirty to 50 patients have had to have eyes removed, Place said, and one Soldier arrived at LRMC blind and deaf. “Through the care he received here, he'll have reasonable sight with corrective lenses and hearing with hearing devices.”

Dr. (LTC) Kevin Kumke is chief of LRMC's Pulmonary and Critical Care Medical Service and is among the ICU physician team at LRMC, which also includes three surgery-trauma specialists.

A typical ICU patient from the combat theater comes in to LRMC breathing with the help of a mechanical ventilator, with various intravenous lines delivering medications, and a number of wounds bandaged, Kumke said.

“We convert the patient from the equipment used during his transport to ICU equipment, assess his stability and evaluate his condition through lab work and CAT scans.”

The survival rate for combat casualties at LRMC is very high “due to the emergency care performed in the combat theater, Kumke said. “We're able to build on that.

“We train for a decade to be able to make a difference, and here we can make that difference,” he said. “It's been very humbling to be here at this important place and time.”