Partnering in Critical Care Projection

Dr. Timothy Nunez
Division of Trauma & Surgical Critical Care
Brooke Army Medical Center

From Combat & Casualty Care , Q4 Winter 2021

Timothy Nuñez, MD, MMHC, FACS is currently Professor of Surgery in the Department of Surgery, at F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences.  He is Chief of the Division of Trauma & Surgical Critical Care at Brooke Army Medical Center. Prior to his arrival at BAMC he was on faculty at Vanderbilt University School of Medicine in the Division of Trauma, Emergency Surgery and Surgical Critical Care.  He received a Masters from Vanderbilt University Owen Graduate School of Management.  From 2001-2011 he was an active duty Army General/Trauma surgeon.  He is board certified in general surgery and surgical critical care.  He completed his fellowship training at Vanderbilt University Medical Center and his general surgery training at The Good Samaritan Hospital, Cincinnati Ohio. 

Combat & Casualty Care had the opportunity to speak with Dr. Tim Nunez, head of Brooke Army Medical Center’s Trauma & Surgical Critical Care Division regarding areas of focus and challenge in meeting today’s combat medical care mission.

C&CC: What are your primary responsibilities as Chief, Division of Trauma & Surgical Critical Care?

Dr. Nunez: To understand the duties of the Chief of Trauma at Brooke Army Medical Center (BAMC) you need to understand the history and the unique mission of trauma at BAMC. The Division of Trauma at BAMC is unique compared to all the other divisions and departments at BAMC. The Trauma Division is the largest division in the Department of Surgery and is responsible for the mission of caring for civilian trauma patients. At least 85% of the patients that are cared for by the division are civilian non beneficiaries. BAMC started taking civilian trauma patients in 1996 as part of an agreement with the Bexar County Texas Hospital District. In 1996 the trauma mission for South Texas was shared by University Hospital, Wilford Hall Medical Center, and Brooke Army Medical Center. In 2009 due to Base Realignment and Closure (BRAC), Wilford Hall and BAMC combined into one trauma center at BAMC. Since BRAC, the growth of trauma at BAMC has been exponential. Over the past decade the trauma volume has increased 264%. To participate in the care of civilian trauma patients in Texas, BAMC needs to be compliant with the State trauma rules. My role has a clinical, academic and administrative role. My job is to serve as a subject matter expert in trauma care. I am working to develop trauma medical leaders from an outstanding group of young surgeons. I work very closely with the assistant chief of Trauma/Trauma Medical Director to make sure we adhere to the high standards set by the American College of Surgeons.

C&CC: From a trauma care perspective, speak to some key evolutions you’ve seen take place in the last decade or so.

Dr. Nunez: Key evolutions largely driven by military medicine have been hemorrhage control and resuscitation of trauma victims. It is common that we learn to take care of trauma patients from war time injuries; this has been no different over the past twenty years. We have really focused on what we resuscitate a patient with, providing a much more balanced resuscitation with far less crystalloids. This focuses on what the patient is losing, which is blood and clotting factors. So this balanced resuscitation uses blood products much earlier than we were taught 20-30 years ago. We have also pushed forward to the first responder, combat medic and bystanders the need for hemorrhage control. The American College of Surgeons has worked extensively to push out and teach hemorrhage control to non-medical personnel with the creation of the Stop the Bleed Course. Tourniquets and bleeding kits are becoming prevalent in the community just as AED did after being pushed by the American Heart Association.

C&CC: From a surgical care perspective, what types of advances do you see as critical to positive outcomes not seen even just a decade ago?

Dr. Nunez: It is hard to separate out surgical care from trauma care. They are essentially the same when it comes to the management of injured patients. For not emergent care the instrumentation and technique with the use of laparoscopic and robotic tools has greatly expanded surgical approaches. This type of minimally invasive specialized surgical skills is prevalent in health care but not that prevalent in trauma surgical circles. The use of advanced minimally invasive techniques have not grown substantially in the trauma surgical practice

C&CC: In terms of any recent advances in mobile trauma or surgical care, can you speak to any trends? The biggest trends are in the prehospital management of major injury, again pushing the care of the patient far forward.

Dr. Nunez: Training medics, paramedics, and prehospital physicians advance techniques such as airway management, hemorrhage control and major surgical procedures. Some EMS systems have moved forward with surgical procedures prehospital, these procedures can be controversial and are not widely practiced at this time. However in mature, well-run regional systems, this type of care can be standardized and implemented well. These type of advanced surgical techniques need the entire system (EMS, Regional trauma system, trauma centers) on board in the implementation and maturation of these procedures being introduced prehospital.

C&CC: Feel free to add any comment on achievements/goals moving forward.

Dr. Nunez: BAMC has been a trusted partner in the regional trauma system of south Texas for 25 years. This relationship cannot be highlighted enough to demonstrate the readiness value that this trauma center provides to military health care personnel. BAMC has shown that every member of our health care team gets readiness touches from our institution’s dedication to the care of trauma patients. Furthermore, during the pandemic BAMC was able to clearly show its value as a member of our regional trauma system. Due to the overwhelming nature COVID-19 attacked the community, BAMC increased trauma volume to offload our civilian partners from the burden placed on their need for space to accomdate the increased number of COVID patients. For over 5 months covering 3 separate surges of COVID, BAMC increased trauma volume by over 35% to maintain the integrity of our regional trauma system. During this same time we developed a state of the art predeployment platform for deploying teams that included hands-on clinical care at BAMC.