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# Honduran MEDRETEs Provide Invaluable Surgical, Training Opportunities

By Lori Newman, Brooke Army Medical Center Public Affairs

Brooke Army Medical Center personnel participated in two separate Medical Readiness Exercises in Honduras recently.

These exercises, commonly called MEDRETEs, help U.S. military personnel maintain readiness by allowing them to train in the delivery of medical care in austere conditions. They also promote diplomatic relations between the United States and the host nation, and provide humanitarian and civic assistance.

“MEDRETEs play a critical role in the training and readiness of our military medical personnel,” said BAMC Commanding General Brig. Gen. Wendy Harter. “These exercises allow our doctors, nurses, and medics to practice vital skills in austere environments -- conditions that closely mirror what they may experience while deployed -- while also fostering relationships with partnering nations.”

**Tegucigalpa, Honduras**

A team of 19 military medical personnel from BAMC and other military treatment facilities participated in an orthopaedic and hand mission in Tegucigalpa, Honduras from Sept. 14-27.

“This was the first time many of us have participated in a MEDRETE,” said Army Lt. Col. Lori Tapley, the mission’s executive officer.

The team from BAMC met up with their counterparts from the other MTFs at the airport before flying into Honduras. “Some of the others who had been there before were able to fill us in about what to expect when we arrived,” Tapley said.

When they arrived at Hospital Escuela the team hit the ground running. The hospital, which normally has 22 operating rooms, is currently undergoing renovation leaving them with only nine functioning ORs.

“As a result, the hospital was at full capacity with inpatient trauma patients,” explained Air Force Maj. (Dr.) Julia Nuelle, chief of Orthopaedic Hand and Microvascular Surgery at BAMC, and the officer in charge for the mission. “They actually had patients staying in the emergency room, because there were no inpatient rooms available on the floors.”

“A lot of the work we did was operating on these patients who have been there for several weeks,” Nuelle added.

The first day, the team went through the entire hospital accessing the patients, viewing multiple sets of x-rays, organizing the information, and creating a planning schedule for the following weeks.

Nuelle led a team to care for the hand and upper extremity injuries, while Army Lt. Col. (Dr.) David Gloystein, chief of Spinal Reconstructive Surgery at Eisenhower Army Medical Center, led another team to care for the lower extremity injuries.

“Currently in Honduras the main mechanism for upper extremity injury is likely a machete attack, and we saw a lot of those patients,” said Air Force Capt. (Dr.) Tayt Ellison, one of the residents who was on the mission.

The teams treated several patients who had multiple tendon and nerve injuries.

“Not just on the flexor or the extensor side, but the machete cut both sides,” Nuelle said. “There were several severe polytrauma patients we took care of with injuries that were several weeks old. That made the cases much more challenging than if they had been taken care of within the first week or two.”

Both teams worked long hours, rotating shifts to best utilize the space and equipment needed to perform the complex procedures. Even though the team brought the supplies and equipment they needed, they were faced with a myriad of challenges, including power surges, power outages, no air conditioning in the ORs and the threat of a water shortage.

“We were also using instruments and equipment we don’t commonly use in the U.S. because we have different options,” Nuelle said. “For instance, typically when we are drilling for screws, we use a power drill, but to sterilize our power drills in Honduras it took several hours, so if we had multiple cases, we actually used hand crank drills to put the screws in. It required a lot of coordination between the teams to make sure we were utilizing our supplies and equipment the optimal way.”

Every day the entire team had to collectively decide which sets of instruments each team was going to use that day.

“Every day was a different problem, and different problem-solving situation,” Ellison said.

Tapley, a family nurse practitioner, became a rotating OR nurse, and Ellison assisted in most of the trauma and upper extremity surgeries.

“We all stepped into roles we don’t do on a regular basis, just like you would in a deployed environment,” Tapley said.

In the end, the team completed 128 procedures, and Army Capt. Lina Ochoa, an occupational therapist who is fluent in Spanish, was able to hand write therapy protocols for patients to follow after the team left.In addition to the daily surgical regiment, some of the team members completed a lecture series with the Honduran plastic surgery department on advanced upper extremity surgical techniques.

“They were very receptive to having us there and working with them,” Nuelle said.

The last day, the team finished their mission by visiting their patients and delivering toys and coloring books to the hospital’s pediatric ward.

“This was the type of training that you can’t get anywhere else,” Nuelle said. “We dealt with things you don’t think about happening here (in the U.S.), but could certainly happen downrange.”

“I thought it was a great experience,” Ellison said. “The ultimate goal is to be in a situation where you are ready to be deployable.”

**Meanwhile in La Ceiba, Honduras**

In addition to the MEDRETE in Tegucigalpa, a separate team of 12 U.S. military medical personnel went to La Ceiba, Honduras from Sept. 19-27.

The team consisted of two surgeons, two anesthesiologists, three OR technicians, one OR nurse, one emergency room physician assistant, a pediatrician, Army Maj. Jordan Guice, officer in charge, and Army Sgt. 1st Class Michael Foglio, noncommissioned officer in charge. Seven of the personnel were from BAMC.

“We were working in a government hospital, and they had a backlog of cases, so we were helping work through their backlog,” said Guice. “Our mission initially was trauma, but it turned out to be more of a humanitarian mission.”

This team worked alongside their Honduran counterparts completing 32 operations which included 10 gallbladder operations, 21 hernia repairs and one trauma case.

“This was my first time working in a hospital in a foreign country and the first time working in an austere and resource limited environment,” Guice said. “Training here at BAMC I’m used to having everything available.”During the trauma case, which was also a patient who had severe machete wounds, the power went out.

“As we were suturing the lights went out and we all had to grab our cell phones for light,” Guice said.

The team anticipated the surgical cases, but they didn’t anticipate a pediatric burn patient with second and third degree burns. The patient was from a remote area of Honduras and the family traveled three days by motorcycle to bring the child to the hospital.

Thankfully Foglio had previous experience with burn care and pediatric patients.

“It was edifying for me to be able to take the skills that I have learned here (at BAMC and the U.S. Army Institute of Surgical Research) 10 years ago and pass them onto our pediatrician, our OR tech and our combat medic,” Foglio said. “I was also able to teach the patient’s dad how to do burn care.”

The team heavily relied on Army Sgt. Luisa Rodriguez-Harmon, OR technician, because she was fluent in Spanish. Her family is from El Salvador, which is a neighboring country to Honduras.

“We share a lot of similarities,” she said. “I have always liked helping people, especially people with language barriers; just helping translate and getting their point across. Going on this mission and having the ability to do that was a blessing.”

Rodriguez said the people were very nice and welcoming.

“Every chance they got, they made sure we ate,” she added. “They would bring their native plates. It was just really awesome. They were the sweetest people.”

As with the MEDRETE in Tegucigalpa, BAMC personnel said they enjoyed the experience and learned many valuable lessons.

“The intent of these MEDRETEs is to give us the opportunity to function in a more austere environment,” Foglio said. “This is an area that has increased trauma, and that real-world trauma is something that is difficult to replicate in a training environment.

“It makes you appreciate everything we have here in the U.S. on a personal level and on a medical level,” he added. “I think every single one of us grew for this experience.”

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MEDRETEHondurasJoint Task Force BravoBrooke Army Medical Center