Washington — Dr. Peter Rhee, a Navy veteran, spent his life searching for battlefields in a race for the latest developments in trauma care. Last Saturday, the battlefield came to what was supposed to be his tranquil adopted hometown.
Rhee knew instinctively that how quickly he and his staff at University Medical Center in Tucson, Ariz., handled the 10 victims, including a 9-year-old girl who'd been shot in the chest and a popular local congresswoman with a gunshot wound to the brain, could mean the difference between life and death.
Just 38 minutes after the gunman opened fire, U.S. Rep. Gabrielle Giffords was wheeled into surgery at University Medical Center, metropolitan Tucson's only trauma center. A week later, Giffords and most of the other wounded are recovering. Of those who got to the hospital, only 9-year-old Christina Taylor Green died. The five others who died never made it to a hospital.
How Rhee, the director of trauma treatment at UMC, handled the patients in the first minutes after their arrival at the hospital is the latest installment in the story of the interdependence between the battlefield and the emergency rooms of civilian hospitals throughout America.
Trauma care has developed through warfare, and in the last 50 years, each major U.S. conflict has brought advances. Military hospitals are arguably the nation's first trauma centers, with military surgeons as the first trauma doctors.
During World War II, many soldiers never saw a hospital, instead depending on fellow troops. Those who made it to hospitals often had waited days for transportation. As many as 4 percent died once they were on surgeons' tables, said Dr. Dale Smith, a professor of medical history and a senior vice president at Uniformed Services University of the Health Sciences in Bethesda, Md.
Then came the Korean War and its mobile Army surgical hospitals, or MASH units, spare medical centers set up just behind the front lines. The military also moved to get the wounded to medical care quickly, ferrying them to hospitals by helicopter, something soon adopted in the United States, where medevac flights became commonplace throughout the country. With MASH units and medevacs, the chances of dying on the surgeon's table dropped by half, to 2 percent, Smith said.
In Vietnam, the Navy learned to freeze blood, develop plasma for patients with severe blood loss and finesse getting patients to proper medical care within an hour, what's known now as the golden hour.
Modern warfare in Iraq and Afghanistan led to advances in tourniquets and blood clotting.
It's had smaller impacts as well, such as Rhee's decision after 24 years as a surgeon in the Navy to find a post-retirement home at a trauma center just 80 miles from the U.S.-Mexico border.
It was unique luck, said Dr. Basil Pruitt, the editor of The Journal of Trauma and a one-time chief of professional services at the 12th Evacuation Hospital during the Vietnam War.
"Rhee has had more experience than most see in a lifetime," Pruitt said.
The lessons of trauma care haven't flowed only from the military. In the post-Vietnam peacetime era, military doctors such as Rhee depended on the civilian world, especially crime-ridden cities, to develop their skills.
Rhee, who earned his medical degree at the Uniformed Services University of the Health Sciences' F. Edward Hebert School of Medicine in 1987, remembers it as a frustrating time. While the civilian world had embraced the military's medical lessons — civilian hospitals were building helicopter landing pads, and trauma centers bloomed across the nation — the military had no interest in addressing war wounds.
Rhee, who's now 49, recalls working with Navy doctors who'd served 28 years and had never seen a gunshot wound. They lived in relatively safe communities. The battlefield was nowhere near them.
"It was so maddening that I could not practice my trade and that I was surrounded by people that had no experience in trauma," Rhee said. "After the horrors of the Vietnam War, the last thing on their (the military's) mind was allocating money for trauma. Everyone wanted to sit back and enjoy the decades of peace."
That changed after the 1990-91 Persian Gulf War, when the military realized that it was unprepared for casualties, even though the conflict had meant wounds to only 147 American service members. "What we learned after the Gulf War is, boy, are we lucky we didn't take a lot of casualties," Rhee said.
In 1992, the Navy set up the Navy Trauma Training Center at the Los Angeles County-University of Southern California hospital. The idea was straightforward: Navy doctors would work side by side with civilian doctors as the gunshot victims of L.A.'s street violence came through the hospital. Doctors there were seeing wounds from weapons that once were fired only by soldiers.
Rhee got his first exposure to a steady diet of trauma after he became the training center's director in 2002.
"The Gulf War started that whole conversation," Rhee remembers. "Before, no one wanted to give us funding, even though there were a group of surgeons saying, 'Come on, we could have a war at any time.' "
Rhee was sent to Camp Rhino outside Kandahar, Afghanistan, in 2002, but it was in Iraq in 2005, at the height of the violence there, that he saw how horrible wartime trauma could be. It was nothing like the gunshot wounds and automobile accidents he'd treated in Los Angeles.
"I thought I knew what I was getting into. I was astonished by the world every day," Rhee said.
His patients often had lost both legs and had shrapnel lodged in their heads, he said. And instead of working at a top hospital with state-of-the-art facilities, he had to build one under a tent. A piece of wood became the operating table.
There was no blood bank; instead, he called for volunteer blood donors from soldiers enjoying a chow break. As many as 600 would line up without delay, he said.
"The wounds I saw there were devastating," Rhee recalled.
"After I got back from that, seeing 15 people in L.A. with gunshot wounds (in one night) was nothing."
In Iraq, Rhee also discovered that, despite the medical community's belief that plasma, platelets and packed red cells could replace lost blood, nothing is as valuable as whole, fresh blood when treating catastrophic blood loss.
"I hate to say it, but I experimented in the field," Rhee said.
"It's like sex," he said of trauma care, in his characteristically direct way. "You can read about sex but you ultimately have to do it to understand it."
Shortly after returning from Iraq, Rhee decided to retire from the military. He began a nationwide search for a new home. He wanted an academic setting, a place where he would see trauma and yet a community that would offer a stable family life.
Tucson, Rhee said, was the perfect place for him after his military career, allowing him to teach at the University of Arizona and see regular trauma, in part because of its proximity to the U.S.-Mexico border.
"We don't get a madman shooting 20 people but we get mass casualties," he said. "We know we how to handle them."
On that bloody Saturday, Rhee said, he knew reflexively to get the neurosurgeons and nurses in place and notify the blood bank. He knew he had to stay calm.
The hospital's preparation for the arrival of patients "happened exactly the way it should," he said.
Rhee revealed little about Giffords' care, other than that her blood loss had not been so severe that she needed anything other than plasma for transfusions.
Rhee also called on other military doctors to help treat Giffords. Dr. Geoffrey Ling, an Army colonel and an expert on brain trauma, was on his way to Afghanistan when he was diverted to Tucson. He and Dr. James Ecklund, a retired Army colonel, assessed the treatments and met with Giffords' family, including her husband, Mark Kelly, an active-duty Navy captain and astronaut.
Rhee said he thought that Kelly would feel better with a second opinion from two of the nation's most renowned experts.
"Dr. Ecklund has done a lot of the pioneering work of taking the skull off the head and leaving it off in this type of situation so the brain can swell," he said. "The Army has been doing a lot of that in battle in Baghdad and so the results that they've been getting are astonishing, better than the civilian sector, despite the fact that the wounding mechanism in Iraq is much worse than in the civilian sector, which are most usually handguns."
Dr. Demetrios Demetriades, who directs trauma care at the Los Angeles County-University of Southern California hospital and worked with Rhee when Rhee ran the Navy's training center there, called Rhee "a unique commodity" for a hospital such as Tucson's.
"You can't buy that kind of experience," he said.
(Sam Stanton of The Sacramento Bee contributed to this article from Tucson, Ariz.)