Why civilian and military trauma systems must collaborate

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Trauma leaders have been interested in building stronger links between civilian and military trauma systems for several decades. In the past few years, however, the goal of civilian-military trauma collaboration has taken on a new urgency.

Last year, the National Defense Authorization Act of 2017 directed the U.S. Department of Defense (DoD) to integrate with civilian trauma centers to ensure readiness. Specifically, the act directs larger military medical centers to seek Level I or II trauma center verification and integrate with local civilian trauma systems. Military trauma centers are also directed to partner with civilian trauma centers to provide further opportunities for active-duty military to maintain trauma skills readiness. In addition, the act requires the DoD to establish a Joint Trauma Education and Training Directorate to ensure readiness for current and future military conflicts.

Here in the National Capital Region (NCR), trauma collaboration is a top priority. Given the preponderance of federal agencies headquartered here — not to mention the White House and Congress — the NCR is a high-threat region. Trauma systems form the foundation for a timely and coherent medical response to a disaster. Any response to a large-scale mass casualty event in Washington must be based on an existing organized trauma system across Maryland, the District of Columbia and Virginia.

Some people may ask why increased civilian-military trauma collaboration is that important outside of the DC area. My answer is that the biggest killer of our youth and working-age population is injury. Building integrated trauma systems across cities, states and regions — and eventually nationally — should therefore be a top priority for the nation as a whole. To understand why, we need to go back to the origins of modern trauma care in the U.S. and our recent advances in creating a deployed joint trauma system for combat.

From Vietnam to Afghanistan

During the Vietnam War, the U.S. military deployed significant hospital and air medical resources in support of military operations. This effectively created a robust system of trauma care within a relatively small area of operations, yielding very low rates of death by injury.

When U.S. surgeons returned from Vietnam, they realized that injured soldiers had benefited from an organized system of trauma care with dedicated trauma resources. They also realized that this kind of system did not exist in our country. Thus began great efforts by individual surgeons dedicated to improving trauma care for our citizens. These efforts began in cities starting in the 1970s and over time expanded beyond urban areas to regional and state systems.

Simultaneous to the development of trauma systems in the U.S., the specialties of paramedic, emergency medicine and trauma surgery became uniquely defined and prominent. Trauma centers were verified based on state requirements and by the American College of Surgeons Resources for Optimal Care of the Injured Patient consensus manual.

In 2004, the U.S. military benefited by carrying these lessons in trauma systems of care back to the battlefields of Iraq and Afghanistan through creation of the DoD Joint Trauma System (JTS). This was a success for the U.S. military — one that was taught to the military by those civilians who had created stateside trauma systems over the prior four decades.

New obstacles to preparedness

Over the last 20 years, training in general surgery has dramatically shifted to a new era dominated by minimally invasive surgery. General surgeons have been graduating with less and less experience in open major surgical procedures. While general surgeons were the de facto trauma surgeons of the 20th century based on the breadth of their practice, general surgeons today are less prepared to care for major trauma from their residency training alone.

Today most surgeons leave their residency with only the very minimum number of major trauma cases needed to graduate. The majority of Level I trauma centers utilize fellowship-trained trauma surgeons, and those general surgeons interested in trauma care practice mostly at Level II trauma centers. With few exceptions, most of today’s military medical centers do not care for civilian trauma as a Level I or a Level II trauma center integrated within the local trauma system.

As a result, we have general surgeons who are less prepared for trauma care during their residency graduating and working at military medical centers in which they never care for trauma patients. Some military surgeons do pursue trauma fellowship training at civilian trauma centers, but then they are brought back into military medical centers where they also never care for trauma patients.

Consequently, while specialized trauma centers and surgeons care for our injured citizens, the U.S. military has a cadre of general and trauma surgeons who do not regularly practice trauma care. It is these surgeons who are expected to deploy to remote and austere locations to care for the most severely combat-injured service members.

The current state of the Joint Trauma System

One must also consider the current state of the military’s trauma system. The JTS encompasses not only areas of military operations, but also military facilities outside the combat zone, including military hospitals back in the U.S.

The Walter Reed National Military Medical Center (WRB) is one of these stateside facilities. WRB has been an ACS-verified Level II trauma center since 2013. This came about through strong military leadership with a goal of ensuring that U.S. service members were receiving optimal care based on civilian standards.

However, as the scale of the war against terrorism has decreased — from 100,000 to 200,000 deployed troops during the height of the wars in Afghanistan and Iraq to just 10,000 to 20,000 troops today — WRB has also seen a dramatic decrease in the number of military trauma admissions from overseas. Since WRB is not part of the local civilian trauma system, its resources are not used by local civilians. Thus the resources once built up rapidly out of necessity to care for large numbers of combat casualties are at risk of dwindling due to lack of use.

The importance of maintaining the trauma center resources in Bethesda cannot be overstated. Without the opportunity to care for local injured civilians on a regular basis and with a predictable volume, the resources at WRB will dwindle. The risk is that these resources will not be available for service members injured in the next major conflict.

How civilian trauma systems will benefit

Clearly, the military trauma system has an urgent need to collaborate with civilian trauma centers. However, trauma collaboration and integration are not just to the advantage of the military. The benefit is bidirectional. There are three reasons:

First, it is well known that the advance of trauma care accelerates during time of war, and this has certainly been true over the past 15 years. The lessons recently learned by U.S. military surgeons can and must be shared with our civilian colleagues. Civilian-military trauma collaboration will help disseminate these lessons to benefit our citizens at home.

Second, military trauma facilities in the U.S. provide capabilities in all aspects of trauma care from acute resuscitation to rehabilitation. These resources are already “bought and paid for” by the U.S. taxpayer. Not only is it important for the military to maintain those resources, it makes sense that citizens have the opportunity to benefit by using these services.

Lastly, should there be a disaster anywhere in the nation, natural or man-made, we need to bring all possible resources to bear. Pre-integrating civilian and military trauma centers into an all-hazards trauma system will form the foundation of a successful medical response.

What to do

Achieving closer integration of trauma systems is a big undertaking. I believe the first step is for civilian and military trauma leaders to meet in regional forums to discuss their common challenges and take advantage of shared opportunities.

This effort is well underway here in the NCR. On April 17-19, 2018, the Department of Surgery at the Uniformed Services University and the Walter Reed National Military Medical Center will host our annual trauma symposium. The theme of this year’s conference is “Building a Unified Civilian-Military Trauma System in the National Capital Region.”

The symposium will bring together the trauma leadership of the NCR — including representatives of area trauma centers and systems, EMS agencies, fire departments and law enforcement — to discuss how best to collaborate and integrate trauma care systems for optimal preparedness. This effort hopes to increase the communication, integration and planning across the NCR to ensure the best trauma system response occurs should there be a large-scale disaster.

A strong foundational system

In a very real sense, the need for civilian-military collaboration is magnified by the importance of the National Capital Region as the federal hub for the nation. The success of a medical response to a large-scale casualty event in the NCR will be directly determined by how well we can collaborate to build a strong foundational trauma system. The same is true of every region in our country, and our efforts at collaboration in the NCR can act as a template for development of regional trauma systems in other areas of the U.S. and eventually for a trauma care support infrastructure hosted at the national level.

As witnessed by the military experience in creation of the JTS, a national trauma care system infrastructure would provide overarching strategic direction through federal leadership, a national trauma research action plan with dedicated federal funding for injury care, a unified data collection system to drive a continuously learning trauma system, and data-driven guidelines for optimal care of the injured. Only upon achieving this goal will we be postured as a nation to provide optimal care for our citizens at home and for our troops deployed to combat.

With troops deployed for “advise and assist” operations around the world and with reason to plan for the possibility of larger-scale conflicts, there has never been a time when it has been more important for us to work as one trauma system in our nation.

Kyle N. Remick, MD, FACS is Trauma Medical Director for the National Capital Region Military Trauma System and an Associate Professor of Surgery at the Uniformed Services University (USU) and Walter Reed National Military Medical Center in Bethesda, Maryland. Dr. Remick is a Colonel in the United States Army. The opinions expressed are those of the author and do not represent the views of USU or the Department of Defense.

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