American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Part 2: Why the U.S. Trauma System Needs a Robust Civilian-Military Partnership

The conflicts in Iraq and Afghanistan have led to remarkable achievements in medicine resulting in more lives saved than ever before.  In fact, service members injured today have a better chance of surviving than during any previous war in history.1 But as our nation unwinds from its longest period of armed conflict, those advances in care are at risk of being lost.2

The American College of Surgeons (ACS) and a broad coalition of trauma stakeholders are actively working to preserve lessons learned from the battlefield, translate those lessons to civilian care, and ensure service members maintain their readiness to deploy in the future. Through the Military Health System Strategic Partnership American College of Surgeons (MHSSPACS) and collaborative efforts with the Department of Defense Joint Trauma System, the ACS Committee on Trauma’s (ACS COT's) trauma system and quality consultation with the Department of Defense, and initiatives such as Stop the Bleed, ACS is taking a lead role in a national effort to join the nation’s military and civilian trauma systems into one composite national trauma system. The goal of this initiative is the prevention of all unnecessary deaths from injury on the battlefield and on the homefront.

A Long History of Shared Advances

“Since George Washington first called on men to serve in the Continental Army in 1775—and in every conflict through World War II–physicians, and later nurses, volunteered to provide care under the terrible conditions of war,” said C. William Schwab, MD, FACS, founding chief of the division of traumatology, surgical critical care and emergency surgery, and senior consultant, University of Pennsylvania Health System.

William Schwab, MD, FACS, of the University of Pennsylvania Health System, served in the Vietnam War.

These civilians brought their skills to the warfront and returned home with new advances that they put into practice on the homefront. For example, advances in clearing the battlefield, triage, wound care, anesthesiology, blood transfusion, and patient transfer (moving patients from where they were injured to a medical area), intended to save lives of service members, became standard practice in civilian care.

But those links were broken after the Vietnam War. The political nature of the war and public opposition discouraged military physicians from sharing their lessons learned with civilian physicians.

“Because the war was so political, people were bitter and distrusted the military. These feelings prevented us from ever talking about the advances. The number of lessons lost is astounding,” said Dr. Schwab, who served during the Vietnam War. “It took two decades for the medical community to understand what had been lost.”

Soldiers carry a wounded comrade, 1969. <br>Still Picture Records Section, The U.S. National Archives, 111-SC-651408.

Following the Gulf War of the early 1990s, a series of reports by the U.S. Government Accountability Office highlighted the fact that the military no longer had sufficient capability to train physicians and nurses to go to war.

A 1995 report found only 5 percent of cases treated by medical personnel at military hospitals (which include Military Health System facilities such as Walter Reed National Military Medical Center, Naval Medical Center San Diego, or Brooke Army Medical Center at Joint Base San Antonio, TX), reflected cases these caregivers might see on the battlefield, while 98 percent of cases at a high-volume civilian trauma center would reflect battlefield injuries.3 Simply put, caregivers weren’t treating patients during peacetime that reflected the care they would have to provide when called to war.

This realization came at the same time that America’s trauma centers began to see a much greater frequency of wounds due to the increasing use of semi-automatic handguns in urban areas. The Reserve force of military surgeons, working in the civilian sector, gained tremendous experience and developed new ways to care for people who had been shot multiple times. Soon after, with the leadership of Kenneth Mattox, MD, FACS, and Jay Johannigman, MD, FACS, the first of five innovative U.S. military training initiatives was piloted in Houston to enhance the training of active duty military surgeons and trauma care teams.

As early as 1996, the three services began to approve trauma and surgical critical care fellowship training for general surgeons at the busier Level I trauma centers around the country. These programs allowed the Army, Navy, and Air Force to support the career development of military surgeons and create a small but vibrant stream of young trauma surgeons within their ranks.4

At about the same time, two military medical centers in San Antonio requested and were verified by the ACS as Level I trauma centers. These military trauma centers provide comprehensive trauma care to civilians in an integrated civilian-military trauma system through the Southwest Texas Regional Advisory Council’s trauma system.

“Military surgeons were at the surgery table, in our classrooms and in our trauma centers alongside civilian surgeons,” said Dr. Schwab. “They helped us devise new strategies to address firearm injuries. As a result, these military surgeons were better prepared to return to war when they were later called to serve in the days following 9-11.”

Joint Trauma System Modeled After Civilian Trauma System

Still, as the nation went to war after the September 11, 2001, attacks, the military found its trauma care lagged behind civilian care. Clinical best practice guidelines (documents outlining the best ways to treat patients supported by medical research) didn’t exist for the battlefield, patient information wasn’t readily available as patients were transferred from the battlefield to definitive care (a trauma center or other facility that could provide a spectrum of care for injured patients), and advances in care were not well documented. Lives were being lost unnecessarily because of the military’s patchwork provision of care.

So, military surgeons who had spent the previous decade leading ACS-verified trauma centers in San Antonio, such as Col. Don Jenkins, MD, FACS; Col. Brian Eastridge, MD, FACS; and Col. Steve Flaherty, MD, FACS, were able to translate trauma system lessons learned on the home front directly to the frontline of combat casualty care in the theaters of war.

COL Shawn Nessen, Commander of the US Army Institute for Surgical Research and Dr. Deborah Kuhls, Chair of the ACS COT Injury Prevention Committee. (

“After 9-11, we realized we were starting a step behind due to the significant loss of institutional knowledge and advancement that had been applied to develop trauma systems in the U.S. after Vietnam, but had not been translated into military practice,” said Brian Eastridge, MD, FACS, chief of trauma at the University of Texas Health Science Center,  San Antonio.  Dr. Eastridge is also a colonel in the U.S. Army and served six tours in Iraq and Afghanistan, two on active duty and four as a U.S. Army Reserve surgeon. 

In 2003, under the leadership of Col. John Holcomb, MD, FACS, and the Central Command Surgeon, the Department of Defense launched the Joint Trauma System, spanning three continents and five levels of trauma center care. Over the next few years, engaged military surgical leaders developed and integrated the Joint Theater Trauma Registry, evidence-based clinical practice guidelines, weekly performance improvement conferences, and strategic evacuation capability equipped with aircraft-based intensive care. Near real-time review of data allowed for rapid development of new clinical best practices to improve care and save lives. Providers with limited trauma experience prior to the war could readily access best practices and tailor them for use on the battlefield.  Likewise, collection of data in a registry afforded research opportunity and consequent improvement in combat casualty and translatable advances in trauma care.

The Joint Trauma System was built on the foundation of civilian trauma systems, using standards developed by the ACS COT in its Resources for Optimal Care of the Injured Patient manual, which is used by trauma systems and centers around the country. Once established, the Joint Trauma System helped drive significant advances including bleeding control and use of tourniquets, forward surgical care (small surgical teams that provide life-saving surgical care near the battlefield before transfer to definitive care), use of whole blood for resuscitation, rapid transport of injured patients, and new brain injury treatments.

U.S. Air Force 43rd Medical Company training exercise in Iraq. <br>Photo courtesy National Archives #6682608.

Programs such as the joint American Association for the Surgery of Trauma/Society of Vascular Surgery/ACS COT visiting senior surgeons program further increased the collaboration between senior civilian surgeons and military surgeons within the Joint Trauma System. Treatment advances first flowed to the military, but then they began to flow from the military. Civilian surgeons became increasingly engaged with their military colleagues, which improved both civilian and military trauma care.

“Close partnerships like these between the military and civilian trauma systems have helped speed the sharing of lessons learned, improve training, and save lives both at home and in combat zones,” said M. Margaret (Peggy) Knudson, MD, FACS, Medical Director of the MHSSPACS.

“The Joint Trauma System has delivered remarkable results,” said Dr. Schwab. “They changed the dogma of what care needed to be delivered: critical care and damage control surgery. Their approach to delivering care, which is aimed at providing only the necessary treatment needed to save lives before transferring to definitive care, is now becoming the model for mass casualty events. They developed it, they refined it and they proved that it works. These types of advances wouldn’t have been possible without support from civilian surgeons and decades of advances in trauma care led by the ACS Committee on Trauma.”

U.S. Army personnel with the 86th Combat Support Hospital in southern Iraq during Operation Iraqi Freedom. <br>Photo courtesy National Archives #6644700.

Success of the Joint Trauma System helped bring the fatality rate after injury from 18 percent at the start of the wars in Iraq and Afghanistan, to approximately 10 percent at the end of the conflicts, even though the severity of injuries increased during that time. It is the lowest combat case-fatality rate in the history of armed conflict.5

Lessons learned from their care have already begun to impact civilian care.

"The implications of hemorrhage and hemorrhage control after injury have been a significant success story.  Because we had access to data, we found that 25 percent of casualty deaths were potentially survivable and a full 90 percent of these casualties were dying of hemorrhage,” said Dr. Eastridge. “We realized there may be more we can do to save many of these combat casualties. Before the Joint Trauma System, we really had no data to tell us what needed to improve, so the implications of having these kinds of data were astounding.”

Service members from the U.S. Army 86th Combat Support Hospital at a forward-deployed location during Operation Iraqi Freedom. <br>Photo courtesy National Archives #6644699.

Preserving the Lessons of War

Today, ACS is working to translate the lessons of war into civilian trauma care. Its Stop the Bleed program was created under the leadership of Lenworth M. Jacobs, MD, FACS, based upon recommendations of the Hartford Consensus panel following the 2012 shootings at Sandy Hook Elementary in Newtown, CT. The effort trains citizens to act as immediate responders using bleeding control techniques developed and honed for Tactical Combat Casualty Care. The Department of Defense and the National Association of EMTs were key partners in developing and promulgating this program. It builds upon lessons from the military, which provides tourniquets to every soldier in a combat zone.

The Stop the Bleed program trains the public to act as immediate responders, applying pressure, dressings and tourniquets to wounds.

In 2014, ACS and the Military Health System signed a memorandum of understanding to form the MHSSPACS. The partnership’s goal is to expand pre-deployment training opportunities for military surgeons, provide disaster response training for civilian surgeons, partner on surgical practice guideline development and quality improvement, and develop an “optimal resources” manual specific to the needs of the Joint Trauma System. The partnership provides military surgeons with the ongoing skills they need to maintain their readiness to deploy, while civilian surgeons benefit from advances coming from the front lines.

ACS is also supporting federal policies aimed at strengthening the national trauma system. The National Defense Authorization Act (NDAA), passed in late 2016, formalizes the Joint Trauma System within the Department of Defense and aligns all military treatment facilities under common trauma and pre-deployment training standards, rather than having separate protocols for each branch of the military (Army, Navy, Air Force). NDAA also establishes the Joint Trauma Education and Training Directorate, which ensures trauma providers and teams maintain readiness by embedding them in high-volume civilian trauma centers, while military treatment facilities will provide trauma care to civilians in their areas.

Related legislation currently before Congress, called the Mission Zero Act (H.R. 880), would provide $40 million in funding to facilitate partnerships between military trauma care teams/providers, and high-volume civilian Level I trauma facilities. Congress is expected to vote on the bill in 2017.

Following the release of a 2016 report by the National Academies of Science, Engineering, and Medicine (NASEM), “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths,” ACS has joined with a broad coalition of trauma stakeholders such as the National Highway Traffic Safety Administration (NHTSA), the U.S. Department of Defense, NASEM, and the National Institutes of Health to develop a National Trauma Action Plan. In addition, ACS has strengthened collaboration with trauma system specialists including EMS, nursing, orthopedic surgeons, and emergency physicians, whose associations sponsored the NASEM report and were members of the NASEM committee.

The National Trauma Action Plan will outline steps to establish Federal leadership for one national trauma system inclusive of military and civilian trauma care, identify and close the gaps in trauma care in the United States, reduce unnecessary deaths, encourage data sharing and system-wide performance improvement, and increase trauma research funding commensurate with the ongoing burden of trauma to our society.

“Santayana said, ‘Those who cannot remember the past are condemned to repeat it.’ Joining our nation’s trauma systems together under one national trauma system ensures the hard-won lessons of war contribute to lives saved at home, and the advances in care on the homefront benefit those called to serve,” said Ronald M. Stewart, MD, FACS, Chair, ACS Committee on Trauma.