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

Part 3: Sixty-Year Military-Civilian Partnership Serves as a Model for the National Trauma System

One of the oldest and busiest trauma centers in the country, Baltimore’s Shock Trauma, has a long history of taking on the most challenging injuries. Shock Trauma is known to its community for its characteristic pink scrubs and its military precision in saving lives. For 60 years, it has partnered with the military to advance trauma care at home and on the battlefield. Today, it’s a leader in a type of military-civilian trauma center integration that national trauma leaders hope will be a significant factor in the pursuit of the goal of zero preventable deaths and disability from injury.

R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center is named in honor of its founder, R Adams Cowley, MD, FACS, a pioneer in trauma medicine. The military-civilian partnership at Shock Trauma began 60 years ago, with a $100,000 grant from the U.S. Army for a two-bed-unit designed to study shock. With this effort, Dr. Cowley simultaneously laid the foundation for the modern trauma center and the modern civilian-military training center.1,2 Dr. Cowley’s seminal partnership with the U.S. Army grew into one of the largest and most successful trauma centers in the United States.

True to its foundation, the Baltimore R Adams Cowley Shock Trauma Center has continued to create innovative military-civilian partnerships aimed at optimizing both civilian and military trauma care.

Baltimore’s R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center partnered with <br>the U.S. Air Force nearly 20 years ago to help create the C-STARS pre-deployment training program.

The Need for Military-Civilian Integration

In the 1990s, U.S. government reports showed that most military treatment facilities had limited capability to train physicians and nurses to go to war because the patients they were treating in these facilities were different from those the military medical teams would treat on the battlefield.3 The Department of Defense (DoD) began to look for partnerships with high-volume civilian trauma centers that treated injuries more comparable to wartime injuries. The beginnings of these partnerships were explored in our recent story: Why the U.S. Trauma System Needs a Robust Civilian-Military Partnership.

DoD reviewed more than 100 trauma centers nationally4 and in 2001, it selected three centers at which to pilot programs embedding military trauma caregivers into a civilian hospital: the Army selected the University of Miami Ryder Trauma Center, the Navy selected the University of Southern California + Los Angeles County Medical Center (USC+LAC), and the Air Force selected Shock Trauma. The leaders of these three centers were eager to partner on the program.

“‘Shock is shock,’ we said. There are more similarities between military and civilian care than differences. We thought we would be able to make this work,” said Thomas Scalea, MD, FACS, Francis X Kelly Distinguished Professor of Trauma and Director of the Program in Trauma, University of Maryland School of Medicine. “Once we decided to do it, I never looked back. It wasn’t a question of if, but how.”

The pathway chosen by Shock Trauma and the Air Force was the creation of the C-STARS program, or Center for the Sustainment of Trauma and Readiness Skills, and today it is the largest of three C-STARS programs in the country including St. Louis (MO) University and the University of Cincinnati (OH).5,6  C-STARS benefited from lessons learned from more than 20 years of partnership between Shock Trauma and Walter Reed Army Medical Center to train general surgery residents.

The program places Air Force personnel side-by-side with civilian trauma teams, caring for patients who have been injured by motor vehicle crashes, firearm injuries, falls, and other injuries. The goal is to ensure airmen maintain their readiness to return to combat, while civilian hospitals benefit from lessons learned in the military.7 The programs developed between the other branches of the armed forces and their partnering trauma centers have developed along similar, though not identical, lines.

“While we may not have the type of blast injuries you’ll see on the battlefield, this is as close as you can get to those types of injuries away from a combat zone,” said Dr. Scalea. “There are many similarities in the philosophy of the way care gets delivered. ‘The right care for the right patient at the right time’ is a universal set of principles.”

Shock Trauma’s C-STARS program operates for 10 months a year, training 30-40 people per month. Over the years the program has grown to include nurses, anesthesiologists, orthopedic and oral surgeons, and technicians. The busy center treats more than 8,000 trauma patients a year, providing daily opportunities to build skills. Some participants are embedded as regular staff members with academic appointments, and the program has expanded to include a focus on clinical research.

“There was so much demand, we kept adding specialties,” Dr. Scalea said. Since it began, he estimates C-STARS at Shock Trauma has trained 5,000 Air Force trauma professionals.

“Think about the number of casualties they’ve treated,” said Dr. Scalea. “The effect of the program has been enormous. I had the chance to visit Afghanistan, and everywhere I went I met someone who had gone through our program. We created this program because it was the right thing to do. Now it’s part of our DNA. We wouldn’t be Shock Trauma without C-STARS.”

C-STARS helps Air Force medical personnel prepare for deployment by caring for trauma patients <br>with injuries similar to what service members will see in a combat zone.

Other Models of Military-Civilian Trauma Integration

C-STARS serves as just one example of military-civilian integration. Two other notable programs also have made significant contributions to advancing trauma care and trauma care system integration.

In 2002, the Navy chose to partner with LAC+USC to provide trauma training for its surgeons, emergency medicine physicians, anesthesiologists, nurses and corpsman, and help them improve and maintain skills. LAC+USC was selected because of its patient volume and complexity of cases it encounters. Similar to the C-STARS model, leadership is provided by key civilian surgical leaders, such as Dr. Demetrios Demetriades, MD, PhD, FACS.

"For somebody who hasn't seen a lot of trauma before, our trauma center, especially on a Friday or Saturday night, is simply overwhelming," said Dr. Demetriades, professor of surgery and chief of trauma and critical care at LAC + USC. "Seeing severe trauma and patients near death where every minute counts, cannot be learned with simulation. You need to participate and learn in the real environment. You don’t want a young physician to learn on the battlefield. You want them to experience these dramatic events in the controlled environment of a busy trauma center with experienced supervision in place.”

The Naval medical teams receive extensive, specialized training while LAC+USC benefits from full-time teams of Navy physicians and nurses. In 2015, research8  by the University of California Davis found that university hospital trauma centers provide the best experience for military surgeons who will someday be working in a combat zone.

Meanwhile, the University of Miami Ryder Trauma Center, one of the busiest trauma centers in the nation, has been home to the United States Army Trauma Training Center (USATTC) since a month after the terrorist attacks on Sept. 11, 2001. Research indicates this training center has been critical to preparing forward surgical teams of individuals with minimal combat (or trauma) experience for the rigors of medical care and triage on the battlefield.

“Our USATTC has a specialized multidisciplinary staff which has trained hundreds of forward surgical teams in preparation for the deployed trauma setting,” notes Dr. Nicholas Namias, Professor and Chief of Trauma and Acute Care Surgery at the University of Miami-Ryder Trauma Center.9

“Through these programs, it is likely that very significant advancements will be made in the care of the injured in the civilian community,” said Air Force Col. Jeffrey A. Bailey, MD, FACS, a former director of the Joint Trauma System (JTS).10 JTS, which was formed in 2003, has played an important part in the advancements made in trauma and combat casualty care during the recent conflicts in Iraq and Afghanistan through its continuous data collection and analysis.

These trauma training centers compliment the Brooke Army Medical Center (BAMC)-San Antonio Military Medical Center (SAMMC) model. BAMC, which in 2005 became the Army’s largest in-patient medical center, serves as an ACS Verified Level I Trauma Center and is fully integrated into a civilian trauma system. In this role, BAMC/SAMMC has played a critical role in bringing advances from the battlefield to the civilian trauma system, and translating advances in civilian trauma systems to the battlefield. According to Dr. Bailey, examples of these advances include, “balloon aortic occlusion for trauma resuscitation,11,12 the use of tourniquets by non-medical personnel in the field,13 and advanced extracorporeal care for trauma patients with severe acute respiratory distress syndrome,14 and creation and practice of best evidence-based practice guidelines.”15  Translating from civilian to military, the JTS modeled its in-theatre trauma systems on the southwest Texas regional trauma system.

Dr. Scalea and his team at Shock Trauma were eager to participate in C-STARS. <br>Today the program has become “part of the DNA” of Shock Trauma.

A Model for One National Trauma System

C-STARS and the aligned programs at Miami Ryder Trauma Center and the USC+LAC Medical Center are serving as a model for the future of state of the art trauma training in U.S. trauma centers. The American College of Surgeons Committee on Trauma and partner organizations are advancing proposals to create one national trauma system inclusive of both military and civilian trauma care with Federal oversight and local adaptation. Such a system would ensure the military maintains its readiness for deployment, while lessons learned during times of war are not lost when military personnel return home. Col. Jeff Bailey succinctly summarized what is needed is: “One nation, one system.” The JTS is envisioned to become the lead and, potentially, unifying agent for military trauma systems.16,17

Moving Forward: Broadening and Improving Trauma Training

Although the programs described are successfully preparing military service members for deployment, some significant gaps remain. A recent survey found less than a quarter of military surgeons reported participating in C-STARS or the equivalent Army and Navy programs prior to deployment, and just 42 percent had any pre-deployment trauma surgical training.18

Further, there are not yet enough programs that are structured to train full military teams, even though teamwork is essential to managing a patient’s care through the five stages of the military’s JTS during combat.19 Since common training standards don’t exist, there is variability in the scope and duration of pre-deployment training across branches of the military, and there are no formal means to share learnings or measure success. Finally, most participants in these courses receive “just-in-time” pre-deployment training, which typically occurs two to four weeks before deployment, rather than embedding military personnel in civilian centers, or working in military trauma centers on an ongoing basis.

Several steps are being taken to address these training gaps. In 2016, the National Defense Authorization Act (NDAA) established the Joint Trauma Education and Training Directorate to develop additional partnerships with civilian hospitals and embed military trauma teams into high-volume Level I centers. The Mission Zero Act (H.R. 880/S. 1022) currently before Congress would provide $40 million to hospitals to support embedding military caregivers or trauma teams in high-volume trauma centers. These efforts would expand cooperative military-civilian programs to more locations across the country.

The 2016 National Academies of Science, Engineering, and Medicine (NASEM), “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths,” suggests one of four military trauma deaths and one of five civilian trauma deaths could be prevented if advances in trauma care reach all injured patients.  The report concludes that military and civilian integration is critical to saving these lives both on the battlefield and at home, preserving the hard-won lessons of war, and maintaining the nation’s readiness and homeland security.

“This wouldn’t have worked if it wasn’t mutually beneficial,” said Dr. Scalea, a member of the NASEM report’s panel. “Everyone has gotten smarter and more lives have been saved – in the military and in Baltimore. We know this is the right thing to do for trauma. We’ve been doing it for nearly 17 years and it works.”

While visiting Afghanistan, Dr. Scalea met dozens of service members who had trained in one of the C-STARS programs around the country. C-STARS and programs in the Army and Navy are serving as models for the national trauma system.


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  11. White JM, Cannon JW, Stannard A, Markov NP, Spencer JR, Rasmussen TE. Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock. Surgery. 2011;150(3):400–9.
  12. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011 Dec;71(6):1869–72.
  13. Kragh JF, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009 Jan;249(1):1–7.
  14. Neff LP, Cannon JW, Stewart IJ, Batchinsky AI, Zonies DH, Pamplin JC, et al. Extracorporeal organ support following trauma: the dawn of a new era in combat casualty critical care. J Trauma Acute Care Surg. 2013 Aug;75(2 Suppl 2):S120–9.