April 2023 - Military Trauma
April 2023
EAST Monthly Literature Review
"Keeping You Up-to-Date with Current Literature"
Brought to you by the EAST Manuscript and Literature Review Committee
This issue was prepared by EAST Military Committee Members Christopher Horn, MD, Joshua Dilday, DO and James Wiseman, MD.
Thank you to Haemonetics for supporting the EAST Monthly Literature Review.
In This Issue: Military Trauma
Scroll down to see summaries of these articles
Article 1 reviewed by Christopher Horn, MD
Military-civilian partnerships and the clinical readiness mission: A preliminary study from the Military Health System and the American College of Surgeons. Grabo DJ, Gurney JM, Parascandola L, Knudson MM. J Trauma Acute Care Surg. 2022 Aug 1;93(2):S16-S21.
Article 2 reviewed by Joshua Dilday, DO
Data-driven readiness: A preliminary report on cataloging best practices in military civilian partnerships.
Gurney JM, John SK, Whitt EH, Slinger BJ, Luan WP, Lindly J, Graybill JC, and Bailey JA. J Trauma Acute Care Surg. 2022 Aug 1;93(2):S155-S159.
Article 3 reviewed by James Wiseman, MD
Building trauma capability: using geospatial analysis to consider military treatment facilities for trauma center development. Lee BC, McEcEvoy CS, Ross-Li D, Norris EA, Tadlock MD, Shackelford SA, Jensen SD. Trauma Surg Acute Care Open. 2022 May 9;7(1):e000832.
Article 1
Military-civilian partnerships and the clinical readiness mission: A preliminary study from the Military Health System and the American College of Surgeons. Grabo DJ, Gurney JM, Parascandola L, Knudson MM. J Trauma Acute Care Surg. 2022 Aug 1;93(2):S16-S21.
Military-civilian partnerships (MCPs) have existed both formally and informally for years. Recently, the formal establishment of the Joint Trauma System in 2017, the formation of the Military Health System Strategic Partnership (MHSSPACS) with the American College of Surgeons and the passage of the Mission Zero Act funding selected MCPs have reinvigorated support. To guide selection and evaluation of MCPs, MHSSPACS recently published the Blue Book. The purpose of this study was to determine whether historically successful MCPs matched best practice criteria found in the Blue Book.
Study authors created two surveys- one for military surgeons at MCPs, one for MCP host champions. Military surgeons were asked about their experience transitioning to civilian hospitals, demographics, workload, case volume, supervision of fellows and residents and involvement in educational and quality programs. Civilian champions were asked questions about institutional trauma surgical volume, potential for military surgical participation in ICU and ACS care and potential for research and non-general surgical procedural support.
The survey was distributed to 13 MCP surgeons and 9 champions at 9 MCPs representing the Army, Navy and Air Force. Responses were received from 10 MCP surgeons and 7 champions. The majority (90%) of surgeons were assigned as cadre for a 3-year tour, while the remaining 10% served in skills-sustainment positions. All military surgeons were trauma surgeons and boarded in general surgery. 90% were further boarded in surgical critical care, 10% were further boarded in vascular surgery. All surgeons performed procedures independently and supervised residents. Most military surgeons (80%) reported 10 or more cases of TBI, spine fractures, soft tissue injuries, pelvic fractures, massive transfusion, respiratory failure, damage control resuscitation and damage control laparotomy over their time at the MCPs. 60% of military surgeons reported working 7 or more 12-hour trauma shifts a month. Deficiencies were noted in burn care and in REBOA placement. Host champions noted that research opportunities, dedicated ICU time and the opportunity to serve as trauma team leaders were benefits of MCPs. Lack of a centralized MCP database was noted as a drawback.
Authors found that among the historical MCPs surveyed, Blue Book criteria were met. The authors note that this was a preliminary study focusing solely on trauma surgeons. No other physicians or non-physician medical providers were surveyed, though they note future research will focus on these members of the medical team. They also note that the relatively small study and reporting biases limit generalizability. Nonetheless, this study represents an important first step towards assessing successful MCPs and building on the lessons learned from them.
Article 2
Data-driven readiness: A preliminary report on cataloging best practices in military civilian partnerships.
Gurney JM, John SK, Whitt EH, Slinger BJ, Luan WP, Lindly J, Graybill JC, and Bailey JA. J Trauma Acute Care Surg. 2022 Aug 1;93(2):S155-S159.
As awful as war is, trauma care has been advanced by its unfortunate existence. Many developments in military and civilian casualty care have been conceived from the fog and fires of battle. However, the progress in trauma care seen during military conflict historically fades during peacetime. Peacetime operations make the maintenance of both military and surgical readiness a more daunting task. In order to sustain military trauma readiness, previous efforts focused on collaborative efforts with civilian trauma centers. Although these military-civilian partnerships (MCP’s) have existed for decades, they have been recently realigned in the partnership of the MCP Working Group (MCP-WG) under the Defense Health Agency (DHA). As the previous military engagements have yielded to peacetime operations, the MCP-WG recognized a lack in quantifying the effect and benefit of MCP on military trauma readiness. In this study, the authors described the most comprehensive enterprise-wide data set of MCPs. They also detailed how data were captured, and reported how a novel MCP registry supports the efforts of readiness described by the Defense Health Agency. The authors queried data from the Institute of Defense Analysis on current and future MCPs. The data was classified into descriptive categories based upon the type of MCP: short-term rotational models (SRMs), embedded sustainment models (ESMs), and part-time sustainment models (PSMs). However, multiple MCP models could be present at one site. In order to assess the prevalence of current and potential MCP across the United States, a database of all ACS-verified trauma centers was created. The analysis identified a total of 87 MCP’s across 55 ACS-verified trauma centers. Due to the capacity of larger trauma centers, some sites housed multiple partnerships. Broken down by DoD affiliation, the Air Force had the most partnerships represented, with 30 (34%) partnerships identified. The MCP classifications varied greatly across DoD affiliation with the Army representing the most ESM’s. Additionally, the authors found variability in the management of MCPs depending on their classification. However, despite having 80 ESM individuals and 110 SRM cadre, MCPs are only present in 5% of all ACS-verified trauma centers.
The data found in this article provide a current landscape of the military’s efforts to maintain readiness through its civilian collaboration. These MCPs vary greatly and currently lack a centralized method of evaluating efficacy and sustainability. The authors argue that the ability to identify and monitor DoD-wide MCP’s using a centralized registry will increase readiness by evaluating current training metrics. As military readiness is often quantified by medical knowledge, skills, and abilities (KSA) metrics, a registry could track the KSAs across the MCP’s. Additionally, the current prevalence of MCP’s can guide implementation of new sites, as only 17% of all ACS Level 1 trauma centers utilize a dedicated partnership. This article provides a framework for ongoing efforts to identify and establish best practices of MCPs in an effort to improve the nation’s ability to respond to war and disaster.
Article 3
Building trauma capability: using geospatial analysis to consider military treatment facilities for trauma center development. Lee BC, McEcEvoy CS, Ross-Li D, Norris EA, Tadlock MD, Shackelford SA, Jensen SD. Trauma Surg Acute Care Open. 2022 May 9;7(1):e000832.
With the withdrawal of American troops from Afghanistan over the summer of 2022 and the drawdown of combat operations in Syria, the American military has entered a phase of decreased combat intensity. For military surgeons, such intervals of relative peace have long been associated with the degradation of surgical and critical care skills through a phenomenon known as the “peacetime effect.” A major contributor to this effect is the practice of stationing surgical teams at domestic military medical treatment facilities (MTFs) when not deployed, where surgical volumes can be dramatically less than those of civilian institutions, with little (if any) exposure to trauma. As a result of this effect, the onset of any new conflict has brought with it a period of “relearning” combat surgical skills for military surgeons, at the expense of poorer outcomes in the initial months of that conflict. A number of solutions have been proposed to mitigate the impact of the peacetime effect, including military-civilian partnerships (MCPs) in which military surgeons are embedded within civilian trauma centers. Although providing a vital service to the military enterprise, this strategy is limited by a number of factors and can only be expected to serve as one component of a much broader solution.
The expansion of services at existing MTFs to include trauma care to civilian patients is one proposed answer to the peacetime effect. Although formidable obstacles exist to implementation of this solution, there is precedent: two existing MTFs currently function within greater regional trauma systems. This study is an innovative pilot investigation aimed at identifying domestic MTFs uniquely poised to offer a “win-win” scenario for the military and local trauma systems: increasing access to trauma care for the local population without creating competitive relationships with existing local trauma centers. The authors used public data to identify adult level 1 and 2 trauma centers throughout the continental United States, as well as military hospitals and medical centers. Population data from the US Census Bureau was used to place each MTF in context with respect to the population size of the surrounding area. Sophisticated computer-based algorithms were then used to determine which MTFs offered significant reductions in distance to existing civilian trauma centers. The results demonstrated seven MTFs are positioned to offer significant benefit to larger population centers. On the strength of these results, the authors offer the recommendation that these seven MTFs receive specific, focused investigation into expanding their services to include trauma care to local civilian populations. This is a well-done and forward-thinking project that plants itself firmly on the side of presenting actionable solutions to a daunting system-level problem.
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