A National Trauma Care System Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury (2016) / Chapter Skim
Currently Skimming:
5 Creating and Sustaining an Expert Trauma Care Workforce
5 Creating and Sustaining an Expert Trauma Care Workforce
Pages 233-270
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 233... ...
is sufficient to ensure a ready military trauma care workforce2 and how that system facilitates knowledge sharing between the military and civilian sectors. THE MILITARY HEALTH SYSTEM READINESS MISSION The principle mission of the Military Health System is readiness (MHS, 2014)
|
From page 234... ...
. Readiness is multifaceted; in the medical context, however, it means that the total military workforce is medically ready to deploy and, most relevant to the work of this committee, that the military medical force is ready to deliver expert health care (including combat casualty care)
|
From page 235... ...
. The Civilian Trauma Care Workforce Initial trauma care in the prehospital setting is delivered by emergency medical technicians and paramedics.
|
From page 236... ...
. The Military Trauma Care Workforce The military trauma care workforce is far more complex in structure than its civilian counterpart.
|
From page 237... ...
. In this respect they differ from their civilian counterparts: the trauma care workforce in the civilian sector includes a set of core professionals whose primary focus is the daily delivery of trauma care (e.g., emergency physicians, trauma surgeons, trauma nurses, EMS providers)
|
From page 238... ...
provide leadership and oversight at Level I and II trauma centers. Within the trauma care workforce, nurses are crucial members of multi disciplinary clinical teams and often assume responsibility for managing patient flow between phases of care (Richmond, 2016)
|
From page 239... ...
. The military trauma care workforce further consists of nearly 4,000 members of the Nurse Corps and 36,000 members of the Enlisted Corps (Sorbero et al., 2013)
|
From page 240... ...
Military flight crews are required to take the critical care air transport course offered by the Air Force. Transport personnel in the civilian sector are required to be certified in basic life support, advanced life support, and advanced trauma life support.
|
From page 241... ...
. CHALLENGES TO ENSURING AN EXPERT MILITARY TRAUMA CARE WORKFORCE In an expert military trauma care workforce, as envisioned by the committee, every military provider is not expected to be an expert (as defined in Table 5-1)
|
From page 242... ...
In contrast, the civilian sector sees a more sustained volume of trauma cases over time, particularly in Level I and II trauma centers. Deployed military medical providers can face a sustained high trauma workload not commonly experienced by their civilian counterparts, depending on operational tempo.
|
From page 243... ...
Although this dual role of medical providers helps the Military Health System achieve cost efficiencies, it exacts a toll on the combat casualty care readiness mission. The common types of beneficiary surgical care provided at MTFs -- obstetric, general, and elective -- are rarely applicable to combat care (Eibner, 2008; Maldon et al., 2015)
|
From page 244... ...
. The reports cited cases of deployed nurses and physicians who had never treated trauma patients, many of whom had not even received training in combat casualty care (GAO, 1998)
|
From page 245... ...
As a result of the absence of defined trauma career pathways, a notable difference between the military and civilian sectors is the routine delivery of trauma and critical care by nonspecialists in the deployed setting. This lack of specialty expertise is not limited to the surgical teams but is a broader problem for combat casualty care, much of which is delivered after patients leave the operating room (e.g., within the intensive care unit)
|
From page 246... ...
The committee recognizes that the entire military medical system need not be combat care oriented; however, given that combat care can be delivered only by the Military Health System, that system needs to allocate the necessary resources to maintain a well-trained and adequately staffed workforce. CURRENT MILITARY APPROACHES TO ACHIEVING A READY MEDICAL FORCE To address deficiencies in combat casualty care capabilities noted during the Gulf War, a number of changes were instituted to improve the readiness of the medical force.
|
From page 247... ...
AMC = academic medical center; EMS = emergency medical services; HPSP = Health Professionals Scholarship Program; METC = Medical Education & Training Campus; MTF = military treatment facility; ROTC = Reserve O fficer Training Corps; USUHS = Uniformed Services University of the Health Sciences. SOURCE: Adapted from Cannon, 2016.
|
From page 248... ...
The military has unquestionably benefited from trauma surgeons trained in the civilian sector -- such individuals were key in applying the principles of systems-based approaches to trauma care to the creation of an in-theater trauma system. As with graduate medical education, however, exposure to combat casualty care-relevant experiences (e.g., through contact with experienced military trauma faculty)
|
From page 249... ...
SOURCE: Reprinted, with permission, from the National Registry of Emergency Medical Technicians (NREMT)
|
From page 250... ...
,9 only 6 are either verified by the American College of Surgeons or state-designated as trauma centers: • Level I -- San Antonio Military Medical Center (ACS verified) • Level II -- Walter Reed National Medical Center (ACS verified)
|
From page 251... ...
Joint Military–Civilian Predeployment Training Programs To address the disparity between the number of military trauma specialists (in all provider categories) and the battlefield requirements for combat casualty care, the majority of military trauma training is outsourced as just-in-time training (2- to 4-week rotations)
|
From page 252... ...
It is working to streamline readiness training efforts across the services, reduce duplication of training programs, and coordinate readiness training efforts between the military and civilian sectors. DMRTI sponsors the Emergency War Surgery Course and the Tactical Combat Casualty Care Course (Miller, 2015)
|
From page 253... ...
Advanced 1 day Surgeons Operative Didactic sessions, Trauma management of simulated casualty CIVILIAN Operative penetrating injuries scenarios using ACS Management to the chest and cadaver and live abdomen tissue models Advanced 1 day Surgeons Surgical exposures Didactic sessions, Surgical Skills in key areas: neck, simulated casualty for Exposure chest, abdomen scenarios using in Trauma and pelvis, and cadaver and live upper and lower tissue models extremities continued
|
From page 254... ...
. A notable example is tactical combat casualty care (TCCC)
|
From page 255... ...
Maintaining a well-trained and adequately staffed military trauma care workforce is crucial given that the volume and degree of trauma found in combat generally will not allow for an on-deployment learning curve ( amasamy et al., 2010)
|
From page 256... ...
In a recent survey of 137 military surgeons, only 23 percent had attended a Center for Sustainment of Trauma and Readiness Skills (C-STARS) , Army Trauma Training Center (ATTC)
|
From page 257... ...
One hundred surveys were returned, 86 of which contained complete data for analysis. ASSET = Advanced Surgical Skills for Exposure in Trauma; ATLS = Advanced Trauma Life Support; ATOM = Advanced Trauma Operative Management; ATTC = Army Trauma Training Center; C-STARS = Center for Sustainment of Trauma and Readiness Skills; NTTC = Navy Trauma Training Center.
|
From page 258... ...
Reliance on Just-in-Time and On-the-Job Training At the start of Operation Enduring Freedom and Operation Iraqi F reedom, the military medical force was overstaffed with specialists in pediatrics and obstetrics/gynecology but understaffed in specialties critical for combat casualty care. In 2004, the military medical force was short 59 a nesthesiologists and 242 general surgeons (Maldon et al., 2015)
|
From page 259... ...
It is important to realize that these providers would not be credentialed to care for civilian trauma patients in the United States, but are allowed to care for military trauma casualties when deployed. In effect, the standard of care for trauma patients in the United States was not being met on the battlefield.
|
From page 260... ...
Learning Context In the case of this soldier and many others in the early phases of Operation Iraqi Freedom, a trauma team in a forward hospital found themselves lacking competency in fasciotomy, a key surgical skill for combat casualty care. General surgeons as well as nurses, anesthesiologists, medics, and other members of trauma teams who deploy to war come from diverse backgrounds; many do not receive training in or experience with extremity injuries in routine civilian practice or during in-garrison care, as these wounds are frequently managed by colleagues with orthopedic or vascular specialties.
|
From page 261... ...
. Although performance improvement initiatives are an important means of addressing skill deficiencies, front-line surgeons and other members of deployed trauma teams need to arrive fully proficient in combat casualty care to avoid preventable death and disability on the battlefield.
|
From page 262... ...
The deployment requirements for Navy reservists include a combat casualty care course and in some cases training at the Naval Trauma Training Center at Los Angeles County Hospital (DuBose et al., 2012)
|
From page 263... ...
During the Afghanistan and Iraq wars, a formalized program to facilitate the exchange of trauma care knowledge and e xperience -- the Senior Visiting Surgeon Program (described in Chapter 4) was established, but there remains a lack of robust collaboration between the two sectors, except in the few civilian trauma centers with assigned military personnel or recently retired or separated personnel.
|
From page 264... ...
Moreover, prehospital military trauma care is often more advanced than what civilian EMS protocols allow, m aking it challenging for medics to practice their skills in the civilian sector and limiting bidirectional sharing of knowledge (Rodriguez, 2015)
|
From page 265... ...
This variation makes the identification and generalization of best practices challenging even within the civilian sector, much less across the military and civilian sectors. SUMMARY OF FINDINGS AND CONCLUSIONS CONCLUSION: To eliminate preventable mortality and morbidity at the start of and throughout future conflicts, comprehensive trauma training, education, and sustainment programs throughout DoD are needed for battlefield-critical physicians, nurses, medics, administrators, and other allied health professionals who comprise military trauma teams.
|
From page 266... ...
Paper commissioned by the Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector. nationalacademies.org/TraumaCare.
|
From page 267... ...
: Implications for the future of combat casualty care. Journal of Trauma and Acute Care Surgery 73(6 Suppl.
|
From page 268... ...
2015. Establishing a DoD standard for Tactical combat casualty care (TCCC)
|
From page 269... ...
Paper presented to the Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector, Meeting Two, July 23-24, Washington, DC. Richmond, T
|
From page 270... ...
2002. Military trauma training performed in a civilian trauma center.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.