A National Trauma Care System Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury (2016) / Chapter Skim
Currently Skimming:
1 Introduction
1 Introduction
Pages 37-72
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From page 37... ...
On January 29, 2006, Bob and his cameraman were filming from the top of an Iraqi armored vehicle when the convoy came under a ttack. The detonation of a roadside improvised explosive device (IED)
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From page 38... ...
Bob received the same standard of quality trauma care afforded to every military service member. He was treated by world-class surgeons, nurses, and other military medical professionals whose knowledge of best treatment practices for traumatic brain injury had been greatly advanced through years of experience during the war -- experience and knowledge that today, 10 years later, has yet to be fully and systematically passed on to their civilian counterparts.
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From page 39... ...
. Because the military has historically relied on the voluntary and obligatory recruitment of medical professionals from the civilian sector during wartime, further integration of the military and civilian trauma communities is critically important to ensure that military readiness is maintained between conflicts and that trauma care improves in both settings (Eastman, 2010; Schwab, 2015)
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From page 40... ...
Box 1-2 TOURNIQUETS: MILITARY LESSONS LOST Prior to combat operations in Afghanistan and Iraq, tourniquet use had been the subject of debate for decades. This debate persisted despite data from World War II, the Korean War, and the Vietnam War showing that hemorrhage from extremity wounds was the leading cause of medically preventable deaths on the battlefield -- such deaths from extremity wounds could be averted by simple first-aid measures, including the application of tourniquets (Bellamy, 1984; Lindsey, 1957)
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From page 41... ...
, and its associated trauma registry (discussed in more detail in Chapter 4) to meet combat casualty care needs during the wars in Iraq (Operation Iraqi Freedom)
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At this time, data on prehospital trauma deaths in the civilian sector are lacking. Therefore, the overall incidence of preventable death after injury is likely higher than that found by Kwon and colleagues (2014)
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This loss has implications for the quality of trauma care both in the military and in the civilian sector, where the adoption of military advances can improve the delivery of everyday trauma care and the response to multiple-casualty incidents. Recent events in Sandy Hook, Boston, Paris, and San Bernardino highlight the unfortunate reality that active shooter and mass casualty incidents have become increasingly common in everyday American life and lend urgency to the translation of wartime lessons in trauma care to the civilian sector.
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From page 44... ...
. Assuming that as many as 20 percent of civilian trauma deaths are the result of survivable injuries (Kwon et al., 2014)
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. Moreover, traumatic brain injury (TBI)
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. The burden of injury-related disability in the civilian sector is equally striking.
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. Given this burden, as well as the military's success in reducing trauma deaths and advancing rehabilitative care, the civilian sector has much to gain from the translation of military best practices in trauma care.
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From page 48... ...
DoD Combat Casualty Care Research Program & Defense Casualty Analysis System FIGURE 1-3 Case fatality rates during the Korean War, the Vietnam War, Operation Enduring Freedom, and Operation Iraqi Freedom. NOTES: The statistics presented in this figure were calculated using data collected from the Defense Casualty Analysis System (DCAS)
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* 100 %DOW reflects the effectiveness of care provided at military treatment facilities and perhaps also the appropriateness of field triage and initial care, the use of optimal evacuation routes, and the application of a coordinated trauma systems approach in a mature theater of war.
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An important emphasis of this report is that sustaining and building upon the advances in military trauma care achieved over the past decade are essential to ensuring medical readiness so that the military has the capability to provide optimal care for the very first injured soldier in the next conflict, whenever and wherever it may occur. It is not clear, however, that the military's broader health system can support the continued level of excellence in trauma care delivered at the peak of the wars in Afghanistan and Iraq without substantial commitment from leadership and change in 12 Survivability determinations were based on medical information only and did not take into account resource restrictions or operational conditions that may have prevented timely access to medical care (Eastridge et al., 2012)
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From page 51... ...
The effective translation of advances in care -- for example, in hemorrhage control, damage control resuscitation, and the development of cutting-edge prosthetic and orthotic devices -- from the military to the civilian sector can benefit not only trauma care provided on a daily basis but also that provided during and after mass casualty incidents. The increasing incidence of civilian trauma resembling that seen on the battlefield
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From page 52... ...
Percentage 10% 15% 20% 25% 30% 0% 5% No v-2 003 Ma y- 200 4 No v- 200 4 Ma y- 200 5 No v-2 005 Ma y-2 006 No v-2 006 Ma y-2 007 CUM %KIA No v-2 007 Ma y- 200 8 No v- 200 8 Ma y-2 CUM %DOW 009 No A v-2 009 Ma y-2 010 No v-2 010 CUM CFR Ma y-2 011 No v-2 011 Ma y- 201 2 No v-2 012 Ma CUM Avg mISS y-2 013 No v-2 013 Ma y-2 014 No v-2 014 Ma y-2 015 0 2 4 6 8 10 12 14 16 CUM Average mISS 52
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, Operation Enduring Freedom (A) and Operation Iraqi Freedom (B)
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. The value of military trauma care practices applied to domestic mass casualty incidents is highlighted by the success of the medical response following the Boston Marathon bombing (see Box 1-5)
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. Yet despite the clear importance of a domestic trauma response capability, no systematic processes have been instituted to ensure that the lessons learned from military experience are translated comprehensively to the civilian sector (Hunt, 2015)
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Capitalizing on lessons learned at the patient level, in capability development, and in system design and quality improvement within both sectors makes sense; would help appropriately address the burden of disease; would leverage economies of scale to save lives through trauma care; and would prepare the nation to provide optimal care for daily trauma events, as well as those occurring on the battlefield and during mass casualty incidents. The 75th Ranger Regiment, an element of U.S.
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From page 57... ...
. The regiment's line commander at the time, then Colonel Stanley McChrystal,14 took complete ownership of the unit's casualty care system, issuing a directive that all Rangers focus on medical training as one of the regiment's four major training priorities (placing combat casualty care on a par, for example, with marksmanship)
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Deliberate steps to codify and harvest the lessons learned within the military's trauma care system are needed to ensure a ready military medical force for future combat and to eliminate preventable trauma deaths and disability after injury in both the military and civilian sectors. The end of the wars in Afghanistan and Iraq represents a unique moment in history in that there now exists a nascent military trauma system built on a learning system framework and an organized civilian trauma system that is well positioned to assimilate and distribute the recent wartime trauma lessons learned and to serve as a repository and an incubator for innovation in trauma care during the inter war period.
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From page 59... ...
. This group of sponsors, representing both the military and civilian sectors, asked the National Academies of Sciences, Engineering, and Medicine to conduct a consensus study to define the components of a learning health system necessary to enable continued improvement in trauma care in both the civilian and military sectors, and to provide recommendations for ensuring that lessons learned over the past decade from the military's experiences in Afghanistan and Iraq will be sustained and built upon for future combat operations, as well as translated to the U.S.
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From page 60... ...
are sustained and built upon for future combat operations. Finally, the committee will consider the strategies necessary to more effectively translate, sustain and build upon elements of knowledge and practice from the military's learning health system into the civilian health sector and lessons learned from the civilian sector into the military sector.
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To address the above tasks, the committee will draw on 3-4 case studies centered around common combat-related injuries that are also relevant to civilian sector trauma cases and highlight the opportunities and challenges to establishing and sustaining a trauma care learning health system. The case studies may be based upon the following traumatic injuries, or other relevant examples, and should feature real life medical cases.
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From page 62... ...
. That said, it is important to recognize that care delivered in the acute phase has significant implications for later rehabilitation; improved acute care and reduced mortality will certainly increase the need for robust rehabilitation support to ensure quality of life.
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From page 63... ...
2011. Nutrition and traumatic brain injury: Improving acute and subacute health outcomes in military personnel.
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From page 64... ...
These mechanisms included a series of information-gathering meetings that were open to the public, including a public workshop held to obtain background information on leadership and accountability, trauma data and information systems, clinical guideline development, and military education and training for readiness. A second meeting, held in September 2015, included two additional informationgathering sessions, the first of which focused on ethics and regulatory i ssues that influence a learning system, and the second of which addressed the burden of injury and trauma research investment in the military and civilian sectors.
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From page 65... ...
Throughout this report, the committee uses boxes drawing from these case studies to demonstrate the opportunities and challenges of establishing a learning trauma care system. ORGANIZATION OF THE REPORT This report is organized into three parts that collectively define a learning trauma care system necessary to sustain and build on the recent advances in military trauma care and to facilitate continuous bidirectional translation of trauma care advances between the military and civilian sectors.
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From page 66... ...
While focusing on the military sector, these chapters do provide a general overview of civilian-sector differences to highlight areas in which the structure and processes of the civilian sector impact military sustainment of trauma care advances and bidirectional translation of lessons learned and best practices between the two sectors. The final part of this report, Chapter 8, highlights the committee's key messages -- articularly p the need for an integrated national approach to trauma care -- and concludes with recommendations on advancing a national learning trauma care system.
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From page 67... ...
Paper presented to the Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector, Meeting Three, September 16-17, Washington, DC. Butler, F
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From page 68... ...
: Implications for the future of combat casualty care. Journal of Trauma and Acute Care Surgery 73(6 Suppl.
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Paper presented at the Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector, October 2, Washington, DC. NCIPC (National Center for Injury Prevention and Control)
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2008. The symbiosis of combat casualty care and civilian trauma care: 1914 2007.
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2008. A national US study of posttraumatic stress disorder, depression, and work and functional outcomes after hospitalization for traumatic injury.
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