Trauma System Development and the Joint Trauma System

Abstract

A report by Mullins and colleagues identified the benefits of trauma systems in the late 1990s. When war developed in response to the September 11 attack on the World Trade Center and Pentagon, the concepts of trauma systems had yet to be incorporated into the US military medical planning. Col John Holcomb, Commander of the US Army Institute of Surgical Research, traveled to Iraq for a survey of trauma care. The survey was conducted in May 2003, 2 months after onset of hostilities. He identified no trauma system existed in Iraq. Medical planning had indeed been conducted, but in many circumstances, the planning was service specific. Col Holcomb, Col Don Jenkins (US Air Force), and Lt Col Brian Eastridge (US Army Reserve) proposed the establishment of a theater trauma system for the entire battlespace. The proposal to establish a Joint Theater Trauma System for the US Central Command (CENTCOM) area of responsibility was subsequently approved.

Critical to the success of the Joint Theater Trauma System (JTTS) was assigning the Director of the JTTS directly responsible to the CENTCOM Surgeon. By doing so, the JTTS Director served as the CENTCOM Surgeon’s advisor on combat casualty care. For issues in the CENTCOM area of responsibility that could not be resolved locally by the JTTS Director, the CENTCOM Surgeon would provide direction. This command oversight was imperative in the complex environment of a theater of operations. Over the subsequent decade-plus of sustained combat operations in Iraq and Afghanistan, the JTTS achieved unparalleled success in data collection, real-time data analysis, and robust evidence and data-based quality/process improvement initiatives. The implementation of the JTTS, now known as the Joint Trauma System (JTS) as it encompasses care along the entire continuum and not just “in theater,” is widely credited for achieving improved battlefield survival despite an increase in the average injury severity and the lowest battlefield mortality statistics in history.

Civilian Translation of Military Experience and Lessons Learned

• M. Margaret Knudson 

As a way of a full disclosure, I must confess that I am not (nor have I ever been) a member of the US military. My exposure to military surgery began in 2003 when I traveled with other members of the American College of Surgeons (ACS) National Ultrasound Faculty to a small military treatment facility on the US Army base at Landstuhl, Germany. During the visit, while we were teaching deploying surgeons how to perform FAST exams for trauma patients that they would be evaluating in Iraq, I was exposed for the first time to the severity of the injuries being encountered in that theater of war. I subsequently returned to Landstuhl several times as part of the Senior Visiting Surgeons program, a program that allowed civilian surgeons to work alongside their military colleagues in the ICU and operating room while caring for those evacuated from theater. This collaboration, jointly sponsored by the Department of Defense, the American College of Surgeons, and the American Association for the Surgery of Trauma, assisted in the transition of Landstuhl Regional Medical Center (LRMC) from a relatively small hospital to a level 1 trauma center verified by the ACS Committee on Trauma. While working in Germany, I expressed my desire to see the military trauma system in its entirety and was honored to be allowed to travel into the theater of war for a 10-day tour. My orders allowed me to obtain operating privileges through the Air Force, and I took call with the deployed surgeons, caring for troops evacuated directly from the battlefield. I twice flew with the Air Force’s Critical Care Air Transport Teams (CCATT), observing with fascination how critical care could be provided with professionalism and compassion during prolonged flights across three continents. I traveled to Walter Reed Army Medical Center with patients and visited the Bethesda Navy Medical Center as well as the Army’s ISR burn center in San Antonio during the periods of highest ops tempo. Additionally, I had an opportunity to participate in the weekly military video teleconference (VTC) from various locations including in theater, in Germany, and in San Antonio. A tour of the Palo Alto VA Polytrauma Center as well as the Center for the Intrepid in San Antonio was part of the final stages of my military education as I observed firsthand the advances in rehabilitation accelerated by the large number of returning troops with TBI and amputations. As a result of these personal experiences, I have developed a deep appreciation for the challenges encountered by military medical personnel who are called upon to care for war injuries but also a passionate drive to preserve the Joint Trauma System and to facilitate the translation of the lessons learned on the battlefield over the past 15 years into the civilian trauma system [8].

It should be noted that the US military did not go off to the wars in Iraq and Afghanistan with a trauma system in place. This remarkable system, the Joint Theater Trauma System (JTTS) that has saved the lives and limbs of so many service men and women, was developed during combat operations by trauma surgeons with experience in the civilian trauma system. And while there is no doubt that mature trauma systems save lives, even within the United States, an estimated 45 million people lack access to major trauma centers within 1 h of their injury [9]. A marriage of the US military and civilian trauma systems, as advocated by the recently released report by the National Academies of Sciences, Engineering, and Medicine, would insure a well-maintained and ready military trauma system while increasing access and augmenting disaster response throughout the United States [10]. In order to accomplish this, however, it is necessary to understand the current similarities and differences between these two systems as outlined in Table 44.3.

Table 44.3 Comparison of civilian and military trauma systems

The biggest difference, however, is what happens to the systems over time. The civilian trauma system, although imperfect, will continue to function, whereas, if history repeats itself, the military trauma system that currently exists is in jeopardy of being put into senescence until it is needed for the next conflict. Fortunately, at this time, there is considerable movement to assure that does not happen, and there is recognition that maintaining a ready military trauma system within military treatment facilities and selected civilian trauma centers would be beneficial to both systems. The public should expect ready access to high-level trauma care throughout the United States, while those who volunteer to place themselves in harm’s way deserve the same high-quality care no matter where in the world they are injured. Now is perhaps the best opportunity to get this right.