John P. Pryor, MD, Penn trauma surgeon and a Major in the United States Army Reserve Medical Corps (left), and C. William Schwab. On Christmas Day 2008, Pryor was serving his second tour of duty in Iraq with a forward surgical team in the Army’s 1st Medical Detachment when he was killed by enemy fire. Since 1996, Penn has trained more than 20 military trauma fellows.
In June, a committee from the National Academies of Sciences, Engineering and Medicine (NASEM) issued a report calling for a national goal of zero preventable deaths after injury by creating a national trauma system. The committee, which urges the White House to lead the integration of military and civilian trauma training, education and research programs, says as many as 20 percent of trauma deaths in the United States could be prevented with improved care and a long overdue federal effort to organized trauma care.
I spoke with C. William Schwab, MD, FACS, a professor of Surgery in the division of Traumatology, Surgical Critical Care, and Emergency Surgery, to better understand the benefits of an integrated trauma system, and why it’s time to make the change. A senior member of the NASEM committee that developed the report and recommendations, Schwab brought a specific focus on how to train surgeons, physicians, nurses and allied health professionals in traumatology, trauma surgery and critical care through the integrative approach recommended by the NASEM report. In 1989, Schwab, a military veteran, founded the Penn trauma training programs, which has since trained more than 100 surgeons, 20 of whom have been military surgeons.
Q: What spurred the creation of the report and its recommendations?
A: The Departments of Defense (DOD), and in particular, its Medical Research and Material Command, the Department of Homeland Security, the Department of Transportation and its National Highway Traffic Safety Agency, partnered with seven professional organizations and asked the NASEM to bring together a group that could advise the nation on how to avoid losing the military medical lessons learned in the Iraq and Afghanistan wars. The DOD sought advice on how to maintain a readiness combat medical force during peacetime. And finally, with the escalation of mass casualty events, there was a compelling need to strengthen our civilian trauma systems to respond to these horrific events.
During the wars in Iraq and Afghanistan, the military created a worldwide trauma system and made remarkable strides in caring for those who had sustained devastating wounds. Many of the advances from the battlefield were not being adopted by the civilian EMS and hospital based emergency departments and trauma centers. Of particular note, the military trauma system observed that as many as 20 percent of deaths during combat could have been prevented with more rapid and better trauma and combat casualty care.
If the military’s observation was correct and 20 percent of lives lost after injury were preventable, one could argue that transferring those numbers to the civilian sector would result in 20,000 to 30,000 preventable deaths per year. Thus, the committee felt compelled to study the gaps in civilian trauma care and how research was being funded to address these gaps.
These were strong motivators to find ways to advance both systems, and it became obvious that both sectors must partner to constantly learn from each other.
Q: Was there a timeliness factor involved? Why now?
A: Three historic things happened that made this report possible and drove the need for the recommendations in the report:
- Iraq and Afghanistan were the longest period of warfare in American history. This long experience provided many insights into how best to prepare military medical personnel for combat surgery and battlefield medicine.
- Battlefield and system-wide data collection and reporting provided a detailed picture of the causes of death. These comprehensive preventable death studies were also a historic advance and revealed that even with the advances in trauma care on the battlefield, there were still major flaws. For the first time during warfare, we had clear insights as to what improvements were needed, and survival improved despite increasing numbers of severe wounding.
- Last, over the previous 25 years in the civilian sector, we had developed more mature trauma systems and centers based in some of America’s leading Academic Medical Centers. Penn is one of these centers. For the first time, these regional trauma systems and centers were seen as having the best potential to provide the solution to keep our military medical readiness mission strong and become a nationwide response network for mass casualty events and disaster.
Q: Can you put this into perspective? How big is trauma care in the United States?
A: When you look at the statistics, annually, traumatic injuries – falls, shootings, car accidents, etc. – account for approximately 160,000 deaths and cost $670 billion, which doesn’t account for the subsequent years of disability or remote death after injury. That figure - $670 billion – seems large, but is an under representation of the burden of injury to our country if you look over a decade or two. Beyond cost, another important perspective is that death and disability from injury is concentrated in young Americans. Injury remains the leading cause of death in those under 46 years and accounts for the greatest number of years lost for a productive life.
Q: Why has the military struggled to stay proficient in trauma surgery?
A: The short answer is that in peacetime, the U.S. military medical services have very little opportunity to train for trauma and combat casualty care.
The missions of the Military Health System (MSH) under the DOD are to provide readiness (trauma and combat casualty care) and beneficiary care, meaning, care for active duty personnel, veterans, their dependents, and military contractors. More than nine million people depend on the military health system to get their health care. Beneficiary care is dominant and drives the MHS, so physicians and surgeons are not routinely focused on trauma care. There’s only one Level 1 trauma center in the military (San Antonio), so the opportunity to do the kind of medical and surgical training needed on the battlefield is extremely limited.
Second, only the MSH can deliver medical care on the battlefield and to deployed troops. Yet, there is no medical readiness command or commander. No one is in charge of assuring ongoing training and the infrastructures necessary to have expert rapidly deployable trauma teams.
Much of the knowledge the military gained during the Iraq war came from placing surgeons into civilian trauma centers, like Penn's, in the 1990s and over the last 16 years. But these individuals spanned the military trauma system and expanded it by their personal commitment rather by directive of the DOD. Now with a military system that seems to have out-performed the civilian sector, it was apparent to the committee that a formal partnership between the two sectors to assure ongoing improvements is an imperative.
Q: Zero preventable deaths seems lofty. Is that realistic?
A: Absolutely. And, the reality is that even one preventable death is unacceptable. Again, lessons learned in the military show us the way.
In 1998, Stanley McChrystal, then Colonel in the U.S. Army and commander of the 75th Ranger Regiment, mandated that every ranger – from Private and up – be proficient in delivering emergency care to a wounded buddy, applying tourniquets, and/or performing prompt evacuation. The Rangers’ put their new skills to the test in Iraq and Afghanistan; in some of the most dangerous combat situations and on thousands of missions. They lost only 28 men – and not one had a survivable wound. McChrystal’s order to add a battlefield medical skill set had eliminated preventable deaths.
On a larger scale, the Secretary of Defense, Robert Gates, issued the directive that led to a staggering decline in the death rate. He mandated that troops work with medical teams to ensure that every wounded soldier would be at a medical treatment facility within an hour. At Penn, our trauma patients arrive within minutes, so an hour might seem like a long time, but when there’s a battle going on, getting someone in an OR within an hour is difficult to say the least. Despite the lofty goal, within a short period of time, transport times dropped and the rate of death from injury fell.
These two efforts have achieved astounding results because leaders in the central command - which oversaw the wars in Iraq and Afghanistan – placed medical care as a high priority and directed improvements in the system for combat trauma care.
Q: What would the end result of the proposed system look like?
A: The end result would be a national military-civilian system with bi-directional, intentional flow of experience, information, and knowledge. It would be a system that provides a way for the military to constantly train within our best and busiest academic Level I trauma centers. By embedding these military teams as a sustained part of our faculty and staffs, we would learn from their experiences with mass casualty and disaster response. And at the same time, the MSH would gain access to the best civilian centers for military trauma career development. The symbiotic relationship would provide an opportunity for identifying gaps in care, education, technology and research more rapidly and, if supported by enriched national funding for research, has the potential to advance our knowledge of injury science at an unprecedented rate.
In order to accomplish such an integration, we need national leadership from the White House and across several major federal agencies and departments. The report includes eleven major recommendations supported by 60 subordinate and action recommendations, all of which reinforce the committee’s vision that the best trauma system is one that’s a national system and combines the civilian and military sectors and advances together to achieve zero preventable deaths for all Americans.