Abstract
Trauma care in the military and civilian sectors is a portrait of contradiction—lethal contradiction. On one hand, the nation has never seen better systems of care for those wounded on the battlefield or severely injured within the United States. On the other hand, many trauma patients, depending on when or where they are injured, do not receive the benefit of those gains. Far too many needlessly die or sustain lifelong disabilities as a result. Between 2001 and 2011, approximately 1,000 American service members who perished on the battlefield (roughly 25 percent of all battlefield deaths) died of wounds they could potentially have survived. In the civilian sector, where injury is the leading cause of death for Americans under age 46, as many as 1 in 5 deaths from traumatic injuries may be preventable with optimal trauma care, equating to 200,000-300,000 lives that could be saved over the same 10-year period.
The paradox arises from the laudable successes, pockets of excellence, and numerous examples of innovation in both military and civilian trauma care that can be observed even in the face of such sobering statistics. Battlefield fatality rates have declined substantially since the Vietnam War, particularly in the prehospital setting, and in one special operations unit—the 75th Ranger Regiment—preventable trauma deaths among wounded soldiers were all but eliminated. Wartime innovations in trauma care have included, among others, new paradigms for management of hemorrhage (e.g., early tourniquet use, damage control resuscitation) and prehospital casualty care. Many of these military innovations have emerged in the civilian trauma care setting, but with variable degrees of penetration.
Much of the progress achieved in military trauma care over more than a decade of war was driven by learning processes that align with the cultural and systemic attributes of a “learning health system” as described by the Institute of Medicine. In such systems, data from each care experience is captured and care practices evolve incrementally and pragmatically based on best available evidence. The sense of urgency stemming from deaths on the battlefield drove trauma care practices to evolve to a new level of excellence, and the resulting military medical force represents an enormous store of knowledge and experience. The reality, however, is that the window of opportunity to tap into this pool of knowledge is brief. The threat of system degradation and institutional memory loss looms as many of the leaders who enabled this military medical transformation and who serve as advocates for its perpetuation retire or transition to the civilian sector. Recognizing the magnitude and the immediacy of the need, a group of sponsors, representing both the military and civilian sectors, asked the National Academies of Sciences, Engineering, and Medicine to convene a committee charged with defining the components of a learning health system necessary to enable continued improvement in military and civilian trauma care, and with providing recommendations to ensure that lessons learned from the military’s experiences in Afghanistan and Iraq are sustained and built upon for future combat operations and translated into the civilian system (the full statement of task is included in Box 1-6 in Chapter 1).
In its examination of military and civilian trauma systems, the committee observed striking similarities in gaps that lead to preventable death and disability after injury including inconsistency in trauma care capabilities and utilization of best practices across time and geography, as well as diffusion of leadership responsibility. With regard to learning capacity, although many of the individual components of a learning system are in place, the full potential of such a system is not being realized in either sector. Hundreds or more lives could likely be saved in future wars if military trauma care were optimal, and that potential gain soars into the tens of thousands of lives if past and future improvements could be systematically translated into civilian trauma care.
Some significant improvements in military trauma care and learning can be achieved within the military sector alone including, for example, the standardization of best practices and training requirements across the U.S. Department of Defense. However, it is neither feasible nor, in the face of the evidence, rational to address the deficiencies in military trauma care and learning more broadly without extending change efforts to encompass the civilian trauma system, which must serve as a training platform for military trauma care providers, particularly during the interwar period. The low clinical volume of trauma cases outside of the combat setting does not allow military trauma teams to acquire and maintain the expertise neces-
sary to deliver combat casualty care at the level of excellence that is both deserved and needed by the men and women who serve in the U.S. Armed Forces. Military and civilian trauma care and learning will be optimized together, or not at all.
Currently, a national strategy and joint military–civilian approach for improving trauma care are lacking, placing lives unnecessarily at risk. The committee concludes that a unified effort is needed to address this gap and ensure the delivery of optimal trauma care to save the lives of Americans injured within the United States and on the battlefield.
In this report, the committee presents a vision for a national trauma care system driven by a clear and bold aim: zero preventable deaths after injury and minimal disability, for those the nation sends into harm’s way in combat, and for every American. It offers 11 recommendations that, if implemented, would help the nation realize this vision through stronger and more consolidated leadership; comprehensive and more accessible trauma data and information management systems; robust research programs and supportive regulatory systems that promote innovation; incentives that drive quality improvement processes; and a network of civilian and military trauma centers to serve as an integrated trauma training platform. This will require an unprecedented partnership across military and civilian sectors and a sustained commitment from trauma system leaders at all levels, but the benefits are clear: the first casualties of the next war would experience better outcomes than the casualties of the last war, and all Americans would benefit from the hard-won lessons learned on the battlefield.
