Trauma surgeon Dr. Peggy Knudson used special combat gauze perfected during wartime to stop internal bleeding from Zachery Vines’ injured liver. Late last September, the child was treated at Zuckerberg San Francisco General for severe internal injuries he sustained when a 200-pound wet bar fell on top of him. In saving Zachery’s life, the trauma team also used a special ratio of blood products to make sure his blood would clot, modeling their treatment after a technique learned from the U.S. military during current conflicts.
Dr. Knudson explains that in the operating room at ZSFG, “we use a different approach in patients who are unstable. We perform only the amount of surgery needed to stop bleeding and plan to come back when the patient is more stable.”
This approach is called “damage control surgery” and was perfected by the U.S. Military during these past 15 years of war. Dr. Knudson serves as medical director of the Military Health System Strategic Partnership, a collaboration between the American College of Surgeons and the Department of Defense, formally established two-and-a- half years ago.
The partnership gives military surgeons a formal home within the American College of Surgeons for the first time. Its goals include making sure military trauma surgeons are prepared for deployment, establishing trauma systems throughout the United States that include military hospitals, and conducting trauma-related research at civilian trauma centers that is of interest to the military but impossible to investigate in the military setting while war is in progress.
Not everyone is aware that the trauma system in the United States is rather new, and was created out of the military experiences in Korea and Vietnam. War has long driven medical advances. The formal triage system and mass use of penicillin both have roots in treating wounded soldiers during World Wars I and II.
Ongoing conflict in Iraq and Afghanistan have likewise changed civilian trauma care, says Dr. Knudson. “We have learned multiple new ways of treating severe burns from advances in burn care developed for treating wounded soldiers in Iraq,” she says. “The care of major soft tissue injuries induced by IEDs [intermittent explosive devices] greatly advanced wound care in the U.S.”
“We weren’t using tourniquets in our civilian trauma centers until the number of amputee victims in Iraq and Afghanistan increased their use in warzones, and then later here in America.”
Military trauma teams also reap huge benefits from the civilian-military partnership. When the Iraq war began, there was no military trauma care system equivalent to America’s network of domestic trauma centers because years had passed since our military had been engaged in war. Esteemed World War II surgeon Colonel Edward D. Churchill, M.D., who died in 1972, once said, “Surgeons in a current war never begin where the surgeons in the previous war left off; they always go through another long learning period.”
More recently, the results of a survey of active duty surgeons from the Army, Navy, and Air Force who had been deployed at least once between 2001 and 2012 were published in the Journal of Trauma and Acute Care Surgery. The surgeons were asked information about cases performed, how they perceived training received prior to deployment, knowledge deficits, and emotional challenges experienced once they returned home.
Nearly half of the surgeons identified knowledge or practice gaps in pre-deployment vascular training. Twenty nine percent of respondents reported gaps in neurosurgical training, and 28.5 percent felt their orthopedic training could have been better.
This reality is nothing new, according to Dr. Knudson. “Once war is over, military surgeons who go back to working within their military are rarely continuously exposed to trauma situations like civilian trauma surgeons,” says Knudson. That means military trauma surgeons and staff were often showing up to battlefields at the start of wars in Iraq and Afghanistan without the latest knowledge and skills, or even the best equipment.
A primary initiative for the partnership is working to make sure that military trauma care providers remain trauma-ready, even in the absence of war. The collaborators are defining and developing special training for military surgical personnel, and looking at ways to keep the military trauma system intact to the degree possible during peacetime.
The surgeons are currently busy identifying what successful military trauma surgeons need to know. They are developing a curriculum around this information base and a test to evaluate a surgeon’s knowledge and skill set prior to deployment. Knudson calls this progress historic and essential to changing the paradigm surrounding our country’s history of forgetting lessons learned in war in between conflicts.
Some military surgeons even have the chance to serve trauma patients in person, right here at home. President Obama signed the National Defense Authorization Act authorizing the military to allow their military trauma centers, such as Tripler Army Medical Center in Honolulu, to serve civilians so they can keep their teams trauma-ready.
Fifty years after America’s trauma system emerged, gaps remain in the level and quality of care available. Studies have shown that as much as 30 percent of Americans (an estimated 45 million) lack access to a Level I or Level II (providing total or near-total care for all injuries) trauma center located within one hour of injury. The parents of six-year-old Zachery Vines, whose life was saved last year by Zuckerberg San Francisco General’s trauma team, know it’s very likely the outcome for Zachery would have been different had they lived in a more remote area without access to a Level 1 trauma center.
Surgeons like Dr. Knudson believe in the power of the Military Health System Strategic Partnership to help make sure trauma surgery staff—whether military or civilian—are ready for anything, wherever they may be.