The exchange of knowledge and practices between the military and civilian sectors was seamless through World War II—civilian surgeons were activated for combat deployment and then returned to civilian practice with their lessons learned. Significant changes in military medical staffing over subsequent decades have led to an all-volunteer medical force with little trauma experience practicing largely in nontrauma hospitals. Because most deploying surgeons, allied medical specialists (e.g., in anesthesia, radiology, and emergency medicine), allied support specialists (e.g., blood bank, pharmacy, and administration personnel), nurses, and medics are not experts in trauma care and do not regularly practice in that field, brief predeployment training courses have minimal impact on their expertise. Postdeployment, they then return to the military sector, relatively isolated from the civilian trauma community. Furthermore, the episodic nature of military trauma care, with periods of intense action separated by many years, results in a “peacetime effect” in which the process of combat casualty care must be recreated almost from scratch every time combat operations escalate.

Because the civilian and military health systems are now largely segregated, scientific meetings and medical journals have become important venues for the exchange of knowledge and practices. However, it may be argued that although these exchanges are important and necessary, they are not sufficient. Attendance of civilian experts at military conferences is quite limited, and military members' attendance at civilian conferences is routinely threatened by various contingencies. Furthermore, dissemination of knowledge through the medical literature is notoriously slow, taking on average up to 17 years (IOM, 2001).

More optimal exchange of knowledge and practices occurs in select military treatment facility (MTF) trauma centers and integrated military–civilian training sites where regular interaction with civilian counterparts takes place. Over the past decade, first-hand interactions between military surgeons and civilian trauma and vascular experts through the Senior Visiting Surgeon (SVS) Program also demonstrated significant value for both the military and civilian communities, although the future of this program or its replacement remains unclear.

At present, the challenges to maintaining consistent practice in combat casualty care, gaining knowledge on the quality of care, and exchanging that knowledge with the civilian sector and vice versa are myriad. The vast complexity of the Military Health System (Schwab, 2015), along with frequent turnover at all levels, creates an inherently unstable system. This reality makes consistency in routine matters difficult, much less the preservation of lessons learned across decades of practice and multiple generations of military physicians. Furthermore, an artificial division exists in who is responsible for the care of patients prehospital and once they reach medical care. The military “line” (i.e., nonmedical forces) rather than the medical corps controls all aspects of the prehospital environment. The result has been significant barriers to collecting prehospital data and understanding the causes of prehospital deaths (i.e., killed in action). Finally, significant legal and policy limitations hinder the involvement of combat-experienced civilian physicians as trainers, educators, and advisors to the military (e.g., the Committee on Tactical Combat Casualty Care). All of these factors result in a highly volatile, internally fragmented system that is stovepiped from external influences and input. It is no wonder that the same mistakes are repeated and the case fatality rate rises significantly at the beginning of each war.

The infrastructure of the Joint Trauma System (JTS) (Bailey et al., 2012; Butler et al., 2015) and the pledge of partnership and collaboration between the American College of Surgeons and the Military Health System (ACS, 2014) represent ideal starting points for addressing the weaknesses identified above. These changes will doubtless benefit both combat casualties and injured civilians. Table C-1 details a number of recommended courses of action for addressing the weaknesses of the current system. The underlying premise behind these recommendations is that military–civilian exchange needs to begin at the earliest stages of medical education. Then in residency and during active practice, although civilian trauma care may be an imperfect training platform for military deployment (Smith and Hazen, 1991), immersion in this environment is far superior to no or very limited trauma care training and experience (Livingston et al., 2014; Sambasivan et al., 2010; Schreiber et al., 2008). This same conclusion was reached years ago by many U.S. allies, which routinely house deployment-eligible military medical units entirely in the reserves or on active duty embedded within high-volume civilian trauma centers (DuBose et al., 2012; Soffer and Klausner, 2012). The first step in this direction is to delineate the critical wartime specialties and the numbers needed in each specialty, and then to ensure that combat-designated military physicians, nurses, and medics are immersed in full-time trauma care either in an MTF trauma center or a high-volume, high-acuity civilian center (Schwab, 2015). Ideally, these personnel would work together as a unit and would also deploy as a unit for optimal effectiveness (Kellicut et al., 2014; Thorson et al., 2012). These units would then contribute lessons learned to the learning health system, which could be modeled after the Center for Army Lessons Learned (Dixon, 2011; USACAC, 2016). Review of these lessons learned and implementation of actionable change could then be effected through the JTS or a newly established military think tank under the auspices of Uniformed Services University of the Health Sciences or the Defense Health Agency (Eiseman and Chandler, 2005; Schwab, 2015).

TABLE C-1

Military–Civilian Exchange of Knowledge and Practices: Strengths, Weaknesses, and Opportunities.

Footnotes

1

This appendix is excerpted from a paper commissioned by the National Academies of Sciences, Engineering, and Medicine Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector, written by Jeremy W. Cannon, Perelman School of Medicine, University of Pennsylvania. The paper in its entirety is available on the study website at nationalacademies​.org/TraumaCare.