A Perfect Storm: 2019 Scudder Oration on Trauma
2019; Lippincott Williams & Wilkins; Volume: 230; Issue: 3 Linguagem: Inglês
10.1016/j.jamcollsurg.2019.11.009
ISSN1879-1190
Autores Tópico(s)Pelvic and Acetabular Injuries
ResumoA perfect storm: a particularly violent storm arising from a rare combination of adverse meteorological phenomena.Wikipedia (accessed August 2, 2019) Thank you, Drs Bulger, Stewart, and Hoyt, for this extraordinary honor of delivering the 2019 Scudder Oration on Trauma. I would also like to take this opportunity to welcome all of you to San Francisco. Just 3 miles south of here is the San Francisco General Hospital/Zuckerberg Trauma Center (SFGH), where I have worked for the past 30 years and been supported by an outstanding group of faculty members, trauma/critical care fellows, and University of California San Francisco surgery residents. I follow in the footsteps of 4 previous Scudder Orators from the SFGH including:1.1982–FW Blaisdell: "The Nature and Consequences of Traumatic Shock"1Blaisdell F.W. Traumatic shock: the search for a toxic factor.Bull Am Coll Surg. 1982; 68: 1-10Google Scholar2.1989–DD Trunkey: "What Is Wrong with Trauma Care"?2Trunkey D.D. What's wrong with trauma care?.Bull Am Coll Surg. 1990; 75: 10-15PubMed Google Scholar31991–GF Sheldon: "Trauma Manpower in the Decade of Aftershock"3Sheldon G.F. Trauma manpower in the decade of aftershock.Bull Am Coll Surg. 1992; 77: 6-12PubMed Google Scholar4.2006–FR Lewis: "Physiology for the 21st Century: Cardiopulmonary Function in Sepsis" (unpublished) (Fig. 1) It was Dr Blaisdell who provided me with the title for this talk when he described for me the perfect storm that occurred in San Francisco in the 1960s. It started with the hippie phenomenon originating in the Haight-Ashbury district of San Francisco, a neighborhood that would become the setting for the "Summer of Love" in 1967. Idealistic youth from across the nation flocked to Haight-Ashbury to participate in the counterculture, where LSD, marijuana, and methamphetamine dominated the scene.4Howard J.R. The flowering of the hippie movement.Ann Am Academy of Political and Social Science. 1969; 382: 43-55Crossref Scopus (14) Google Scholar Meanwhile, over in Berkeley, political activism was thriving, and violent protests against the Vietnam War eventually crossed over the San Francisco Bay as well.5Gales K.E. A campus revolution.Br J Sociology. 1996; 17: 1-19Crossref Google Scholar Coupled with the release of a large number of previously incarcerated mentally ill patients into the streets on the antipsychotic drug chlorpromazine, San Francisco was converted from the "City of Love" to a "City of Crime and Violence."6Fakhourya W. Priebea S. Deinstitionalization and reinstitutionalization: major changes in the provision of mental healthcare.Psychiatry. 2007; 6: 313-316Abstract Full Text Full Text PDF Scopus (81) Google Scholar In response, Dr Blaisdell redesigned the surgical service at SFGH such that there was a dedicated trauma surgical team in house 24/7. Because SFGH was owned by the city and county of San Francisco, as was the ambulance service, it was easy to direct all injured patients into the newly organized trauma center.7Schecter W. Lim R. Sheldon G. Christensen N. The Blaisdell Years in The History of the Surgical Service at San Francisco General Hospital. UCSF Press, San Francisco CA2007: 102-108Google Scholar Therefore, SFGH became the second major trauma center in the US (with Cook County hospital in Chicago being the first) and it became the first city in the nation with an organized trauma system.8Blaisdell F.W. 1991 AAST Presidential Address: The pre-medical role of city/county hospitals in education and healthcare.J Trauma. 1992; 32: 217-228Crossref PubMed Scopus (14) Google Scholar As a result, the number of patients with penetrating injuries treated at SFGH rose from the steady rate of 100 annually up until 1964 to almost 400 in 1969.7Schecter W. Lim R. Sheldon G. Christensen N. The Blaisdell Years in The History of the Surgical Service at San Francisco General Hospital. UCSF Press, San Francisco CA2007: 102-108Google Scholar Surgeons in a current war never begin where the surgeons in the previous war left off: they always go through another learning period. All military medicine, insofar as civilians are concerned, is a discontinuous specialty. Consequently, in every new war the same stupid mistakes are made again and soldiers lose their lives or limbs because the doctor was ignorant of past experience. I cannot overemphasize the need to study military medicine and surgery.Col Edward D Churchill, MD, 19519Churchill E.D. Address to the Army Medical Graduate School in Washington D.C., February 11 1951. Hall, RM. Armed forces consultants remembered at 50.Bull Amer Coll Surg June. 1966; 81: 47-53Google Scholar A perfect storm can exist only with the right levels of humidity, ionic charge, and temperature. That said, the term perfect storm does have a rather negative connotation. On a more positive note, a similar paradigm flows from the discipline of public policy, the Punctuated Equilibrium Theory, which states that policy change can occur rapidly when there is a convergence of interest groups, policy makers, and an opportunity window.10Cairney P. Understanding public policy: theories and issues. Palgrave Macmillan pub, 2011http://www.palgrave.com/products/title.aspz?pio=360100Date accessed: July 31, 2019Google Scholar In 2014, David Hoyt, MD, FACS, who has had a lifetime interest in military surgery, was at the helm of the American College of Surgeons (ACS) as the executive director. COL (ret) Norman Rich, MD, FACS, USA and Captain Eric Elster, MD, FACS, USN, both decorated military surgeons, were directing the Department of Surgery at the Uniformed Services University for the Health Sciences, and Brig Gen Jonathan Woodson, MD, FACS, USAR, was serving as the undersecretary of defense for health affairs. These 4 individuals represented the interest group that had strong connections with the policy makers, and the window of opportunity was the beginning of the withdrawal of US troops from Iraq and Afghanistan, with the accompanying fear that Churchill's prophecy would repeat itself. By 2014, the US had been at war for more than a decade (our longest war in history), during which a comprehensive trauma system (the Joint Theater Trauma System, JTTS) had been built up to include combat casualty treatment centers in Iraq and Afghanistan, Landstuhl Regional Medical Center (Germany), and the military receiving hospitals in the US (Walter Reed Army Medical Center and the National Naval Hospital in Bethesda, and Brooke Army Medical Center in San Antonio). This elaborate trauma system was modeled after the civilian trauma system in the US, which, in turn, was designed based on military experiences during the Korean and Vietnam wars.11Eastridge B.J. Jenkins D. Flaherty S. et al.Trauma system development in a theater of war: experience from Operation Iraqi Freedom and Operation Enduring Freedom.J Trauma. 2006; 61: 1366-1373Crossref PubMed Scopus (206) Google Scholar This contemporary JTTS resulted in a steady decrease in combat case fatality rates despite increasingly severe injuries sustained by wounded troops.12Rasmussen T.E. Baer D.G. Lein B.D. Ahead of the curve: sustained innovation for future combat casualty care.J Trauma Acute Care Surg. 2015; 79: S61-S63Crossref PubMed Scopus (27) Google Scholar, 13Rasmussen T.E. Gross K.R. Baer D.G. Where do we go from here?.J Trauma Acute Care Surg. 2013; 75: S105-S106Crossref PubMed Scopus (37) Google Scholar, 14Kotwal R.S. Howard J.T. Oman J.A. et al.The effect of a golden hour policy on the morbidity and mortality of combat casualties.JAMA Surg. 2016; 151: 15-24Crossref PubMed Scopus (183) Google Scholar The most recent analysis of data documents that between 2001 and 2017, the combat case fatality rates (defined as the number of troops killed in action plus those who died of wounds divided by the sum of those killed in action plus those wounded in action) decreased in Afghanistan from 20% to 8.6%; in Iraq it went from 20.4% to 10%15Howard J.T. Kotwal R.S. Stem C.A. et al.Use of combat casualty care data to assess the US military trauma system during the Afghanistan and Iraq conflicts 2001-2017.JAMA Surg. 2019; 154: 600-608Crossref PubMed Scopus (55) Google Scholar (Fig. 2). Survival for critically injured casualties with Injury Severity Scores of 25 to 75 increased from 2.2% to 39.9% in Afghanistan and from 8.9% to 32.9% in Iraq. These remarkable results are attributed to a mature and continuously learning trauma system and, in particular, to 3 interventions: the use of tourniquets, novel blood transfusion therapies, and shorter prehospital transport times. But as stated previously, after every major conflict, the lessons learned in war are frequently forgotten during peacetime. This so-called "Walker Dip" was coined by Surgeon Commodore Alasdair Walker, the United Kingdom's Military Health Services' medical director, who attributed the past loss of lessons learned during inter-war periods to loss of leader emphasis, the impact of fiscal constraints, the impact of garrison mentality, and loss of institutional experience16Mabry R.L. DeLorenzo R. Challenges to improving combat casualty survival on the battlefield.Mil Med. 2014; 179: 477-482Crossref PubMed Scopus (21) Google Scholar (Fig. 3). One potential solution to these issues is for the military to partner with a civilian organization with institutional memory. With this in mind, Drs Hoyt, Rich, Woodson, and Elster created the Military Health System Strategic Partnership with the American College of Surgeons (MHSSPACS), with an agreement signed at this very meeting 5 years ago.17Knudson M.M. Elster E.E. Woodson J. et al.A shared ethos: the military health system strategic partnership with the American College of Surgeons.J Am Coll Surg. 2016; 222: 1251-1257Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar The goals of this partnership are to share information in the following 4 areas: trauma systems, trauma education and training, trauma/surgical quality, and trauma research. This Punctuated Equilibrium paradigm was completed with the passage of the 2017 National Defense Appropriations Act (NDAA).18National Defense Authorization Act for fiscal year 2017.https://www.congress.gove/114/crpt/hrpt 840/CRPT-144 hrpt840.pdfDate accessed: August 13, 2019Google Scholar This legislation (which was enhanced by the NDAA 2018) provides for 3 innovative directives for the military.19H.R 2810-NDAA for fiscal year 2018.https://www.congress.gov/bill/115th congress/house-bill/2810/textDate accessed: August 13, 2019Google Scholar The first is development and sustainment of a Joint Trauma System (JTS) that unites the 3 branches of the Medical Corps (Army, Navy, and Air Force). The JTS serves as the reference body for all trauma care within US Military Treatment Facilities (MTF) worldwide, develops standards of clinical trauma care, and facilitates the translation of research into practice. Second, the NDAA tasked every major MTF with becoming a trauma center and participating in their local civilian trauma system or partnering with civilian trauma centers for training in and sustainment of trauma skills. Additionally, the NDAA provides for establishment of a Joint Trauma Education and Training Directorate to ensure that military trauma providers maintain deployment readiness. Maintaining readiness and clinical skills is the primary mission of the Military Health System (MHS). Despite this mission, however, the majority of surgeons in the military spend their garrison professional career providing elective and emergency general surgery care for military service members, their families, and retirees. In fact, the MHS is one of the largest healthcare systems in the US, delivering health services to 9.4 million patients in 700 military facilities worldwide.20Smith D.J. Bono R.C. Slinger B.J. Transforming the military health system.JAMA. 2017; 318: 2427-2428Crossref PubMed Scopus (12) Google Scholar Outside of deployment, the majority of military surgeons do not routinely care for trauma patients. Currently, even when deployed, the operational tempo is so slow that trauma surgical volume has diminished dramatically.21Edward M.J. White C.D. Remick K.N. et al.Army general surgery's crisis of conscience.J Am Coll Surg. 2018; 226: 1190-1194Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar How, then, can we expect military surgeons to be prepared at all times for the deployment mission? The solution is a comprehensive clinical readiness program that includes the following 4 elements:1.The military trauma system2.Military-civilian partnerships for training and sustainment3.Periodic assessment of readiness knowledge points and surgical skills4.A continuous learning trauma system informed by research. The end of the wars in Afghanistan and Iraq represents a unique moment in history in that there now exists a military trauma system built on a learning system framework and an organized civilian trauma system that is well positioned to assimilate and distribute the recent wartime trauma lessons learned and to serve as a repository and incubator for innovation in trauma care during the interwar period. Together these two developments present an opportunity to integrate military and civilian trauma systems.From: The National Academies of Sciences, Engineering and Medicine (NASEM) report: A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. 201622The National Academies of Science Engineering and MedicineA national trauma care system: Integrating military and civilian trauma systems to achieve zero preventable deaths after injury. The National Academies Press, Washington DC2016Google Scholar The extremely comprehensive report by the NASEM recognized the current deficiencies in both the civilian and military trauma care systems in the US and strongly advocated for a fully integrated system. The authors emphasized the fact that 20% to 30% of potential trauma patients in our country (an estimated 45 million people) have no access to a major trauma center within 1 hour of their injury (Fig. 4).23Branis C.C. Mackensie E.J. Schwab W.C. et al.Access to trauma centers in the United States.JAMA. 2005; 293: 2626-2633Crossref PubMed Scopus (356) Google Scholar They further advocated for development of integrated, permanent joint civilian and military trauma system training platforms to create and sustain an expert trauma workforce. The report warns that failure to capture the lessons learned from the recent 15 years of conflict would have deadly consequences, with detrimental effects on the quality of trauma care in both the military and the civilian sectors. As stated by Rasmussen,24Rasmussen T.E. A national trauma care system: from call to action.J Trauma Acute Care Surg. 2016; 81: 813-823Crossref PubMed Scopus (4) Google Scholar enactment of the Academies' National Trauma Action Plan has the potential to improve the nation's health and well-being and assure that "the first casualties of the next war will experience better outcomes than the casualties of the last war and all Americans will benefit from the hard-won lessons learned on the battlefield." As mentioned earlier in this manuscript, few MTF care for trauma patients in the US. Currently there is only one level 1 trauma center in the military, at San Antonio Army Medical Center in San Antonio, TX. However, after the NDAA directive, a few other MTFs are now participating or planning to participate in their local civilian trauma system (Table 1). In other areas of the country, combat casualty teams will receive their trauma training in civilian centers.Table 1Military Trauma Centers in the USInstitutionVerified American College of Surgeons levelSan Antonio Army Military Medical Center1Dwight Eisenhower Army Medical CenterPursuing level 3Fort BelvoirPursuing level 3Landstuhl Regional Medical Center3Mike O'Callaghan Military Medical CenterPursuing level 3Naval Medical Center Lejeune3Tripler Army Medical Center2Walter Reed National Military Medical Center2Womack Army Medical Center3 Open table in a new tab The concept of military surgeons and other members of the combat casualty care teams receiving training in civilian trauma centers is not new. Five formal military training platforms were stood up in the early 2000s, including the University of Southern California/Los Angeles County Trauma Center (Navy), St Louis University, the University of Cincinnati, and the University of Maryland/Shock Trauma Center (all Air Force), and the University of Florida/Ryder Trauma Center (Army). Other military-civilian partnerships (MCP) were formed with universities in proximity to military bases including the University of Texas, San Antonio; Wright Patterson University, Dayton; the University of Pennsylvania, Philadelphia; the University of California, Davis; and the University Medical Center of Southern Nevada, Las Vegas.25Hight R.A. Salcedo E.S. Martin S.P. et al.Level 1 academic trauma center integration as a model for sustaining combat surgical skills: the right surgeon in the right place at the right time.J Trauma Acute Care Surg. 2015; 78: 1176-1181Crossref PubMed Scopus (17) Google Scholar Additionally, the US Army has recently contracted for training purposes with the University of Oregon in Portland and Cooper University in New Jersey. As a background for developing additional MCP and in preparation for his 2014 Scudder Oration, Captain (ret) C William Schwab, MD, FACS, USN interviewed several military surgeons with recent deployment experience to gather data on common procedures performed in the theater of war as well as areas in which these surgeons felt that additional training might have been useful.26Schwab W.C. Wind of war: enhancing civilian and military partnerships to assure readiness: white paper. Scudder Oration on Trauma.J Am Coll Surg. 2015; 221: 235-255Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Within the realm of traditional general surgery, these military surgeons listed chest, vascular, liver, and pancreatic injuries as areas in which additional pre-deployment exposure was desirable. Dr Schwab also created an extensive list of important elements to be considered in selecting civilian trauma centers for military training, including patient volume, types of injuries, training facilities, and opportunities for military surgeons to practice semi-independently at the civilian center. Similarly, Dr Demetriades focused his 2018 Excelsior Surgical Society/Edward D Churchill Lecture on civilian and military trauma training and outlined some key lessons learned from the LA County-USC Navy Trauma training program.27Demetriades D. Civilian and military trauma training to successfully intervene and save lives: the Excelsior Surgical Society Edward D. Churchill Lecture.J Am Coll Surg. 2018; 227: 555-563Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar In particular, he emphasized that it is essential to completely integrate key military personnel in the civilian trauma program as clinicians, teachers, and researchers as well. Martin and others28Martin M.J. Dubose J.S. Rodriquez C. et al."One front one battle": civilian professional medical support of military surgeons.J Am Coll Surg. 2012; 215: 432-437Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar recently highlighted the important role that civilian professional societies have in fostering MCP, especially in offering educational opportunities for military surgeons. These authors reported that an often-discussed byproduct of an all-volunteer military force is the increasing sense of isolation and alienation of service members from their civilian counterparts and vice versa. Less than 10% of civilians have had any previous military experience, and less than 0.5% of those living in the US are currently serving. However, organizations including the ACS, the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, the Society of Vascular Surgery, the American Burn Association, the Society of Critical Care Medicine, and the American Academy of Orthopaedic Surgeons (including the Orthopaedic Trauma Association) have consistently offered support for training, development, and capabilities of military surgeons over the past decade of combat operations. An excellent example of this type of collaboration from civilian professional societies to the military mission is the Senior Visiting Surgeon program. Funded jointly by the ACS, the American Association for the Surgery of Trauma, and the Department of Defense, it allowed civilian trauma surgeons to participate in the care of injured troops evacuated from Iraq and Afghanistan to Landstuhl Regional Trauma Center in Germany.29Moore E.E. Knudson M.M. Schwab C.W. et al.Military-civilian collaboration in trauma care and the senior visiting surgeon program.N Engl J Med. 2007; 357: 2723-2727Crossref PubMed Scopus (39) Google Scholar Between the years 2005 and 2012, more than 200 trauma and vascular surgeons volunteered 2 to 4 weeks of their time to work at Landstuhl, providing a 2-way exchange of combat casualty trauma care knowledge between the military and the civilian surgeons.30Knudson M.M. Rasmussen T.E. The senior visiting surgeons program: a model for sustained military-civilian collaboration in times of war and peace.J Trauma Acute Care Surg. 2012; 78: S535-S539Google Scholar,31Knudson M.M. Evans T.W. Fang F. et al.A concluding after-action report of the senior visiting surgeons program with the United States military at Landstuhl Regional Medical Center, Germany.J Trauma Acute Care Surg. 2014; 76: 876-883Crossref Scopus (14) Google Scholar The Orthopaedic Trauma Association also supported civilian orthopaedic surgeons volunteering in Germany. Although the program was sun-downed in 2012, when civilian assistance was no longer needed, the renewed Excelsior Surgical Society at the ACS is developing plans for professional exchange programs between civilian and military treatment facilities. In June 2019, Congress passed the Pandemic and All-Hazards Preparedness and Advancing Innovation Act.32The Pandemic and All-Hazards Preparedness and Advancing Innovation Act. Available at: https://www.congress.gov/bill/115th-congress/house-bill/6378/text. Accessed 9 August 2019Google Scholar Contained within this legislation is Section 1291: Military and Civilian Partnership for Trauma Readiness Grant Program. The monies appropriated by this bill would provide $1 million/year for a period of 3 years to civilian trauma centers that qualify to train a full combat casualty care team, $100,000/year for training of an individual physician, and $50,000/year for an allied health provider. The monies are designed to cover such costs as delivery of educational courses, administrative assistance, liability fees, etc. While the exact mechanism of how and when these grants will be available, and how many civilian centers are needed, are uncertain at the time of this writing, the MHSSPACS has already been conducting meetings to develop a set of guidelines that could be used for selection and subsequent evaluation of interested programs.33Knudson M.M. Elster E.A. Bailey J.A. et al.Military-civilian partnerships in training, sustaining, recruitment, retention and readiness: proceeding from an exploratory first-steps meeting.J Am Coll Surg. 2018; 227: 284-292Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar The MHSSPACS "Blue Book "contains a set of standards that would need to be verified during an on-site visit of centers that apply for this funding (Table 2).Table 2The Military Health System Strategic Partnership with the American College of Surgeons "Blue Book" Criteria for Military Civilian Training CentersStandardRepresentative exampleInstitutional commitmentDocumented support from the highest level of the hospital administration, the dean of the medical school, etc.Governance/administrationJob description with protected time for the civilian surgeon champion of the partnership.Human resourcesCommitted teaching faculty in trauma, surgical specialty, nursing, etc.Physical resourcesAnnual trauma volume, case mix, teaching facility, etc.Education componentGraded military curriculum with scheduled advancement; continuing medical education opportunity, etc.Program evaluationFinancial report; assessment of impact on graduate medical education. Open table in a new tab The military has developed metrics to rigorously measure the expeditionary knowledge, skills, and abilities of our medical personnel to ensure continued excellence on the battlefield and in future operations.Secretary of Defense Dr Mark Esper at his confirmation hearings in the Senate, July 2019. Whether the members of a combat casualty care team train in an MTF or in a civilian trauma center, periodic assessment of knowledge points and hands-on assessment of skills is essential in order to demonstrate a state of constant readiness. The members of the combat casualty care team are listed in Table 3. It is important to understand the difference between an expeditionary general surgeon and a military trauma surgeon for the purposes of this discussion. The expeditionary general surgeon is meant to describe a surgeon who is deployed to a military role 2 facility or to a small far-forward team such as a Golden Hour Offset Surgical Team (GHOST-T) or an Expeditionary Resuscitative Surgical Team (ERST), where he or she is commonly the only general surgeon with limited holding facilities. The role of the expeditionary surgeon is to provide damage control surgical interventions before transfer to a higher level of care. A military trauma surgeon is typically deployed to a role 3 or higher MTF and must be capable of providing definitive surgical care as well as directing the trauma system within that deployed environment. Therefore, the skill sets and knowledge points for these 2 distinct types of surgeons will necessarily differ significantly. The education committee of the MHSSPACS elected to focus first on the expeditionary surgeon. A tri-service team of 14 military surgeons with deployment experience were brought together at the headquarters of the ACS to begin the process of identifying key knowledge points and surgical skills required for the expeditionary surgeon.33Knudson M.M. Elster E.A. Bailey J.A. et al.Military-civilian partnerships in training, sustaining, recruitment, retention and readiness: proceeding from an exploratory first-steps meeting.J Am Coll Surg. 2018; 227: 284-292Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar The primary references used were the JTS Clinical Practice Guidelines (https://JTS/AMEDD.army.mil/index.cfm/PI_CPGs/cpgs.). These 64 guidelines are updated on a periodic basis, usually every 3 years, or when new knowledge dictates a change. We also used the actual roster of cases performed in Iraq and Afghanistan at role 2 facilities gathered from the Department of Defense Trauma Registry (DODTR) as well as other information gathered from military surgeons with deployment experience.34Tyler J.A. Ritchie J.D. Lease M.L. et al.Combat readiness for the modern military surgeon: data from a decade of combat operations.J Trauma Acute Care Surg. 2012; 73: S64-S70Crossref PubMed Scopus (31) Google Scholar The knowledge, skills, and abilities (KSA) were grouped into the following 8 expeditionary domains: wounds and amputations, head and neck injuries, torso trauma, transfusion and resuscitation, airway and breathing, critical care and prevention, military specific, and universal domains (such as professionalism, practice based learning, etc). These KSA were vetted by a separate group of military surgeons for their relevance in the deployed situation. This process was followed by a series of meetings during which an item bank of more than 500 questions focusing on the knowledge points was developed with the aid of a psychometrician. Subsequently, 2 versions of a 200-item beta test were developed and delivered in an electronic format to 113 military surgeons. The test was able to discriminate, with a high degree of sensitivity, differences between trauma surgeons and/or those with extensive deployment experience and surgeons from other disciplines and/or those with little or no deployment history, therefore establishing content validity. It also identified knowledge gaps that can be emphasized in the aligned curriculum (see below).Table 3Members of the Combat Casualty Care TeamCombat casualty care teamEssential members:General/expeditionary surgeonOrthopaedic surgeonEmergency medicine physicianCritical care medicine physicianAnesthesiologistEmergency/trauma nurseCritical care nurseTrauma surgeonCombat casualty care team plus∗Not found at every military treatment facility.Plastic surgeonUrologic surgeonNeurosurgeonVascular surgeonCardiothoracic surgeonOphthalmologistEar nose throat surgeonOral maxillofacial surgeon∗ Not found at every military treatment facility. Open table in a new tab In order to evaluate the skill set needed for deployment, we used the ACS-Committee on Trauma's (ACS-COT) ASSET Course (Advanced Surgical Skills for Exposure in Trauma) and added additional elements to include neurosurgical, orthopaedic, ophthalmologic, and obstetrical surgical skills (so-called ASSET-plus course). For the trauma exposures, perfused cadavers are used, with a 1:1 ratio of students to faculty. Simulators are added for demonstration and for practicing a craniotomy, a lateral canthotomy, placement of an external fixator, and for an emergency Cesarean section. This 2-day course has now been given 4 times under the direction of COL (r
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