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Baird MD, Madha ES, Arnaouti M, Cahill GL, Hewa Kodikarage SN, Harris RE, Murphy TP, Bartel MC, Rich EL, Pathirana YG, Kim E, Bain PA, Alswaiti GT, Ratnayake AS, Worlton TJ, Joseph MN. Global assessment of military and civilian trauma systems integration: a scoping review. Int J Surg 2024; 110:3617-3632. [PMID: 38935828 PMCID: PMC11175771 DOI: 10.1097/js9.0000000000001265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 02/21/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The global burden of trauma disproportionately affects low-income countries and middle-income countries (LMIC), with variability in trauma systems between countries. Military and civilian healthcare systems have a shared interest in building trauma capacity for use during peace and war. However, in LMICs it is largely unknown if and how these entities work together. Understanding the successful integration of these systems can inform partnerships that can strengthen trauma care. This scoping review aims to identify examples of military-civilian trauma systems integration and describe the methods, domains, and indicators associated with integration including barriers and facilitators. METHODS A scoping review of all appropriate databases was performed to identify papers with evidence of military and civilian trauma systems integration. After manuscripts were selected for inclusion, relevant data was extracted and coded into methods of integration, domains of integration, and collected information regarding indicators of integration, which were further categorized into facilitators or barriers. RESULTS Seventy-four studies were included with authors from 18 countries describing experiences in 23 countries. There was a predominance of authorship and experiences from High-Income Countries (91.9 and 75.7%, respectively). Five key domains of integration were identified; Academic Integration was the most common (45.9%). Among indicators, the most common facilitator was administrative support and the lack of this was the most common barrier. The most common method of integration was Collaboration (50%). CONCLUSION Current evidence demonstrates the existence of military and civilian trauma systems integration in several countries. High-income country data dominates the literature, and thus a more robust understanding of trauma systems integration, inclusive of all geographic locations and income statuses, is necessary prior to development of a framework to guide integration. Nonetheless, the facilitators identified in this study describe the factors and environment in which integration is feasible and highlight optimal indicators of entry.
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Affiliation(s)
- Michael D. Baird
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center
| | - Emad S. Madha
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of General Surgery, Walter Reed National Military Medical Center
| | - Matthew Arnaouti
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Royal National Orthopaedic Hospital, Stanmore, Middlesex
| | - Gabrielle L. Cahill
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Sadeesh N. Hewa Kodikarage
- Department of Surgery, Army Hospital Colombo
- Postgraduate Institute of Medicine, University of Colombo, Colombo Sri Lanka
| | | | - Timothy P. Murphy
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center
| | - Megan C. Bartel
- Department of General Surgery, Walter Reed National Military Medical Center
| | - Elizabeth L. Rich
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center
| | - Yasar G. Pathirana
- Department of Surgery, Army Hospital Colombo
- Postgraduate Institute of Medicine, University of Colombo, Colombo Sri Lanka
| | - Eungjae Kim
- School of Medicine, Uniformed Services University
| | - Paul A. Bain
- Countway Library, Harvard Medical School, Boston
| | | | | | - Tamara J. Worlton
- Department of General Surgery, Walter Reed National Military Medical Center
- Department of Surgery, Uniformed Services University, Bethesda
| | - Michelle N. Joseph
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of Surgery, Uniformed Services University, Bethesda
- Clinical Trials Unit, University of Warwick, Warwickshire, UK
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Standifird CH, Kaisler S, Triplett H, Lauria MJ, Fisher AD, Harrell AJ, White CC. Implementing Tourniquet Conversion Guidelines for Civilian EMS and Prehospital Organizations : A Case Report and Review. Wilderness Environ Med 2024; 35:223-233. [PMID: 38509815 DOI: 10.1177/10806032241234667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Since the first documented use of a tourniquet in 1674, the popularity of tourniquets has waxed and waned. During recent wars and more recently in Emergency Medical Services systems, the tourniquet has been proven to be a valuable tool in the treatment of life-threatening hemorrhage. However, tourniquet use is not without risk, and several studies have demonstrated adverse events and morbidity associated with tourniquet use in the prehospital setting, particularly when left in place for more than 2 h. Consequently, the US military's Committee on Tactical Combat Casualty Care has recommended guidelines for prehospital tourniquet conversion to reduce the risk of adverse events associated with tourniquets once the initial hemorrhage has been controlled. Emergency Medical Services systems that operate in rural, frontier, and austere environments, especially those with transport times to definitive care that routinely exceed 2 h, may consider implementing similar tourniquet conversion guidelines.
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Affiliation(s)
| | - Sean Kaisler
- University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Hunter Triplett
- Kirk Kerkorian School of Medicine, University of Nevada, Las Vegas, NV
| | - Michael J Lauria
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Lifeguard Air Emergency Services, Albuquerque, NM, USA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Andrew J Harrell
- Division of Prehospital, Austere, and Disaster Medicine, Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Dr George Kennedy Center for Law Enforcement Operational Medicine, Albuquerque, NM, USA
- Grand Canyon National Park, Arizona, and New Mexico State Police and State Search and Rescue, Sante Fe, NM, USA
| | - Chelsea C White
- Division of Prehospital, Austere, and Disaster Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
- UNM Center for Rural and Tribal Medicine, Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Knudson MM. Service, Synergy, and Surgical Mythology. J Am Coll Surg 2024; 238:794-800. [PMID: 38323626 DOI: 10.1097/xcs.0000000000001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- M Margaret Knudson
- From the Department of Surgery, University of California, San Francisco, San Francisco, CA
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Borg TM, Cavale N, Abu-Sittah G, Ghanem A. Plastic and Maxillofacial Training for War-Zones - A Systematic Review. Craniomaxillofac Trauma Reconstr 2023; 16:154-162. [PMID: 37222978 PMCID: PMC10201192 DOI: 10.1177/19433875221083416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
Study Design Injuries sustained in war-zones are variable and constantly developing according to the nature of the ongoing conflict. Soft tissue involvement of the extremities, head and neck often necessitates reconstructive expertise. However, current training to manage injuries in such settings is heterogenous. This study involves a systematic review. Objective To evaluate interventions in place to train Plastic and Maxillofacial surgeons for war-zone environments so that limitations to current training can be addressed. Methods A literature search of Medline and EMBase was performed using terms relevant to Plastic and Maxillofacial surgery training and war-zone environments. Articles that met the inclusion criteria were scored then educational interventions described in included literature were categorised according to their length, delivery style and training environment. Between-group ANOVA was performed to compare training strategies. Results 2055 citations were identified through this literature search. Thirty-three studies were included in this analysis. The highest scoring interventions were over an extended time-frame with an action-oriented training approach, using simulation or actual patients. Core competencies addressed by these strategies included technical and non-technical skills necessary when working in war-zone type settings. Conclusions Surgical rotations in trauma centers and areas of civil strife, together with didactic courses are valuable strategies to train surgeons for war-zones. These opportunities must be readily available globally and be targeted to the surgical needs of the local population, anticipating the types of combat injuries that often occur in these environments.
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Affiliation(s)
- Tiffanie-Marie Borg
- Academic Plastic Surgery Group, Barts and the London School of
Medicine and Dentistry, Queen Mary University of London, London,
UK
- Department of Surgery, Queen’s Hospital, London, UK
| | | | | | - Ali Ghanem
- Academic Plastic Surgery Group, Barts and the London School of
Medicine and Dentistry, Queen Mary University of London, London,
UK
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Lee JJ, Hall AB, Carr MJ, MacDonald AG, Edson TD, Tadlock MD. Integrated military and civilian partnerships are necessary for effective trauma-related training and skills sustainment during the inter-war period. J Trauma Acute Care Surg 2022; 92:e57-e76. [PMID: 34797811 DOI: 10.1097/ta.0000000000003477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Joseph J Lee
- From the Department of Surgery (J.J.L., M.J.C., M.D.T.), Navy Medicine Readiness & Training Command, San Diego, California; 96th Medical Group (A.B.H.), US Air Force Regional Hospital, Eglin AFB, Florida; Uniformed Services University of the Health Sciences (A.G.M.), Bethesda, Maryland; and 1st Medical Battalion (T.D.E.), 1st Marine Logistics Group, Camp Pendleton, California
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Simpson SA, Goodwin M, Thurstone C. Implementation and Evaluation of a Military-Civilian Partnership to Train Mental Health Specialists. Mil Med 2020; 184:e184-e190. [PMID: 30690507 DOI: 10.1093/milmed/usy358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 09/11/2018] [Accepted: 11/07/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Mental health specialists (MHS, or 68X) play a central role in meeting the growing demand for combat stress care among Service Members. Partnering with civilian institutions may enhance the MHS training experience beyond Advanced Individual Training (AIT). METHODS We describe a novel military-civilian collaboration to train U.S. Army Reserve MHS's in the psychiatric emergency service (PES) of a public, safety-net hospital. Details of implementation are described. The training rotation was evaluated after 1 year through a comprehensive chart abstraction of patients seen as well as surveys of MHS's and civilian partners. RESULTS The roles of MHS and physician officers in this rotation are described. Over 9 days in the PES, the MHS team evaluated 26 patients. MHS's described a high-quality training environment (83% rated very good or excellent) in which they frequently saw high-risk patients relevant to military practice. Experience with a certain patient presentation was correlated with comfort assessing and managing that presentation (p < 0.01). Many civilian staff (40%) felt the PES operated better with the presence of the Army team and 50% of civilians agreed their impression of the U.S. Army Reserve improved as a result of the partnership. Hundred percent of specialists and 80% of civilians reported very good to excellent rapport between military and civilian staff. Two civilian respondents (11%) expressed concern that the military team's presence impeded patient care. CONCLUSION This is the first military-civilian training collaboration for behavioral health specialists, who have already completed AIT. This program provided well-received and mission-relevant training for MHS's without notable adverse effects on patient care or team functioning in a civilian environment. Our findings are based on a small sample size, and no other such programs exist against which to compare these results. We propose that such educational partnerships, which have long been effective for other clinical specialists, may benefit the military, civilian communities, and the country.
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Affiliation(s)
- Scott A Simpson
- Department of Behavioral Health, Denver Health Medical Center, Denver, CO, and Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO
| | - Matthew Goodwin
- Department of Behavioral Health, Denver Health Medical Center, Denver, CO, and Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO.,US Army Reserve Medical Corps
| | - Christian Thurstone
- Department of Behavioral Health, Denver Health Medical Center, Denver, CO, and Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO.,US Army Reserve Medical Corps
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Caring for all: The 2019 WTA Paint the Ceiling lecture. J Trauma Acute Care Surg 2020; 87:1012-1014. [PMID: 30939581 DOI: 10.1097/ta.0000000000002278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Knudson MM. A Perfect Storm: 2019 Scudder Oration on Trauma. J Am Coll Surg 2020; 230:269-282. [DOI: 10.1016/j.jamcollsurg.2019.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/20/2019] [Indexed: 11/25/2022]
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Goodwin T, Moore KN, Pasley JD, Troncoso R, Levy MJ, Goolsby C. From the battlefield to main street: Tourniquet acceptance, use, and translation from the military to civilian settings. J Trauma Acute Care Surg 2019; 87:S35-S39. [PMID: 31246904 DOI: 10.1097/ta.0000000000002198] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Throughout history, battlefield medicine has led to advancements in civilian trauma care. In the most recent conflicts of Operation Enduring Freedom in Afghanistan/Operation Iraqi Freedom, one of the most important advances is increasing use of point-of-injury hemorrhage control with tourniquets. Tourniquets are gradually gaining acceptance in the civilian medical world-in both the prehospital setting and trauma centers. An analysis of Emergency Medical Services (EMS) data shows an increase of prehospital tourniquet utilization from 0 to nearly 4,000 between 2008 and 2016. Additionally, bystander educational campaigns such as the Stop the Bleed program is expanding, now with over 125,000 trained on tourniquet placement. Because the medical community and the population at large has broader acceptance and training on the use of tourniquets, there is greater potential for saving lives from preventable hemorrhagic deaths.
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Affiliation(s)
- Tress Goodwin
- From the Department of Military and Emergency Medicine, Uniformed Services (T.G., K.N.M., C.G.), University of the Health Sciences, Bethesda, MD; Department of Emergency Medicine (T.G.), Children's National Health System and George Washington University, Washington, DC; Department of Surgery (J.D.P.), Cedars Sinai Medical Center, Los Angeles, CA; Johns Hopkins Department of Emergency Medicine (R.T.Jr., M.J.L.), Baltimore, MD; Department of Fire and Rescue (M.J.L.), Howard County. MD; and National Center for Disaster Medicine & Public Health (C.G.), Rockville, MD
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Knudson MM, Elster EA, Bailey JA, Johannigman JA, Bailey PV, Schwab CW, Kirk GG, Woodson JA. Military–Civilian Partnerships in Training, Sustaining, Recruitment, Retention, and Readiness: Proceedings from an Exploratory First-Steps Meeting. J Am Coll Surg 2018; 227:284-292. [DOI: 10.1016/j.jamcollsurg.2018.04.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/11/2018] [Accepted: 04/12/2018] [Indexed: 10/16/2022]
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Responding to Crisis: Surgeons as Leaders in Disaster Response. J Am Coll Surg 2017; 225:691-695. [PMID: 28916323 DOI: 10.1016/j.jamcollsurg.2017.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 08/30/2017] [Indexed: 11/21/2022]
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A Shared Ethos: The Military Health System Strategic Partnership with the American College of Surgeons. J Am Coll Surg 2016; 222:1251-5. [DOI: 10.1016/j.jamcollsurg.2016.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/03/2016] [Accepted: 03/04/2016] [Indexed: 11/20/2022]
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Abstract
This White Paper summarizes the state of readiness of combat surgeons and provides action recommendations that address the problems of how to train, sustain, and retain them for future armed conflicts. As the basis for the 2014 Scudder Oration, I explored how to secure an improved partnership between military and civilian surgery, which would optimize learning platforms and embed military trauma personnel at America's academic medical universities for trauma combat casualty care (TCCC). To craft and validate these recommendations, I conducted an integrative and iterative process of literature reviews, interviews of military and civilian leaders, and a survey of military-affiliated surgeons. The recommended action points advance the training of combat surgeons and their trauma teams by creating an expanded network of TCCC training sites and sourcing the cadre of combat-seasoned surgeons currently populating our civilian and military teaching hospitals and universities. The recommendation for the establishment of a TCCC readiness center or command within the Medical Health System of the Department of Defense includes a military and civilian advisory board, with the reformation of a think tank of content experts to address high-level solutions for military medicine, readiness, and TCCC.
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