Article 1
The 16-Year Evolution of a Military-Civilian Partnership: The University of Alabama at Birmingham Experience. Rokayak OA, Lammers DT, Baird EW, Holcomb JB, Jansen JO, Cox DB, Winkler JP, Betzold RD, Manley NR, Northern DM, Wright JK, Dorsch, J, Kerby JD. J Trauma Acute Care Surg. 2023 Aug 1;95(2S Suppl 1):S19-S25.
In order to sustain military trauma readiness, previous efforts were focused on collaborative efforts with civilian trauma centers. Although these military-civilian partnerships (MCP’s) have existed for decades, they have been recently realized in the partnership of the MCP Working Group (MCP-WG) under the Defense Heath Agency (DHA). As the previous military engagements have yielded to peacetime operations, the MCP-WG recognized a lack in quantifying the effect and benefit of MCP on military trauma readiness. In order to avoid a knowledge dip during peacetime efforts, it is important to recognize and evaluate current the ability to maintain such readiness. The evaluation of these MCP’s falls directly into that initiative. However, the implementation and execution of MCP initiatives has been varied. This variation has been codified into 5 separate focus areas of partnership: Skill Sustainment, Just-In-Time Training, Strategic, Integrated, and Mentorship. Given the known variation, there is bound to be discrepancies in the quality and equality of partnership return on investment. Understanding how to improve these models requires an analysis of the existing MCP’s, with a focus on those that have found documented success.
This study provides that specific insight, by reviewing the multi-faceted evolutionary experience of a sustained MCP over a 16-year period at a single academic institution. The authors analyzed member rosters, clinical duties, deployment tempo, clinical case volume, work relative volume units (wRVU), and research and educational grant money to determine the affect and influence on their specific MCP. Interviews were also employed to identify areas of sustainment and improvement in supporting the goals of the MCP. Located within their academic institution, the authors identified six distinct partnerships. Examples of these partnerships include AFSOC medical training, integrated military GME residency positions, integrated military Surgical Critical Care fellowship positions, assigned Special Operations Surgical Teams, assigned individual military trauma surgeons, and DoD research funding. These partnerships, implemented in a step-wise fashion over 16 years, combine to fulfill all focus areas of an MCP. These authors conclude that such a robust menu of partnership offerings was possible due to the continued military presence at their academic institution. As interest in such alliances increases, this robust and mature MCP can provide a blueprint for successful multi-faceted future partnerships.
Article 2
Putting Medical Boots on the Ground: Lessons from the War in Ukraine and Applications for Future Conflict With Near-Peer Adversaries. Epstein A, Lim R, Johannigman J, Fox CJ, Inaba K, Vercruysse GA, Thomas RW, Martin MJ, Konstantyn G, and Schwaitzberg, SD. J AM Coll Surg. 2023 Aug 1;237(2):364-373.
For this month’s literature review we will be taking a bit of a detour from the conventional path. This is equally in part owing to the gravity of the topic of this paper, as well as the extraordinary historical moment it embodies as modern warfare is evolving before our very eyes. This paper is not “research” per se, nor does it posit any specific hypotheses that were set about to be tested. For that matter, the data contained isn’t readily reproducible, and the findings put forth are certainly not, at this moment, verifiable. The work is extraordinary in that it offers a preview into the next iteration of conventional warfare, and—particularly—the potential implications for modern surgeons. Global Surgical and Medical Support Group (GSMSG) is a nongovernmental organization created by the lead author of the paper, Dr. Aaron Epstein, in 2015 to fill a void in surgical care during the ongoing conflict in Iraq. Through a partnership with the Kurdish people in the area near northern Iraq, GSMSG has built significant competence in assembling and deploying surgical teams that then partner with the local population for the purposes of educating and training them in combat medicine. In the wake of almost a decade of relevant experience, we learn from the article that GSMSG had fielded a team in Ukraine within 2 weeks of the invasion of that country by Russian military forces. Although the mission of the organization in Ukraine remains primarily education and training, their involvement has also included surgical support in more than 300 cases, as close as 10 kilometers to the frontline. This access, breathtaking in its courage, has provided an unparalleled vantage point from which the authors have derived several observations and predictions about the future of surgical care in near-peer adversary (NPA) conflicts. While these are largely speculative in nature, they offer indisputable value in preparing for a future of warfare likely to look substantially different than that seen in either Iraq or Afghanistan.
The authors separate the “lessons learned” from their efforts in Ukraine into four subcategories, beginning with patterns of injury likely to be seen in NPA hostilities. Notably, they predict that current iterations of body armor elements, previously credited with dramatic improvements in combat mortality rates, will be rendered ineffective by weaponry with vastly increased precision and penetrating capability. Similarly, with the accelerating reliance of modern warfare upon artillery and rocket attacks, traumatic brain injury and thermal injury are likely to impose a significant burden on the care of casualties. The notion of a higher incidence of burns is particularly troubling in the intensity of both time and resources necessary to treat these patients. The authors go on to suggest that medical facilities will no longer be spared direct military attack, and medical evacuation itself could be severely constrained by the lack of dominance in any one domain of combat. They propose that the preparation and training of medical teams itself must change to meet the demands of an evolving battlespace. Namely, teams will need to provide more advanced care, for longer periods of time, for more patients simultaneously than has been previously demanded. Further, a larger portion of this care will take place in austere environments with potentially degraded or nonexistent infrastructure than has been previously experienced. Although the idea of conflict emerging between the United States and a near-peer adversary is terrifying, at no time since the Cold War has the possibility been more imminent. The impact of such a conflict will surely be felt well beyond our uniformed colleagues. We are all surgeons, we are all Americans, and we should all be ready.
Article 3
Optimizing combat readiness for military surgeons without trauma fellowship training: Engaging the “voluntary faculty” model. Yonge J, Schaetzel S, Paull J, Jensen G, Wallace J, O'Brien B, Pak G, Schreiber M, Glaser J. J Trauma Acute Care Surg. 2023 Aug 1;95(2S Suppl 1):S31-S35.
The combination of decreasing operative volumes and low operative complexity at military treatment facilities (MTFs) threatens military surgical readiness for sustained combat operations. To formally assess surgeon deployment readiness, the Defense Health Agency (DHA) has developed the Knowledge, Skills, and Abilities (KSA) metric. The KSA metric consolidates a surgeon’s annual procedural activity into a single number. Each CPT code billed by a surgeon is assigned a score based on the code’s assessed applicability to deployed medicine. The total score is the sum of the surgeon’s procedural scores in the past year. A KSA Score of 14000 or greater is considered acceptable for general surgeons. Currently, approximately 10% of military general surgeons meet this threshold.
The authors describe the experience of a single military surgeon at a unique military civilian partnership (MCP). A single surgeon staffed two MTFs, an Army MTF, where the surgeon took trauma call as well as a Navy MTF, an outpatient surgical center. The surgeon also took call at a civilian trauma center (CTC), a level two trauma center, as a “volunteer faculty” member under the direct supervision of civilian trauma surgeons. Case logs were submitted to the contractor responsible for calculating KSA scores and results were reported. Billing data for the two MTFs were also submitted and KSA scores calculated. Data regarding time spent at each hospital and acuity of cases was collected and analyzed.
The military surgeon spent a total of 504 hours at the CTC, 816 hours at the Army MTF and 912 hours at the Navy MTF. 54 procedures were performed at the Navy MTF, 52 at the Army MTF and 50 at the CTC; 6 of these were emergent trauma cases and were done entirely at the CTC. Despite spending less time at the CTC and performing roughly the same number of cases at each, the surgeon generated as many KSA points at the CTC as at the MTFs combined whether calculated from billing data (5954 vs 5395, p = 0.19) or case log data (5954 vs 8534, p =.5). The surgeon generated more KSAs per hour and per case at the CTC than at either MTF. Interestingly, KSA Data generated from billing data and case logs varied significantly suggesting ongoing issues with gathering accurate billing data from MTFs.
There are several limitations to this research. Most importantly, the unique nature of this specific MCP as well as the single surgeon design significantly limits generalizability. This study further highlights the potential pitfalls of reliance on billing data to calculate KSA scores given the differences in calculated scores seen in case log versus billing data and raises important questions regarding the optimal amount of time military surgeons should spend at MCPs vs MTFs. Prior research has demonstrated the utility of MCPs to ongoing readiness training. This paper reinforces the importance of MCPs to ongoing readiness and continues to aid in the development of best practices for successful MCPs.
