Achieving zero preventable deaths: A model of a military-civilian medical training partnership

In 2016, the National Academies of Science, Engineering, and Medicine (NASEM) published A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury.¹ The report called attention to the high number of potentially preventable deaths from trauma in both military and civilian settings. NASEM estimated that nearly 1,000 U.S. service member deaths in Afghanistan and Iraq and approximately 30,000 U.S. civilian trauma deaths in 2014 could have been prevented with optimal trauma care. With the experience of the military, which has a long history of developing new interventions and systems to dramatically improve trauma survival rates, combined with the long-term stability and infrastructure of civilian trauma centers, legislation has been proposed to encourage military-civilian partnerships with the ultimate goal of obtaining zero preventable deaths after injury.

In response to the NASEM report, Congress passed the fiscal year 2017 National Defense Authorization Act (NDAA), establishing the Joint Trauma Education and Training Directorate. The directorate is charged with ensuring that trauma providers in the U.S. Armed Forces maintain a state of readiness by entering into partnerships with civilian academic medical centers and large metropolitan teaching hospitals that have Level I civilian trauma centers. The directorate also will establish metrics for the partnerships to ensure that providers maintain professional competence in trauma care.

Building off of the goals in the NDAA, Congress introduced the Mission Zero Act (H.R. 880/S. 1022) in 2017. The legislation creates a U.S. Department of Health and Human Services (HHS) grant program to assist civilian trauma centers in partnering with military trauma professionals. These HHS grants will help defray the administrative costs associated with bringing military-civilian partnerships to a civilian trauma center. Details about the legislation, which the House of Representatives unanimously passed in February and was awaiting action in the Senate Health, Education, Labor and Pensions Committee at press time, are provided in the article on page 37 of this issue.

The U.S. military has long been a leader of innovative advancements in trauma care, which has translated into dramatic improvements in civilian survival. Recent advancements have been developed through an exchange of ideas among military and civilian partners, including the use of tranexamic acid in trauma resuscitation,^2,3 resuscitative endovascular balloon occlusion of the aorta,⁴ and the use of tourniquets and damage-control resuscitation measures. Close collaborations between researchers from both groups have allowed for these techniques to be developed for use in a variety of settings.⁵

The University of California Davis Medical Center (UCD), Sacramento, is one of several trauma centers in the U.S. with an active military-civilian partnership, both formal and informal. Since 1995, UCD has partnered with the David Grant U.S. Air Force (USAF) Medical Center (DGMC) at Travis Air Force Base in Fairfield, CA, to provide graduate medical education and ongoing clinical currency. This program, called the David Grant Strategic Partnership in Education Advancing Readiness and Research (SPEARR), is an example of what can be achieved through passage of the Mission Zero Act. This article describes the SPEARR partnership, which may serve as an example for future military-civilian partnerships—including trauma care and beyond.

Resident education

The SPEARR partnership is built on a foundation of graduate medical education collaboration. Starting in 1995, USAF general surgery residents conducted their trauma rotation at UCD, and in 2003, the two residencies merged. Each year, UCD accepts nine categorical general surgery residents, including two USAF residents. UCD also hosts a preflight surgery internship (11 residents), and the U.S. military’s only integrated vascular (one resident each year) and cardiothoracic surgery (one resident per six-year cycle) residencies. This program also has international partners, hosting vascular trauma fellows from the U.K. military. Residents rotate at all UCD training locations, including DGMC; the Northern California Veterans Affairs (VA) Center, Sacramento; and community hospitals, and there is no difference in the surgical training of the military or civilian residents. Case volumes between military and civilian chief residents have been comparable. From 2007 to 2016, UCD graduated 72 general surgery residents (including 11 USAF surgeons). The average total case volumes between military and civilian residents (1,020 versus 960 cases, respectively: p = 0.26) were similar.⁶

Residents benefit from research opportunities that both UCD and DGMC offer. Military residents typically perform one year of dedicated research at the DGMC clinical investigation facility (after their third clinical year), and civilian residents have opportunities to perform research at DGMC, just as military residents can also engage in research activities with civilian faculty at UCD.

Other shared resources include simulation equipment and training courses, including Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery training and testing, large animal labs, and robotic simulators, among others. This collaboration also has allowed us to host American College of Surgeons (ACS) Basic Endovascular Skills for Trauma, Advanced Surgical Skills for Exposure in Trauma, and Advanced Trauma Life Support^® courses for both military and civilian health care professionals, which would have been impossible without the partnership.

Surgeon readiness

At present, seven active-duty USAF surgeons are embedded among the UCD faculty, including five trauma and acute care surgeons, one thoracic surgeon, and one pediatric surgeon. Five of these surgeons have full-time volunteer faculty appointments at UCD, whereas two spend most of their appointment at the Air Force base or the VA hospital. Two additional surgeons are reservists in the U.S. Navy and U.S. Air Force, respectively. Beginning in 2012, UCD also hosted full-time Air Force vascular and cardiac surgeons. UCD’s current military faculty members have had appointments ranging from six months to seven years, with a median duration of three years. Most surgeons deploy once every three years (although some deploy annually) and all have deployed at least once.

Integrating active military surgeons into UCD’s department of surgery has been mutually beneficial. To maintain readiness, especially in times of relative peace and minimal military engagements, SPEARR is able to offer our military faculty a high operative caseload, comparable to our civilian faculty. Case complexity is generally higher at UCD than at DGMC because UCD is an academic tertiary hospital with a catchment of 2.5 million people, in contrast to the typically healthier patient population at the active military base. Cases at a Level I trauma center are also more typical of those seen downrange in the military field, which is closer to the battlefield.⁷

Military surgeons also benefit from academic involvement. In 2013–2016, military faculty members in the SPEARR program published more than 20 academic papers and were awarded more than $100,000 in grant funding in collaboration with civilian partners.

Collaboration beyond surgery

Beyond the department of surgery, UCD has expanded its collaboration with the USAF. The department of orthopaedic surgery supports an embedded Air Force orthopaedic oncologist. The UCD emergency medicine department has rotating Air Force physicians who support a new, integrated emergency medicine residency. Among embedded department of surgery faculty, UCD now has an emergency medicine neuro-critical care faculty member who is an active member of the USAF. We also share ongoing training opportunities in trauma, critical care, and cardiac surgery for military student registered nurse anesthetists, physician assistant students, enlisted respiratory therapists, critical care nurses, cardiac anesthesiologists, and operating room (OR) nurses and enlisted technicians. The two hospitals also regularly work together to share resources for enhanced patient care, particularly high-cost resources such as UCD’s cardiac catheter lab.

Structure and challenges

All active duty military surgeons are employed by the USAF (and ultimately report to their command at DGMC) and have volunteer faculty appointments at UCD. UCD’s military colleagues are integrated into essentially all departmental activities, and typically the expectations and roles are the same for military faculty and residents as for civilian surgeons and trainees.

As with any partnership, SPEARR has its challenges. Military faculty may have sudden or prolonged service obligations, requiring flexibility in call coverage on the part of civilian partners. Both partner hospitals also must work continually to ensure adequate clinical coverage. Negotiating contracts, administrative hurdles, and personnel issues are ongoing challenges, but are not unique to a military-civilian partnership.

Another challenge is the time and cost involved in obtaining state medical licensure for military physicians. Whereas military physicians with out-of-state medical licenses typically are exempt from obtaining a new medical license when administering care to military members, they typically must apply for state licensure when treating civilians. This process is time-consuming and costly and is a barrier to the practice of medicine. In California, medical licensure typically takes several months and costs almost $1,300 for a two-year medical license.⁸ We encourage Congress to include in the Mission Zero Act reciprocity policies for medical licensure for military physicians, or at least a fast-track process, to decrease barriers to military-civilian collaboration.

Future directions

UCD and the USAF are proud of the extension of their military-civilian partnership beyond trauma care; nonetheless, this model could be expanded further. For example, including more specialties, as well as mid-level practitioners, nurses, OR technicians, and other ancillary staff, can provide shared educational resources and ongoing readiness for these important providers. Ideal trauma care requires a system, not just a surgeon.

Through our combined expertise, UCD also can provide optimal civilian care, especially in times of disaster. During the 2017 Northern California fires, DGMC medical personnel assisted with evacuations and triage of burn victims, and patients had streamlined transfers to the UCD Firefighters Burn Institute Regional Burn Center for care.

In the future, we anticipate advancements in telemedicine also likely will be a valuable shared resource.

Passage of the Mission Zero Act will help other academic medical centers build relationships with their local military partners. The authors urge readers to engage in advocacy for this piece of legislation by using the tools and information located in SurgeonsVoice.

Conclusion

UCD’s partnership with the USAF has been mutually beneficial and sustainable. Ultimately, this model has improved care for all current and future patients. We encourage the creation of additional military-civilian partnerships for trauma care and other specialties. The SPEARR model is beneficial for both the military and civilian partners, and this symbiotic relationship can be the framework for future partnerships.

Disclaimer

Views expressed herein are those of the authors and do not reflect the official policy or position of the Department of the Air Force and Department of Defense or the U.S. government.

References

1. National Academies of Science, Engineering, and Medicine. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press; 2016.
2. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg. 2012;147(2):113-119.
3. Cole E, Davenport R, Willett K, Brohi K. Tranexamic acid use in severely injured civilian patients and the effect on outcomes: A prospective cohort study. Ann Surg. 2015;261(2):390-394.
4. Rasmussen TE, Eliason JL. Military-civilian partnership in device innovation: Development, commercialization and application of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). J Trauma Acute Care Surg. 2017;83(4):732-735.
5. Russo RM, Neff LP, Lamb CM, et al. Partial resuscitative endovascular balloon occlusion of the aorta in a swine model of hemorrhagic shock. J Am Coll Surg. 2016;223(2):359-368.
6. Anderson JE, David EA, Loge HB, Farmer DL, Galante JM. A model for military-civilian collaboration in academic surgery beyond trauma care. JAMA Surgery. 2017;152(9):891-893.
7. Hight RA, Salcedo ES, Martin SP, Cocanour CS, Utter G, Galante JM. Level I academic trauma center integration as a model for sustaining combat surgical skills: The right surgeon in the right place for the right time. J Trauma Acute Care Surg. 2015;78(6):1176-1181.
8. The Medical Board of California. Applicants. Physicians and Surgeons. Available at: www.mbc.ca.gov/Applicants/Physicians_and_Surgeons/. Accessed April 5, 2018.