DTIC ADA629615: Combat Readiness for the Modern Military Surgeon: Data from a Decade of Combat Operations

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by  Defense Technical Information Center

CLINICAL RESEARCH
Combat readiness for the modern military surgeon: Data from
a decade of combat operations
Joshua A. Tyler, MD, John D. Ritchie, MD, Michelle L. Leas, RN, Kurt D. Edwards, MD,
Brian E. Eastridge, MD, Christopher E. White, MD, M. Margaret Knudson, MD, Todd E. Rasmussen, MD,
R. Russell Martin, MD, and Lorne H. Blackbourne, MD, Fort Sam Houston, Texas
OBJECTIVE: Hundredsofgeneralsurgeonsfromthearmy,navy,andairforcehavebeendeployedduringthepast10yearstosupportcombat
forces,butlittledataexistontheirpreparednesstohandlethechallenginginjuriesthattheyarecurrentlyencountering.Our
objectivewastoassessoperativeandoperationalexperienceintheaterwiththegoalofimprovingcombatreadinessamong
surgeons.
METHODS: Adetailedsurveywassentto246activedutysurgeonsfromthearmy,navy,andairforcewhohavebeendeployedatleastonce
inthepast10years,requestinginformationoncasesperformed,perceptionsofefficacyofpredeploymenttraining,knowledge
deficits,andpostdeploymentemotionalchallenges.Surveydatawerekeptconfidentialandanalyzedusingstandardstatistical
methods.
RESULTS: Of246individuals,137(56%)respondedand93(68%)havebeendeployedtwoormoretimes.Morethan18,500operative
procedures were reported, with abdominal and soft tissue cases predominating. Many surgeons identified knowledge or
practicegapsinpredeploymentvascular(46%),neurosurgical(29.9%),andorthopedic(28.5%)training.Thepersonalburden
ofdeploymentmanifesteditselfwithbothfamily(approximately10%deployment-relateddivorcerate)andpersonal(37
surgeons[27%]withtwoormoresymptomsofposttraumaticstresssyndrome)stressors.
CONCLUSION: Thesedatasupportmodificationsofpredeploymentcombatsurgicaltrainingtoincludeincreasedexposuretoopenvascular
proceduresandcurriculumtraditionallyoutsidegeneralsurgery(neurosurgeryandorthopedics).Theacutecaresurgicalmodel
maybeidealforthemilitarysurgeonpreparingfordeployment.Furtherresearchshouldbedirectedtowardidentifyingfactors
contributingtopsychologicalstressamongmilitarymedics.(JTraumaAcuteCareSurg.2012;73:S64 S70.Copyright*
2012byLippincottWilliams&Wilkins)
LEVELOFEVIDENCE: Epidemiologicstudy,levelIV.
KEYWORDS: Iraq;Afghanistan;deployment;training;survey.
USmilitaryforceshavebeeninvolvedincontinuouscombat dataexistonvarioustopicsdetailingtheexperienceofmilitary
operations since 2001, the longest conflict in American medical providers in the theater of operations during the past
history. During the past 10 years, surgeons have performed decade,verylittleexistsonthetopicofpredeploymenttraining
thousandsofcases on US service members, allied nation ser- of military surgeons and the efficacy of current models. In a
vice members, civilian contractors, enemy combatants, and previousstudy,wecomparedsurgicalcaseloadfora12-month
local nationals. Numerous medical and scientific advances periodatthe31stCombatSupportHospitalduringtheinvasion
have occurred, such as advancement in tourniquet use, he- of Iraq to those of graduating chief residents from a military
mostatic dressings, renal replacement therapy, and endovas- surgical training program and made recommendationsfor ad-
cular techniques in austere environments. Improvement in ditional training to better prepare them to perform war sur-
resuscitation strategies, evacuation models, and the evolution gery.13Otherdescriptivestudiesdetailsmall-unitexperiencein
ofdamagecontroltechniqueshasalsooccurred.1Y12Although the deployed setting,14Y17 and some make recommendations
for predeployment training for military providers using non-
objective means.18 No data, however, exist on subjective or
objective measures of the efficacy of current predeployment
From the Department of General Surgery (J.A.T., J.D.R, R.R.M.), San Antonio surgical training platforms. In addition, several studies have
Military Medical Center, Texas; US Army Institute of Surgical Research shownthatinjurypatternsandmechanismsdifferinthecurrent
(M.L.L,B.E.E,C.E.W.,T.E.R.,L.H.B.),FortSamHouston,Texas;Department
conflict compared with previous conflicts, with increased use
ofGeneralSurgery(K.D.E.),TriplerArmyMedicalCenter,Honolulu,Hawaii;
andDepartmentofSurgery(M.M.K.),UniversityofCaliforniaSanFrancisco. of improvised explosive devices and unconventional warfare
ThisworkwaspresentedasapodiumpresentationattheAdvancedTechnology techniques, withnotableincreasedrates ofextremityvascular
ApplicationsinCombatCasualtyCareMeeting,FortLauderdale,Florida,in injury.19Y20Inhislandmarkarticle‘‘HowtoTrainWarSurgery
August2011,aswellasattheAmericanAssociationfortheSurgeryofTrauma
Specialists, Part II,’’ French general and surgeon Daniel P.
meetingasaposterinChicago,Illinois,inSeptember2011.
Addressforreprints:JoshuaA.Tyler,MD,DepartmentofGeneralSurgery,San Rignault noted that to prepare capable military surgeons,
AntonioMilitaryMedicalCenter,MCHE-SDG,3851RogerBrookeDr,Fort predeployment training must involve an analysis of wounds
SamHouston,TX78234;email:[email protected].
andpatternsseenincurrentoperationsandmustberevisedto
DOI:10.1097/TA.0b013e3182625ebb mirror theinjuries seen.21
JTraumaAcuteCareSurg
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4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
Combat readiness for the modern military surgeon: Data from a decade
5b. GRANT NUMBER
of combat operations
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
Tyler J. A., Ritchie J. D., Leas M. L., Edwards K. D., Eastridge B. E.,
5e. TASK NUMBER
White C. E., Knudson M. M., Rasmussen T. E., Martin R. R.,
Blackbourne L. H., 5f. WORK UNIT NUMBER
7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION
United States Army Institute of Surgical Research, JBSA Fort Sam REPORT NUMBER
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JTraumaAcuteCareSurg
Tyleretal. Volume73,Number2,Supplement1
(44.5%) were in the army, 43 (31.4%) in the air force, and
TABLE3. PredeploymentSurgicalTrainingCourse
33 (24.1%) in the navy. Of the respondents, 44 have been
Attendance
deployedonetimeand46havebeendeployedtwotimes.Forty-
seven respondents have been deployed more than two times: Respondents,
30weredeployedthreetimes,8weredeployedfourtimes,and CourseName n(%)
9 were deployed five times. Most respondents (132) were on EmergencyWarSurgeryCourse 34(24.8)
activedutyatthetimeoftheirfirstdeployment,but5respondents CenterforSustainmentofTraumaandReadinessSkills 13(9.5)
were in the National Guard or Reserve and have since joined (C-STARS)
active duty. At the time of their first deployment, respondents ArmyTraumaTrainingCenter 10(7.3)
hada rangeof0 to 28yearsofactivedutyservice(median, 7; NavalTraumaTrainingCenter 9(6.6)
interquartilerange[IQR],5Y12%)andarangeof0to26years CombatExtremitySurgeryCourse 7(5.1)
of practice as a board-certified surgeon (median, 2; IQR, BrookeArmyMedicalCenter 6(4.4)
0.5Y5%). Eighty-nine surgeons (65%) had not completed a None 58(42.3)
fellowship at the time of their first deployment, whereas 48
surgeons (35%) had completed postgraduate training. Spe-
eficial, with 10 respondents neutralabout theexperience, and
cialty breakdown is shown in Table 2. Sixteen surgeons
only 8 respondents noting that it was not beneficial. Of the
completed postgraduate training between the first and the
respondents, more than 70% had read the Emergency War
subsequent deployments, with the preponderance of those
Surgery text and 80.2% (77 respondents) found it either ben-
seeking training in trauma or critical care surgery (9 indivi-
eficial or very beneficial. Approximately 90% of respondents
duals).DeploymentlocationsvariedfairlyevenlybetweenIraq
wereawareoftheJointTheaterTraumaSystem(JTTS)clinical
and Afghanistan as well as between Level 2 and Level 3 fa-
practiceguidelines(n=120,87.6%).Whenaskedwhetherthey
cilities.Thelengthofdeploymentsrangedfrom1to15months
would have liked additional training on specific injuries or
(median,6; IQR, 4Y6%).
injury patterns before their first deployment, approximately
80%(n=108)ofsurgeonsrespondedaffirmatively.Themost
Predeployment
commonly requested additional training was in extremity vas-
The first section of the survey detailed predeployment cularrepairs(n=63,46%),followedbyneurosurgery(n=41,
trainingtoincludebothsurgicalandmilitary.Ofsurveypartic- 29.9%), orthopedics (n = 39, 28.5%), and abdominal vascular
ipants, 94(68.6%) graduatedfrommilitary residency, whereas repairs (n = 38, 27.7%). The complete breakdown is listed in
43(31.4%)graduatedfromcivilianprograms.Sixty-six(48.2%) Table4.
of the respondents felt that residency training prepared them Regardingpredeploymentmilitarytraining,84surgeons
very well for deployment, and an additional 48 respondents (61.3%) found their home station military training to be un-
(35%) felt well prepared. Only six respondents felt that resi- helpful. An additional 37 surgeons (27%) found this training
dency prepared them either poorly (five respondents, 3.6%) onlysomewhathelpful.Thiswasalsotrueofthe55surgeons
or very poorly (one respondent, 0.7%). Five of the six who who have been deployed via the CONUS Replacement Center,
responded either poorly or very poorly trained in military with most surgeons finding the training either somewhat
training programs. Less than half of respondents attended a helpful (n= 23) or unhelpful (n = 29).
predeployment surgical training course before their first de-
ployment(60respondents,43.8%).Coursesattendedincluded Deployment
severaldifferentcoursesandarebrokendowninTable3.The Because of the high tempo of operations since 2001,
most commonly attended course was the Emergency War numerous individualshavebeendeployedmore than once.In
Surgery course, with 34 respondents attending (24.8% of
the total respondents). Of those who attended courses, 44
TABLE4. RequestedAdditionalTrainingBeforeFirst
(73.3%) rated the experience as either very beneficial or ben-
Deployment
SurgicalDisciplineorInjuryType Respondents,n(%)*
TABLE2. RespondentSubspecialtyTrainingattheTimeof
Extremityvascularrepairs 63(46)
FirstDeployment
Neurosurgery 41(29.9)
FellowshipTraining Respondents,n(%) Orthopedics 39(28.5)
Abdominalvascularrepairs 38(27.7)
None 89(65.0)
Thoracic 32(23.4)
Traumacriticalcare 21(15.3)
Burns 30(21.9)
Vascular 7(5.1)
Oculartrauma 30(21.9)
Colorectal 6(4.4)
None 29(21.2)
Cardiothoracic 3(2.2)
Genitourinaryorreproductive 21(15.3)
Minimallyinvasive 3(2.2)
Pediatricsurgery 14(10.2)
Surgicaloncology 3(2.2)
Criticalcare 10(7.3)
Transplant 2(1.5)
Gastrointestinal 2(1.5)
Pediatricsurgery 2(1.5)
Plasticsurgery 1(0.7) *Respondentswereallowedtocheckmorethanonebox.
S66 *2012Lippincott Williams &Wilkins
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

JTraumaAcuteCareSurg
Tyleretal. Volume73,Number2,Supplement1
Postdeployment uted this finding to a higher percentage of wounding by ex-
Thepersonalandprofessionalburdenofdeploymentwas plosive mechanisms, better armor protection of the torso
evidentinthesurveyresponses.Approximately10%(n=13) compared with previous conflicts, and more accurate data
underwent a divorce they attributed to the stress of deploy- collectionwiththeadventoftheJTTSorJTTR.Thischangein
ment on their marriage, and approximately 40% (n = 53) are injury pattern comes at a time when modern general surgical
considering leaving the military due to deployment-related trainee experience with open vascular procedures is on the
stressors.Whenaskedaboutseveralpsychosocialsymptomsto decline for several reasons, as detailed in a recent letter by
includerecurringnightmares,moodswings,insomnia,feeling Rasmussenetal23intheJournalofTrauma.Ourdataechothe
irritablefornoreason,recurringimagesoftraumaticpatientsor reports from these authors, showing high rates of vascular
experiences, or problems concentrating, 38 surgeons (27%) injury and more than 70% of surgeons performing shunts,
respondedwithtwoormoresymptoms,7surgeons(3.6%)with primaryrepairs,andotherproceduresrelatedtovascularinjury
foursymptoms,and8surgeons(5.8%)withfiveormoreofthe suchasamputationandfasciotomy.Ofthetypesofadditional
previously mentioned symptoms. Two surgeons (1.5%) have training requested by surgeons before their first deployment,
beenclinicallydiagnosedwithposttraumaticstressdisorderor approximately half of the respondents felt that additional
another mental illness since returning from deployment. De- traininginextremityvasculartraumawouldhavebeenhelpful,
spitethegreat personalstress placedonthembydeployment, andmorethanaquarterofrespondentsalsofeltthatadditional
most surgeons (115, 83.9%) felt that deployment was a re- abdominal vascular trauma training was also important. Of
wardingexperience. casesperformeddownrange,fiveofthetopsixmostrequested
Followingthemultiple-choiceportionofthesurveywas injuries for which respondents requested additional training
a free-text section in which respondents were given an op- were related to vascular injury (Table 5). Similarly, the cases
portunitytoanswerseveralquestionsdetailingtheirexperience thatrespondentsreportedasthemostdifficultinthedeployed
andtomakesuggestionsforthefuture.Questionsaskedabout environment were both extremity and abdominal vascular in-
surgeonperceptionsonimprovingcareinthedeployedsetting, jury, with most respondents noting that their skills in treating
how to improve combat surgery training, and opinions on in- suchinjuries had lapsed because theyarenotexposedtovas-
creasingsurgeonretention.Onehundredtwenty-onesurgeons cular trauma in their clinical practice or because there have
(88.3%) provided answers in the free-text section. As topics been a significant time lapse since their training in these in-
werefrequentlyrelatedandoverlapping,resultswereanalyzed juries. This view was also reflected in the free-text question
by grouping responses into commonly mentioned categories. responses: 39 surgeons felt that a more robust, busy clinical
The most commonly mentioned topics, in order, were as fol- practice in the nondeployed setting with more opportunity to
lows: minimize unnecessary training (49 surgeons, 40.5%), moonlightandtaketraumacallwouldnotonlymaintaincritical
improve surgeon utilization in the deployed setting (44 sur- trauma-readiness skills but also improve surgeon morale and
geons,36.4%),shortendeploymenttime(44surgeons,36.4%), compensationandimprovesurgeonretention.
improve or increase surgeon compensation (43 surgeons, Thesedataalsoechothepreviousarticlefromthisstudy
35.5%), change CONUS nondeployed practice to be more groupcomparingcasesperformedinthedeployedsettingatthe
well-rounded and robust (39 surgeons, 32.2%), improve or 31st Combat Support Hospital to 5 years of graduating resi-
standardize predeployment surgical training (36 surgeons, dents from a military residency program. We concluded that
29.8%), and encourage increased surgeons in command of deploying surgeons need additional experience with injuries
deployedsurgical units andhospitals (27 surgeons,22.3%). rarely seen in clinical practice due to low incidence such as
traumatic inferior vena cava and duodenal injuries as well as
injuriesthatfalloutsidethescopeoftraditionalgeneralsurgical
DISCUSSION
curriculum but will be the responsibility of the deployed
This study represents the first large-scale survey of general surgeon such as damage control neurosurgery and
deployed surgeons after a decade of war. Findings from this orthopedic techniques.13 Approximately 30% of respondents
survey confirm that surgical case experience during deploy- requestedadditionaltraininginneurosurgeryandorthopedics.
mentsisextensive,requiringabroadrangeofoperativeskills. A great deal of data have been generated about the
Of injury patterns managed during deployment, vascular medical aspects of the combat operations of the past decade.
traumawas identified as the most challenging and the area in Despitethis,verylittledatahavebeengeneratedassessingthe
which surgeons would have liked more experience before efficacy of current predeployment surgical training. There is
deployment.Surgeonsadditionallyrequestedmoreexperience little standardization between services on course attendance
withrareinjuriesnotoftenseenintrainingaswellaswithsome and often little standardization between different iterations of
injuries that fall outside the traditional general surgical cur- thesamecourseInaddition,manypredeploymentcoursesare
riculum but will fall under the responsibility of the deployed taught to physicians as a group rather than being specific to
general surgeon. deploying general surgeons.Less than half of surgeonsatten-
Hemorrhage controlhasbeenshownbyseveralauthors ded predeployment surgical courses, although of those who
to be the single most important mechanism for mortality pre- did,approximatelythreequartersfoundthemtobebeneficial.
ventionincombat-woundedpatientsinthecurrentconflict.19,22 Course attendance was extremely variable, with six different
Inaddition,Whiteetal20recentlypublisheddatadocumenting courses attended, each with a variable curriculum. Until re-
avascularinjuryrateof12%,approximatelyfivetimeshigher cently, no prospective data have been generated on course
than rates in previous conflicts such as Vietnam. They attrib- attendees documenting course efficacy, and until our current
S68 *2012Lippincott Williams &Wilkins
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JTraumaAcuteCareSurg
Volume73,Number2,Supplement1 Tyleretal.
data set, no data have been generated documenting course mentioned limitations, this study provides insight into the de-
utility after attendees have completed their first deployment. ployedexperienceofmilitarysurgeonsduringthelastdecadeof
Thisstudy representsa retrospectiveattempttogeneratesuch combatoperationsand,assuch,canserveasabasisfromwhich
data in an attempt to both improve and standardize pre- toimprovemilitarysurgicalpredeploymenttrainingandsurgical
deploymentsurgicaltraining.Futurecoursecurriculumshould readiness.
be surgeon specific, designed in an evidence-based fashion,
andstandardizedamongdeployingsurgeons.Inaddition,with CONCLUSION
frequentdeployments,agreatdealoftimeisspentawayfrom
Deployedmilitary surgeons aregenerally well prepared
dutystationsandfamily.Superfluousandunnecessarytraining
totreatabroadrangeof injuries.Theevidence-basedrevision
should be kept to a minimum. This is reflected in our data
andstandardizationofcurrentpredeploymentsurgicaltraining
showingthatapproximately90%ofsurgeonsfoundtheirhome
shouldbepursued,withthegenerationofprospectiveefficacy
station or CONUS Replacement Center training to be either un- metrics.Withdocumentedincreasedratesofvascularinjuryin
helpfuloronlysomewhathelpfulandincommentsinthefree-
thecurrentconflict,combinedwiththediminishedroleofopen
text section from 49 surgeons that eliminating unnecessary
vascular repairs in the current training paradigm, particular
trainingduringthepredeploymentperiodwouldbebeneficial.
attention should begiven to providing additional vascular sur-
A potential solution to enhancing war surgical skills is
gerytrainingtocurrentpredeploymentsurgicaltrainingmodels.
to provide additional training using the Advanced Trauma
Considerationshouldalsobegiventoadditionaltraininginthe
Operative Management and the Advanced Surgical Skills for
treatmentofinjuriesthatfalloutsidetraditionalgeneralsurgery
Exposure in Trauma courses, both currently offered through
curriculumsuchasneurosurgeryandorthopedics.
theAmericanCollegeofSurgeonsCommitteeonTrauma.These
courses offer problem-based modules and hands-on surgical
skillstrainingusinganimalmodelsandcadavericexposures.Our AUTHORSHIP
studygrouprecentlycompletedthevalidationofsuchacourse J.A.T., K.D.E., C.E.W., and L.H.B. designed this study. J.A.T., M.L.L.,
with military chief residents and surgeons preparing for de- M.M.K.,T.E.R.,andL.H.B.collecteddata,whichJ.A.T.,M.M.K.,T.E.R.,
and L.H.R. analyzed. J.A.T., B.E.E., C.E.W., M.M.K., T.E.R., and L.H.B.
ployment. We conducted a 2-day course combining Advanced
interpretedthedata.Allauthorsparticipatedinwritingthearticle.
Trauma Operative Management, Advanced Surgical Skills for
Exposure in Trauma, and military-specific curriculum such as
damagecontrolneurosurgeryandorthopedicsandanoverview ACKNOWLEDGMENTS
oftheJTTSclinicalpracticeguidelines.Weanticipatethepub- Theauthorsthankeach of theserviceconsultantsfor their assistance
licationofourresultssoon.Inaddition,theAcuteCareSurgery withthisprojectaswellasindividualsattheDefenseManpowerData
Center and Tricare Management Activity. They also thank all survey
Fellowship,designedbytheAmericanAssociationfortheSur-
participantsaswell.ThisworkwassupportedbytheUSArmyInstitute
geryofTrauma,allowsthefellowanopportunitytoconcentrate ofSurgicalResearchClinicalTrialsTaskArea.
hisorhertraininginareasidentifiedandneededinwarsurgery.
Thisisanidealsituationbecause56%oftherespondentswho
DISCLOSURE
attendedafellowshipbetweentheirfirstandseconddeployments
Theopinionsorassertionscontainedhereinaretheprivateviewsofthe
didsointraumaorcriticalcare.Thisstudyisnotwithoutlim-
authorandarenottobeconstruedasofficialorasreflectingtheviews
itations.Regulatoryrequirementslimitedthesurveytosurgeons of the Department of the Army or the Department of Defense. The
who were still on active duty. This requirement excluded sur- authorsdeclarenoconflictofinterest.
geons who have been deployed and had since retired or sepa-
ratedfromactiveduty.Inaddition,thesurveypopulationswere
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