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Joint Trauma System takes shape from lessons learned

U.S. Airmen assigned to the 455th Expeditionary Medical Group perform trauma surgery on a gunshot victim at the Craig Joint Theater Hospital, Bagram Air Field, Afghanistan. U.S. Airmen assigned to the 455th Expeditionary Medical Group perform trauma surgery on a gunshot victim at the Craig Joint Theater Hospital, Bagram Air Field, Afghanistan. (U.S. Air Force photo)

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FALLS CHURCH, Va. — The Military Health System has taken a new step in developing a unified medical trauma system, issuing DoD Instruction  6040.47 to codify clinical guidance for the continuum of patient care. 

“For the first time in U.S. military history, we have the necessary policy to create and maintain a durable, enduring trauma system in times of war and peace,” said Deputy Assistant Secretary of Defense for Health Readiness Policy and Oversight, Dr. David Smith. “Our ultimate goal is to produce the best possible outcome for every wounded warrior.” 

The Joint Trauma System began forming in 2003 when U.S. Army Institute of Surgical Research Commander Army Col. John Holcomb recognized that no formal trauma care standards existed in Iraq and Afghanistan. Medical care was being well documented in theater, but critical patient information wasn’t readily available as a wounded member moved through multiple hospitals.  At the time, deployed medical teams mostly relied on telephonic coordination for long-term, follow-up treatments for the wounded. 

To fill the information void, Holcomb created the Joint Theater Trauma System, now renamed the Joint Trauma System.  Holcomb also approached the Air Force Surgeon General at the time, Lt. Gen. P.K. Carlton, and coordinated the assignment of Col. Don Jenkins to be the first Deployed Director of the JTS. Working with the U.S. Central Command Surgeon, then-Col. Doug Robb, and the Army’s 44th Medical Brigade Commander, Brig. Gen. Elder Granger, Jenkins began assisting deployed surgical elements in theater and making systemic improvements in combat casualty care. 

Holcomb brought Mary Ann Spott, Ph.D., on board to take over the trauma registry (now called the DoD Trauma Registry), an electronic data repository for DoD trauma-related injuries. The DoDTR captures a standardized set of information on every trauma patient including mechanism of injury, injuries sustained, treatments, and outcomes. The aggregation of this data has created the ability to do both performance improvement and research projects designed to bring about ongoing improvements to combat casualty care. 

Several years later, in 2006, then-Lt. Col. Warren Dorlac initiated the Weekly JTS Performance Improvement Teleconference, linking military care providers from the combat theater with providers at Landstuhl Regional Medical Center, military medical facilities in the United States, as well as with the evacuation crews who transported casualties between treatment facilities. The weekly teleconferences enabled providers to track the progress of every one of their patients through the continuum of care, to discuss difficult cases, and to rapidly identify opportunities to improve care. 

In 2013, the Committee on Tactical Combat Casualty Care (TCCC) became part of the JTS. TCCC is a set of evidence-based, best practice, prehospital trauma care guidelines customized for use on the battlefield.  TCCC provides wounded warriors a better chance to survive their wounds long enough to reach the care of a surgeon, said Dr. Frank Butler, a former Navy SEAL and now Chairman of the Committee on Tactical Combat Casualty Care. 

“Casualty survival is extremely high if the casualty arrives alive at a surgical treatment facility,” said Butler.  “Most combat fatalities occur before the casualty reaches the care of a surgeon, so the TCCC provided by the military’s combat medics, corpsmen, and PJs (Air Force Pararescuemen) is a critically important element of casualty care.” 

Recognizing the capability that JTS represented, senior leaders across the MHS, in coordination with the Joint Staff, requested a new DoDI to codify the JTS capability and ensure that the lessons learned during 15 years of conflict would help guide optimal trauma care wherever the U.S. Military goes to war. 

“The new DoD guidelines validate all the lessons learned from the ad hoc processes used out of necessity in establishing the JTS,” said JTS Director Navy Capt. Zsolt Stockinger. 

The DoDI provides operational commanders, clinical providers and medical planners with the best known combat medical techniques and procedures to minimize trauma-related disability and eliminate preventable deaths after injury. The issuance also officially recognizes the Joint Trauma System as the DoD Center of Excellence for Trauma, and supports combatant commands establishing regional and individual COCOM Trauma Systems. 

“The JTS DoDI is not meant to dictate ‘how’ and ‘what’ a trauma system should look like,” said Stockinger, “because each environment and location will dictate certain aspects of a trauma system.”  He emphasized that the JTS team is a resource to help others find the best solutions as they establish and grow their own geographic trauma system.  Combatant commanders can use the JTS performance improvement system as a guideline to build their local trauma systems. 

The JTS continues to evolve and update guidelines through continuous engagement with combat medical personnel, casualty care oversight, and using newly published evidence on prehospital trauma care. “Every family member of every U.S. service man or woman should take great comfort knowing the JTS works tirelessly to help military medical personnel provide the best trauma care possible to their loved ones if they should be wounded,” said Butler. “The goal of the JTS is to ensure that every fatality that can be prevented is prevented.”

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