Maintaining Military Medical Readiness Today Saves Lives Tomorrow
[W]e are going to repeat the same mistakes we have made in the past. We are going to think our doctors are trained. They are not going to be trained. You have just got to pray your son or daughter, or granddaughter is not the first casualty of the next war.
– Gen. Peter Chiarelli, the 32nd vice chief of staff of the U.S. Army
Advances in military medicine are hard-won during war but, as Gen. Chiarelli points out, they are also easily lost during peacetime. Though survivability rates of U.S. troops on the battlefield have improved significantly since World War II, the battlefield mortality rate at the beginning of a war often exceeds that at the end of the previous war. This phenomenon is called the “peacetime effect” and is caused by the erosion of the trauma skills of military healthcare providers during periods of relative peace. It has been estimated that maintaining these skills between wars could have prevented more than 100,000 combat deaths over the past 80 years.
At the same time, tens of thousands of U.S. civilians also succumb to potentially preventable trauma-related deaths every year. This creates an important opportunity for cooperation. A sustained national effort focused on military-civilian partnership to eliminate death from survivable traumatic injuries could help to prevent the peacetime effect, saving the lives of servicemembers at the start of the next war and those of civilians before then.
The Peacetime Effect
An unprecedented percentage of the servicemembers wounded on the battlefields of Iraq and Afghanistan over the past 20 years made it home to their loved ones. Much of this success is due to the professionalism of America’s uniformed healthcare providers and their innovations in responding to combat trauma. Unfortunately, during times of peace the U.S. military medical community loses some of its readiness. Statistics from the period illustrate the tragic consequences that arise when military medical readiness erodes during interwar years. Between October 2001 and June 2011, 4,016 U.S. combat troops died before reaching a military hospital. Of those, 976 (almost 25 percent) died from what were assessed to be battlefield-survivable injuries. For theater hospital care, over 50 percent of deaths were from potentially survivable injuries (287 out of 558 fatalities). As Chiarelli notes, these rates fell as the wars went on. A survey of general surgeons who provided deployed casualty care between 2002 and 2012 also found that most felt underprepared to meet the demands of battlefield injuries.
A key reason for the interwar deterioration of military medical readiness is that the Department of Defense’s priorities shift during times of peace. Instead of treating combat trauma, attention returns to the peacetime mission of beneficiary healthcare. While this care is an essential personnel benefit that should not be diminished, it is also essential to recognize that it is a separate mission from the readiness of the military medical force and does not provide sufficient training opportunities to maintain the proficiency of military medical personnel in treating battlefield trauma.
An independent study conducted by the Institute for Defense Analyses found an alarming misalignment between the top diagnoses on the battlefield in Iraq and the 10 leading diagnoses in military treatment facilities. While the former encompassed a variety of combat-related traumas, the latter were generally less severe (consistent with what one would expect for a predominantly young and healthy patient population) and five of the top 10 diagnoses concerned labor, delivery, and neonatal care. It is no surprise that the young, healthy military population has a lot of babies. What is surprising is that this workload was historically viewed as good training for trauma surgeons.
One of the authors of this article served in the senior leadership of the U.S. Army and saw these challenges firsthand. At the start of the wars in Iraq and Afghanistan, it was assumed that beneficiary care providers would be deployed as substitutes for the specialists who were needed. In other words, obstetricians would deploy as trauma surgeons and family practice physicians would deploy as critical-care physicians. As the harm from this plan became apparent, the Army began to gradually recruit and deploy the right specialists. But even when the author served as the acting secretary of the Army only a year ago, the service still did not list trauma surgeon as the required specialty to lead its trauma centers, emergency medicine as the required specialty for its battalion aid stations, or critical-care physician as the required specialty to manage the intensive care wards of its combat hospitals. The author directed those changes during his tenure, but it remains to be seen if the Army will follow through or if the peacetime effect will again drive the service to sacrifice readiness.
These readiness challenges were recognized following the first Gulf war and led to congressional calls for partnerships with civilian medical academic institutions and major metropolitan hospitals that host level I trauma centers. This eventually led to military-civilian partnerships like the U.S. Army Trauma Training Center at Miami Dade Ryder Trauma Center in Florida, the U.S. Navy Trauma Training Center at University of Southern California in Los Angeles County, and the three U.S. Air Force Centers for Sustainment of Trauma and Readiness Skills located at the University of Maryland, the University of Cincinnati, and St. Louis University.
While a step in the right direction, these initial relationships were focused on short-term rotational assignments, which have proven inadequate to meet readiness needs. Providers rotated through for a few weeks and were generally limited to simulation training and observing full-time providers delivering care. Except for the full-time cadre administering the partnership, military providers were not allowed to lead patient care and gain the experience needed to reduce potentially survivable fatalities in war.
Recognizing this failure following the wars in Iraq and Afghanistan, Congress renewed its call for military-civilian partnerships in the Fiscal Year 2017 National Defense Authorization Act. The focus now is on permanently assigning providers to busy trauma centers. The Department of Defense does operate one level I trauma center that is integrated with the civilian Emergency Medical Services system in San Antonio, Texas. There may be other military treatment facilities that could become busy trauma centers through partnerships. For example, the Navy hospital at Camp Lejeune has become a level III trauma center in an underserved market and may be able to attract enough cases to establish itself as a clinical training venue. Similarly, Womack Army Medical Center is close to Cape Fear Valley Medical Center and could form a partnership to grow Cape Fear from a very busy level III to a more capable level II center.
Despite these possibilities, most military treatment facilities are not located in places where they can readily become trauma centers. This means that the Department of Defense has to establish other relationships with civilian facilities, which is where most of the attention from the 2017 act has been focused. Section 757 of the Fiscal Year 2021 National Defense Authorization Act directs the department to conduct a systematic review of its progress to date and identify what more needs to be done.
The benefits for civilians are clear. Traumatic injury is the primary cause of death for Americans under the age of 46. Despite this prevalence, trauma is considered by many to be an “orphaned” disease in the civilian sector. While specialized trauma centers and fellowship-trained trauma specialists are gaining greater importance, trauma does not receive the same level of attention as other diseases. One example of this is in research funding. While the National Institutes of Health provides funding for trauma research, most of this is for basic research. Applied research for trauma pales in comparison to other prominent causes of death like diabetes, heart disease, and cancer.
Trauma specialists have long understood this synergy between military and civilian healthcare needs for research, training, and clinical practice advances. For example, the civilian healthcare sector frequently adopts military medical advances learned during wars. Common examples in recent years include tourniquets and quick-clotting bandages. But these efforts are isolated and have not had the support needed to make a lasting difference to preventable deaths.
Setting National Goals
In 2016, the National Academies of Science, Engineering, and Medicine published a report setting a national goal of zero preventable deaths from trauma, along with an action plan for achieving it. Now would be the appropriate time to revisit it, when military doctors are at their best following the nation’s longest period of war. The White House should embrace the goal of zero preventable trauma deaths and establish a task force to coordinate actions across federal agencies and support the civilian healthcare sector in achieving this goal.
This will be a national effort. The civilian sector has long failed to prioritize trauma. History suggests that the Department of Defense will soon lose interest in medical readiness as well and return to a peacetime healthcare focus. The White House, working with the Departments of Defense, Health and Human Services, Homeland Security, and Veterans Affairs, should build on the National Academies report and work to develop more effective military-civilian partnerships. The Department of Defense should move beyond its fragmented efforts to date and recognize this as a core activity of medical readiness. The civilian sector should be incentivized to embrace partnership with the military and be provided conducive legal and regulatory environments for partnership.
While these partnerships are a necessary condition for progress, they are not sufficient. Research is also key for achieving the national goal. As stated above, trauma research, particularly applied research, has not received the same level of support as other major diseases. This is another natural synergy between the military and civilian healthcare. The Department of Defense should become a focal point and major funder of trauma research. Working with the Department of Health and Human Services and the medical research community, the Department of Defense should lead national research efforts to achieve the goal of zero preventable trauma deaths.
Medical providers and education are also important factors. The Department of Defense should properly identify its clinical requirements, recruit and retain a force that meets these requirements, and support education and training infrastructure across the country. Doing so will drive support to the civilian sector as well. Many of the people trained under this approach will be in the reserves and can therefore support civilian healthcare in their peacetime jobs. Similarly, the military can provide funding for residents who will be a valuable resource for academic medical institutions.
America’s soldiers and civilians will both benefit if the White House promotes partnerships between military and civilian trauma-care units while directing the Department of Defense to expand its research in this area. Reducing preventable deaths would be a major accomplishment domestically and save lives at the start of the next war.
John E. Whitley served as assistant secretary of the Army for financial management and comptroller and as the acting secretary of the Army. He has written on military healthcare reform from various positions of authority, including as a researcher at the Institute for Defense Analyses and as a medical-reform expert on the Presidential Military Compensation and Retirement Modernization Commission.
Jamie Graybeal is a retired U.S. Navy officer who served as a senior executive on the Presidential Military Compensation and Retirement Modernization Commission and as a senior adviser to the director of cost assessment and program evaluation in the Office of the Secretary of Defense.