Being Prepared for the Next Conflict: A Case Analysis of a Military Level I Trauma Center

As we transition to an interwar period, combat-related injuries are at their lowest levels in over a decade, yet we must continue to maintain our surgical skills and train new surgeons. During the recent wars, the importance of the treatment and care for amputations and complex extremity injuries became apparent. This study compares the number of these procedures performed during the treatment of civilian and military orthopaedic trauma patients at a Department of Defense Level I trauma center over the past 9 years. The need to evaluate this unique system is further highlighted by the recent recommendation from the National Academies of Sciences, Engineering, and Medicine's to combine civilian and military trauma systems.

Data derived through a retrospective review of electronic health records were charted and evaluated for statistically unique periods.

There were significant fluctuations in the number of procedures performed within the military cohort, with peaks centered around 2007 and 2011-2012, whereas the number of civilian cases remained relatively steady. On average, the civilian cohort also produced a more consistent and greater number of tibia fractures than the military cohort. For the past 3 years, the civilian cohort has produced 22 more tibia fractures per quarter than the military cohort. Furthermore, although type III open tibia fractures were the most common classification within the military cohort, the civilian cohort provided comparable numbers of type III open fractures despite only being the second most common fracture classification in the civilian cohort. In fact, the civilian volume outpaced the military cohort the past 3 years in this metric. More importantly, the military cohort produced 6 type III fractures in 2013, and 3 in 2014, whereas the civilian cohort produced 14 and 25, respectively, during those years.

Fluctuations in the military cohort's data mirrors surges in operational activity, whereas the civilian cohort demonstrates a higher and more predictable number of tibia fractures; with reliability and numbers being important factors in training new surgeons and maintaining surgical skills. Although this study focused on specific orthopaedic trauma cases deemed essential to combat casualty care, it highlights the universal reality facing U.S. Military Medicine: as combat trauma continues to decline, military medicine as a whole will have to look elsewhere for critical trauma experience. This study confirmed military case volumes fluctuate with operational demands and evaluated one method of supplementing the declining combat trauma volumes with a local civilian trauma mission. This indicates not only the need for a system that is able to quickly adapt to the increased patient load, but also depicts how little reliability there is within the system in terms of perpetuating physician experience when the civilian trauma mission is not considered.