Peggy Knudson Gives 42nd AAST Fitts Oration: "When Peace Breaks Out"

 M. Margaret “Peggy” Knudson, M.D., FACS was invited last year to give the 42nd American Association for the Surgery of Trauma Fitts Oration. The theme, "When peace breaks out", sounded a clarion call for training civilian and military surgeons alike to handle mass trauma cases arising from domestic terror events, natural or man-made disasters, and casualties of future wars.

Dr. Knudson, an academic surgeon, has had a rich and multifacted career in trauma care, including service as a Senior Visiting Surgeon in the Iraq war theater, treating victims of the Asiana Airlines crash at San Francisco International airport in 2014, and serving as Medical Director of the Military Health System Strategic Partnership American College of Surgeons (MHSSPACS), a critical part of the country's national defense and homeland security infrastructure. In her lecture, she evangelizes the goal of achieving zero preventable deaths whether they arise from injuries of war, natural catastrophes, or terrorist events.

Dr. Knudson concluded her talk with a list of recommendations for mass casualty preparedness, one that arguably every practicing surgeon in the U.S. should read and commit to. Her Trauma Fitts Oration is a tour de force on the history of civilian and military trauma programs, underscoring the urgent need to preserve specialized surgical knowledge gained from treating the soldiers in past wars. ABC news reporter Bob Woodruff, who sustained serious wounds from an IUD while covering the war in Iraq, was invited to the AAST conference. In a video he recorded for the meeting, he described Dr. Knudson as "amazing" and "a pure expert".

The Fitts oration of 2016 was published last fall in the Journal of Trauma Acute Care Surgery. Excerpts from Dr. Knudson's lecture appear below, but with footnote, table and chart references omitted. Click here to read the full paper. 

In 2003, while our country was engaged in the early stages of war in Iraq, several of us served as founding members of the American College of Surgeons National Ultrasound Faculty. And yes, there was a time when the Fast exam was not ubiquitous in our trauma centers and assuring competency in ultrasound for surgeons became a priority for the American College of Surgeons. Under the leadership of our president, Dr. Rozycki, and a past AAST president (2005), Dr. Shackford, we had developed several ultrasound training courses at the American College of Surgeons (ACS) and were beginning to export these courses nationally. Our military representative on the faculty was Dr. David Wherry from the Uniformed Services University of the Health Sciences in Bethesda, Maryland. He coordinated a trip to Landstuhl, Germany, for the purpose of teaching deploying Army surgeons the use of ultrasound for trauma. From Germany, we conversed via radio with surgeons “downrange” who were dealing with horrific multi-cavity injuries and wondered how the civilian trauma surgeons might be of assistance. And as the conflicts raged on in Iraq and Afghanistan, we witnessed our military surgical colleagues deployed multiple times and again wished there was a way for us to participate.

Fortunately, two other visionary leaders, Dr. William Schwab, a former captain in the Navy and president of this association in 2006 and past-president (2012) Dr. Wayne Meredith, then the chair of the American College of Surgeons Committee on Trauma, working with members of the Army and Air Force, initiated the Senior Visiting Surgeons program, allowing civilian surgeons to participate in the care of those injured in combat who were evacuated from Iraq and Afghanistan to Landstuhl Regional Trauma Center, Germany (LRMC).

Some of us have had the rare opportunity as civilians to travel into theater to see first- hand the challenges of caring for multiple severely injured casualties directly from the battlefield.This program set the stage for sustained military-civilian collaboration in trauma care. My personal experiences through the Senior Visiting Surgeons program changed my life as I know it did for many others here in this room today.

The principle mission of the Military Health System (MHS) is readiness. Yet how prepared will the next generation of military surgeons be? To address that question, several surveys have been conducted recently in order to develop a blueprint for the future. A comprehensive survey of Army surgeons revealed that the majority of those deploying for the first time were within one year of completing their surgical residencies and few had received any specific pre-deployment surgical training. (Col. Jennifer Gurney, US Army, personal communication). Despite the severity of the injuries seen in combat, only 15% of current military surgeons are trauma/critical care trained. In another survey sent to 246 active duty surgeons from the Army, Navy, and Air Force, 89% responded that they had no fellowship training before their first deployment and less than half had attended a pre-deployment surgical training course. The courses that were available varied by service with the most commonly attended being the Emergency War Surgery Course (24.8% of total respondents). Regarding pre-deployment military training, over 60% of responding surgeons found their home station military training to be unhelpful.

So what happens when peace breaks out and surgeons either deploy on missions with little surgical activity or are assigned to a practice caring for military beneficiaries? Sadly, many with extensive combat experience have already separated from the service, and others return to a garrison practice with little or no trauma exposure. Currently, of the 57 Military Treatment Facilities, only seven serve as trauma centers and only one is verified by the ACS Committee on Trauma (COT) as a Level I (Table 1). A recent article in the Wall Street Journal brought this topic of readiness to national attention with a headline that read: “Pentagon Faulted Over Combat Casualty Care.”18 In the article, the author states that “top military doctors say medical advances won on Afghan and Iraqi battlefields might be lost unless Secretary of Defense Ash Carter orders the Pentagon to make techniques, drugs, and devices mandatory for military physicians, nurses and medics.” The article that he was referencing appeared in our Journal authored by Drs. Butler, Smith and Carmona, highlighting in particular the advances in Tactical Combat Casualty Care that have greatly improved the care on the battlefield and advocating that these advances must be preserved for the future. As you might expect, the reporter’s accusation was not well received by the generals in the Pentagon! 

Over the past 15 years of war, our military surgeons have had extensive experience in dealing with mass casualty events and many lessons learned can be translated into the civilian setting. Propper and others25 summarized the surgical response to two explosive events occurring at the US Air Force Theater Hospital in Balad Iraq in 2008. These authors provide useful data on the transfusion, operative care, intensive care, and nursing requirements following such an event (Table 3). Elster et al.26 reviewed the implications of Combat Casualty Care for civilian mass casualty events and emphasized the importance of care at the point of injury (i.e., bleeding control), care during transport using advanced evacuation platforms (i.e., MERT-E helicopter teams), and hospital-based care(i.e., damage control surgery). In that article, the authors point out that few military clinical practice guidelines are the result of standard, randomized clinical trials but rather are developed by identifying what works and what does not work, refining it over time and embracing a culture of continuous process improvement, referred to collectively as “focused empiricism.”

On a personal note, I witnessed mass casualty events during my visit to Balad (Iraq) and made the following five observations: (1) a senior surgeon maintained control of the triage in the emergency department; (2) a small team (physician, nurse, and medic) was assigned to each patient and reported directly to the triage surgeon; (3) it was important to keep track of all patients, including their ID, injuries, and whereabouts; (4) Preservation of blood products was key and resuscitation guided by thrombelastography was used and (5) It was possible to perform surgery on two patients in one operating room. These observations proved useful when a major airliner carrying 307 people crashed at San Francisco International airport in 2014. Our trauma center received 63 injured patients including 10 critical, and 5 requiring immediate surgery. We used a dual triage system, with an experience trauma surgeon evaluating incoming patients while a second surgeon directed flow in the operating room. We also learned that these types of disasters may last for weeks, that it is important to keep your team rested and fresh, and that time must be reserved for decompression of all hospital personnel after such an event.

The US military did not go off to the wars in Afghanistan and Iraq with a trauma system in place. The Joint Theater Trauma System (JTTS) was developed by military trauma surgeons with experience in civilian trauma care who stood up the system during engagement in combat operations. These visionary leaders included General Douglas Robb the then United States Central Command surgeon, Don Jenkins, John Holcomb, Jeff Bailey, Brian Eastridge, Jay Johannigman and Steve Flaherty to name but a few. These surgeons built the system from the ground up because in their words, they knew what “right” looked like. The JTTS, which spanned three continents and thousands of miles, included 5 levels of trauma center care, en route critical care, practice guidelines that spanned across service lines, a robust injury data base (Joint Trauma Theater Registry) and a worldwide performance improvement conference (the video teleconference), all supporting the vision that every soldier, marine, sailor, or airman injured on any battlefield or in any theater of operation would have the optimal chance for survival and maximal potential for functional recovery (Fig. 2).

Indeed, the JTTS resulted in the lowest number of fatalities ever recorded despite a steadily increasing injury severity (Fig. 3). But as combat operations wind down, there is concern that this remarkable system of care will be shelved away only to collect dust, and that the next generation of military surgeons will be forced to invent their own system with an initial higher fatality rate at the start of the next conflict. In other words, what happens when peace breaks out? Those of you who are millennials (or maybe Generation Xers) may not know that the trauma system in the United States has not been in existence for that long and was really born out of the military experiences in Korea and Vietnam. As Brent Eastman pointed out in his 2009 Scudder Address, trauma systems in the United States really began in the 1970s with national funding provided through Emergency Medical Services.

As stated in the NASEM report, “the end of the wars in Afghanistan and Iraq represents a unique moment in history in that there now exists a military trauma system built on a learning system framework and an organized civilian trauma system that is well positioned to assimilate and distribute the recent wartime trauma lessons learned and to serve as a repository and incubator for innovation in trauma care during the interwar period.” Our military personnel deserve our deepest respect and gratitude, but they are unlikely to continue their service without the knowledge that a competent medical team is ready to provide care should they be injured during conflict. Keeping our military medical teams trauma-ready strengthens our national security and enhances our collaborative ability to respond to mass casualties and disasters wherever they occur.

So what can you do to contribute to readiness? Here are a few suggestions for your consideration:

1. Really participate in your local hospital and regional disaster plans, recognizing that the response to any disaster is local. 
2. Avail yourself of the ACS COT disaster course or the online modules being developed by the AAST under the auspices of Dr. Susan Briggs and the disaster committee. 
3. If you are able to volunteer for a disaster, sign up now on the AAST website. This information is also being shared with the ACS Operation Giving Back program. 
4. Have a “go-pack” ready at all times as well as a personal disaster plan for you and your family. 
5. Promote the “Stop the Bleed “campaign at the local level including the training of all first responders and the lay public on methods to control hemorrhage. Support the placement of bleeding control kits in public places like shopping malls, theaters and schools. 
6. Become an instructor for ATOM and ASSET and encourage the exportation of these courses to local Military Treatment Facilities in your area. 
7. Support Coalition for National Trauma Research in its efforts to address research gaps in military/civilian trauma care. Educate your local congressional representatives on the need for dedicated funding for trauma research. 
8. If the opportunity presents itself, welcome military surgical teams into your trauma center for training and exchange of information. Support the national effort to expand the inclusion of additional civilian centers into the military trauma system. 
9. Recognize that strengthening our partnership with the military strengthens our security at home and worldwide. 
10. And don’t forget to pass along the pizza……the value of your message of support for your fellow trauma surgeons during times of disaster (demonstrated by sending food or messages of encouragement) cannot be underestimated.

Can we really achieve zero preventable trauma deaths with a collaborative military-civilian trauma system? Well, the 75th rangers were able to in the fields of Iraq and Afghanistan. And there were zero preventable deaths among those that reached the hospital after the recent mass casualty events in Boston, San Francisco, and Orlando. So it is an achievable goal; one that our war fighters deserve and the American public should expect. Through education, organization and research, this should be the AAST's mission going forward.We owe it to a generation of service members who have given so much during these past 15 years, the longest period of conflict in our nation's history and especially to those who have paid the ultimate price for our freedom.We must honor their sacrifices by ensuring that lessons learned are not forgotten when peace breaks out.