The only winner in war is medicine: Safeguarding military trauma lessons learned through a military surgery partnership with the American Association for the Surgery of Trauma

Sivis pacem, para bellum, “in a time of peace, prepare for war,” was written by Publius Flavius Vegetius Renatus, a Roman military writer and philosopher from 400 AD. Those words ring true two millennia later. As the US military experiences attrition of the generation of military surgeons who were involved in the wars in Iraq and Afghanistan and a new generation of surgeons, who have never experienced combat casualty care, take their place, the US military faces challenges to maintain clinical and operational capabilities to best care for wartime injuries. In addition, as the military health system enterprise shifts its focus to a digital generation with focus on primary care, combat casualty care, trauma care, and complex injury management do not remain a priority. This shift in priorities has been observed throughout the last century during interwar periods. Many trauma surgeons, both active duty and retiree, have recognized the compounded risk of the lack of a laser focus on wartime combat casualty care readiness. Organizations such as the American Association for the Surgery for Trauma (AAST) continue to demonstrate commitment to military surgery. The AAST has done so by supporting the Military Liaison Committee (MLC) to host the American College of Surgeons Committee on Trauma Region 13 (Military) Resident Paper Competition at the annual AAST meeting and also provided the MLC a full-day presession to focus on military relevant issues. Examples of civilian organization support for military surgery are crucial for the viability of readiness efforts during interwar periods. The publication highlights the AAST support for military trauma and combat casualty care. The members of the MLC of the AAST wrote this article to highlight the AAST support for wartime readiness and to express gratitude to the AAST Board current and past presidents and the board of managers who have demonstrated unwavering support for the military trauma care mission during this interwar period. Thank you for remembering the importance of the age-old dictum: Si vis pacem, para bellum. COL Jennifer Gurney, MD, FACS Chair, AAST MLC Military surgeons recognize the risk of the “peacetime effect” for all forward-deployed surgeons and other caregivers who may have limited opportunities to maintain skills relevant to combat casualty care at military medical treatment facilities (MTFs). This issue results in difficulty in effectively maintaining a ready medical force.1–4 Efforts to avoid or minimize this dip should be lauded, but they take time and are difficult to implement. One barrier to sustainment is the lack of battlefield-relevant trauma seen in military hospitals. Previous studies showed that less than 4% of all surgical diagnoses treated at MTFs are wartime related.5,6 Positive efforts have been made to overcome this issue by implementing national incentives focusing on military and civilian trauma partnerships.7–10 While these partnerships have significantly improved civilian and military care for trauma patients, it may not be a universal fix to address every readiness issue. We believe that three main components should be addressed to maintain a deployable surgical force of the highest quality: (1) combat casualty care relevant skill sustainment and prevention of lessons lost, (2) academic rigor focusing on scientific advancement, and (3) developing new surgical ready forces through graduate medical education (GME). One obvious organization primed to address various important issues affecting a surgically deployable military force is the AAST. The AAST has proven to be a potent supporter of military surgeons, with one tangible example being the creation and support of the AAST MLC. The AAST MLC committee was established in 2004 by military members of the AAST and commemorated with the creation of the AAST Honorary Medal for Combat Surgical Care by AAST then-president, Dr. H. Gill Cryer, MD, PhD (Fig. 1). The committee exists for “facilitating military-civilian collaborations to create a national trauma care system with the aim of zero-preventable deaths after injury and minimal trauma-related disability for the servicemen and women our nation sends into harm's way as well as every American at home and abroad.” The AAST MLC currently consists of 37 AAST active and associate military members, retirees, and civilian trauma surgeons interested in supporting the military health system and combat readiness.Figure 1: The AAST Honorary Medal for Combat Surgical Care.The AAST and MLC have supported domestic and deployed surgeons through various webinars, conferences, and access to academic resources.4,11 Because of this, it seemed only logical for the AAST MLC to continue this support on a larger scale at the AAST annual meeting. These efforts coalesced, and the first Military Fallen Surgeons Educational Symposium (MFSES) was held in 2023 at the 89th AAST annual meeting in Anaheim, California. This review is designed to highlight the MFSES benefits and continued collaboration with the AAST on military surgical readiness. THE MFSES The MFSES was proposed by the MLC in 2022, unanimously approved by the AAST Board of Managers, and subsequently inaugurated at the AAST annual meeting in 2023. The purposes of convening this symposium were to provide a forum for education and collaboration of military trauma surgeons from all services, to facilitate collaboration between military and civilian trauma experts, and to provide a unifying venue for the American College of Surgeons (ACS) Committee on Trauma (COT) Region 13 state-level resident paper competition into one venue. The AAST Board of Managers has subsequently approved this symposium to be an enduring part of the AAST annual meeting and graciously committed to its continued support. The AAST MLC planned this symposium over a year with the support of the AAST staff. The agenda was developed to include the Region 13 state-level resident paper competition and focused on sessions providing tangible avenues to address the issues surrounding military trauma surgical readiness. The themes and structure of the conference were identified and characterized based on three areas affecting current military trauma surgical care: skill/knowledge sustainment, academic rigor, and GME. These themes were described in light of their potential to improve readiness. The expanded benefits of an ongoing partnership with the AAST on readiness efforts were also analyzed and described. THE PROGRAM The MFSES was the most well-attended “presession” event of the 2023 AAST annual meeting. The event recorded an overall attendance of 90 registered participants, including 40 active-duty military and 20 reserve military personnel. Twenty-three attendees were in a GME resident or fellowship program, and 79% of all attendees were non–AAST MLC members. The total program was 12 hours in length, including the ACS COT Region 13 state-level resident paper competition; submissions for which were seven times greater than the previous year. The MFSES also included a keynote speaker and closed with a highly attended networking reception. Symposium Structure The symposium was designed to be a full-day academic and professional event. The MFSES opened with a color guard, the national anthem, and a tribute to the fallen including the presentation of a Fallen Comrades Table that was present for the duration of the symposium (Fig. 2). Before each session, a verbal tribute was delivered for the surgeons and nurses who died during combat operations in Iraq and Afghanistan (Table 1, Fig. 3). These military traditions set the tone of patriotism, remembrance, and the quest to improve our mission through academic professionalism. The morning session consisted of an opening talk by Dr. Eileen Bulger, the AAST 81st President. This was followed by the ACS COT Region 13 state-level resident paper competition, where 19 original research presentations from military residents and fellows were presented. The remainder of the symposium comprised multiple original research presentations, expert panel sessions, individual military service updates, and keynote speakers. In review of the program content, the symposium featured a total of 19 original scientific research presentations, two panel sessions consisting of 14 expert panelists, three breakout sessions focused on military status and improvement, and a professional development keynote address on reducing error.Figure 2: The Fallen Comrade Table. TABLE 1 - Fallen Service Members Honored at the 2023 AAST MFSES Name Specialty Killed in Action Tribute LTC Mark Taylor, MDMedical Corps, US Army General Surgery Fallujah, IraqMarch 2004 “Mark was a great and noble man, very committed to caring for the sick and wounded. He had an easy manner and an infectious laugh. Mark was friends with everyone within a day of meeting them. He was and is an inspiration to me. I still miss him deeply.” COL Brian Allgood, MDMedical Corps, US Army Orthopedic Surgery Baghdad, IraqJanuary 2007 “I think that he always wanted to be in the military, and I think that's what he thought his life and function was going to be. I think he did it willingly. I don't think he had any reservations about what he was doing.” CPT Maria Ortiz, RNNursing Corps US Army Nurse Baghdad, IraqJuly 2007 “When you get the word that one has given the ultimate sacrifice, it takes your breath away and the world stops. This happened to me in July when I received word that Maria had been killed in a mortar attack. I know that she was doing what touched her heart and that was caring for the wounded Iraqis at her hospital.” MAJ John Pryor, MDMedical Corps, US Army Trauma Surgery Mosul, IraqDecember 2008 “He was a doctor, a surgeon, a saver of lives in HUP's operating rooms, then in the tented, improvised, inadequate ORs of Mosul and Abu Ghraib. And while his cause was righteous, he never was.” CPT Jennifer Moreno, RNNursing Corps US Army Nurse Kandahar, AfghanistanOctober 2013 Capt. Amanda King, commander of Moreno's cultural support team, wrote in her eulogy, “None of us would have done what you did, running into hell to save your wounded brothers, knowing full well you probably wouldn't make it back.” Figure 3: Script for the Fallen Comrade Table with pictures of fallen military medical service members honored at the 2023 AAST MFSES.Triservice Collaboration A theme that shone through the majority of the programming was Army, Navy, and Air Force collaboration. Dedicated breakout sessions were separated by each branch of service and allowed for the surgery consultants of each service to provide an update on their respective branches. These breakout sessions encouraged discussion on current deployment tempo, future operational strategies, issues at MTFs, and quality efforts moving forward. A briefing following the individual breakout sessions showed the consistency of problems facing the surgical forces across each branch of service. Having the surgical consultants present at the national meeting promoted direct engagement and real-time assessment of the needs of those military general and trauma surgeons who provide forward deployed trauma care. The breakout sessions also provided transparency in developing forward deployable surgeon readiness. Academic Opportunities The program consisted of multiple academic avenues across different committees. The expert panel sessions consisted of experts in ethics, rural surgery, humanitarian efforts, and deployment readiness. In addition, 19 individual research presentations were given as part of the ACS COT Region 13 state-level resident trauma paper competition. The presenters represented all three service branches with military-affiliated GME (9 Army, 6 Air Force, and 4 Navy) at military and military-civilian partnership training institutions. The original research comprised 16 clinical science-focused papers and three basic-science focused papers. The competition produced two winners from each branch of service selected to move on to the ACS COT Region 13 state-level resident trauma paper competition. Mitigating the Walker Dip Unsurprisingly, most of the programming focused on the retention of lessons learned, skills sustainment, and avoidance of knowledge regression. However, the current change in geopolitical climate was also addressed, as new battlefield scenarios may unfold in the years to come. Panelists discussed large-scale and near-peer combat operations from both a clinical and triage perspective. Leading experts in their respective fields addressed the ethical and legal ramifications of previous and future conflicts. Additional panel sessions featured collaborative conversations with civilian experts in rural and humanitarian care. Establishing ongoing relationships between military surgeons, rural surgeons, and surgeons practicing in international host nations in austere environments was emphasized. Lessons learned and best practices from military, humanitarian, and rural surgeons were shared through robust case presentations and the discussion of best practices in their respective austere environments to promote ongoing learning for surgical residents and less-seasoned surgeons. Professional Development Another theme throughout the conference was the focus on professional development geared toward the early career surgeon. The expert panelists led discussions on clinical and ethical conundrums that attending surgeons may encounter during their first deployment. Direct engagement with the audience prompted a discussion with a mixed variety of resident, novice, and experienced surgeons. In addition, the program allowed for multiple avenues of mentorship and networking. A reception event designed to encourage mentoring across the military spectrum was well attended and met with significant enthusiasm. The keynote speaker, a nationally recognized leader in team building and systems improvement, provided expert content geared toward improving the delivery of military trauma care. The AAST MFSES is a unique collaboration between a civilian trauma organization (AAST) and the military surgery community. This collaboration was purposely designed to simultaneously prevent regression of combat casualty care knowledge and to promote the academic rigor important for sustaining the deployability and continued excellence of the modern military trauma surgeon. The symposium reflects continued efforts by the AAST and the military trauma community. We believe that this symposium exists purely because of past laudable efforts in building a bedrock on which continued academic excellence in military surgery can be expanded. The design of the symposium program addressed the key components of maintaining a deployable trauma surgical force: prevention of skill and knowledge regression, academic rigor, and GME. In addition, we found it to align with previous reports calling for strengthened military-civilian collaboration at scientific conferences. Cancio et al.12 documented the benefit of military surgeons' presence and participation at scientific conferences. In their review, the authors found decreased rates of military presence at academic conferences. They pleaded for additional efforts to foster better relations between academic surgical societies and military surgeon participation.12 Their arguments highlighted four “pillars” of a surgeon's scientific career that would benefit from such collaborations. These pillars were education, professionalism, ethics, and peer review. Reviewing the recent AAST MFSES, we found that all four of these “pillars” were simultaneously addressed. This is an encouraging representation of the strengthened bonds between the AAST and the military community. Although such a successful conference should be praised, the authors understand that difficultly forged bonds may still be easily broken. With that in mind, these collaborative efforts expand beyond an annual symposium. The MFSES is the start of an integrated initiative that involves all three military services, and more work needs to be done to support military trauma care be sustained during interwar periods. The dividends will be reciprocated, as lessons learned from wartime casualty care will be more readily integrated into civilian practices during the next conflict. Efforts have already been made to ensure that the symposium will last annually with continued academic programming and solidification of this partnership. The AAST MFSES is now the ongoing home of the ACS COT state-level resident paper competition. This ensures continued academic support, GME enhancement, and military surgeon presence at a nationally recognized scientific trauma conference. In addition, the AAST graciously allows educational platforms to the military surgical community. Such platforms as webinars, educational content, and avenues for professional development help to solidify the ongoing partnership between the ASST and the community of general and trauma surgeons providing combat casualty care. Moreover, the AAST has also shown support to early-career trauma surgeons through alliances with the AAST Associate Membership. The task is far from over, but partnerships such as this should be viewed as an optimistic step in maintaining military-civilian collaboration and ensuring military surgeon readiness for future wartime efforts. The authors would like to thank the continued support and leadership of the AAST in spearheading such an important endeavor. The academic partnership between the AAST and the MFSES should be viewed as an example of a lasting academic collaboration focused on enhancing military trauma surgeon readiness.