Top Army Surgeon Blasts Military’s Capability to Handle War Traumas – By Steve Sternberg (Health Initiatives) / Oct 28 2019
The top trauma surgeon says the military is ill-equipped to handle battlefield casualties even in a limited war.
The Army’s top trauma surgeon has issued a powerful critique of military surgery, asserting that Army medicine is not “manned, trained or equipped” for the flood of complex battlefield casualties that would occur in even a limited war.
“The failure of military medical leaders to acknowledge the critical requirement for trauma surgeons … puts our future wounded in great peril,” asserts Col. Shawn Nessen, M.D., trauma consultant to Army Surgeon General R. Scott Dingle and director of the medical theater in Iraq.
Nessen is a distinguished graduate of the U.S. Army War College and a surgeon with nearly 30 years of military experience, including multiple combat deployments. During the global war on terror, Nessen served as chief of surgery at Landstuhl Regional Medical Center in Germany.
His appraisal of Army medicine’s lack of readiness for major combat operations – a mission that competes for resources with the military’s commitment to provide comprehensive care for service members and their families – reinforces the findings of a 9-month U.S. News investigation. The investigation identified flaws in the military’s combat casualty care system that could, in a major conflict, cost hundreds or thousands of injured young combatants their limbs or their lives.
Nessen drafted a 13-page document, which he titled “The Forgotten Surgeon Warriors,” in response to the surgeon general’s request for reactions to the U.S. News probe. It is circulating widely among military surgeons and residents. A copy was obtained by U.S. News. Surgeon General Dingle did not respond to a U.S. News request for comment.
Among the U.S. News findings:
· Severe shortages of skilled surgeons, especially trauma surgeons, on active duty and in the reserves.
· Field hospitals that are not configured or staffed appropriately to manage battlefield injuries.
· An active-duty patient population that so rarely needs surgery that military surgeons must struggle to practice their craft. Many moonlight in civilian hospitals to keep their skills from eroding.
· Lengthening deployments that keep surgeons out of the operating room for months at a time, making it even more difficult to sustain their proficiency.
Nessen’s appraisal offers a lengthy list of concerns such as the “persistent surgeon shortage throughout the Global War on Terror” and the military’s unwillingness to promote active trauma surgeons to top leadership positions in battlefield and critical care.
He cites a 2016 report by the National Academies of Sciences, Engineering and Medicine lamenting that the military lacks a single command with the “responsibility and authority” to sustain readiness and ensure “the performance of military trauma care teams and of the system as a whole.”
Trauma surgeons specialize in treating the most devastating injuries, including burns. They created the Army, Navy and Air Force Joint Trauma System and Department of Defense Trauma Registry and also turned Landstuhl Regional Medical Center in Germany into a level I trauma center during the highest volume periods of the Afghanistan and Iraq wars.
Poor results prompted the military to assign trauma surgeons to military hospitals close to the battlefields in Iraq and Afghanistan. In Afghanistan, a trauma surgeon was permanently assigned after an injured combatant was flown to Landstuhl without blood flow in a leg, requiring surgeons to amputate it.
Military leadership has steadfastly ignored recommendations from the National Academies of Sciences, Engineering and Medicine and others to establish a unified combat casualty command with trauma surgeons at the top and to create a career track that enables surgeons to achieve high military rank without abandoning patient care, Nessen says.
He condemns as “unethical” the practice of substituting OB-GYNs, urologists and other non-trauma specialists for trauma and trauma-trained general surgeons in forward surgical teams. These teams, sometimes operating without electric lights or running water, are responsible for the care of wounded combatants suffering from devastating injuries.
“The conversation should no longer be which specialties can substitute for a general surgeon,” Nessen writes. “It should be which general surgeons are trauma competent and can substitute for a trauma surgeon.”
He challenges what he describes as the “insidious myth” that the military can bolster its trauma care by making some, or all, military treatment facilities into “National Trauma Centers.”
For trauma centers to succeed, they need thousands of trauma patients a year. Fortunately, major trauma is relatively rare and even the biggest cities can only support one or two Level I trauma centers, certified by the American College of Surgeons to care for the most severe injuries.
Opening their doors to trauma patients would put military hospitals in direct competition with civilian hospitals that, at a meeting of the American College of Surgeons Committee on Trauma in 2017, “made it clear that they could not give up their trauma patients and remain financially viable.”
The military’s only Level I trauma center, Brooke Army Medical Center in San Antonio, costs $90 million a year to operate and, due to its cost, is “constantly scrutinized” by the Department of Defense, Nessen says.
Even with massive U.S. government support, he asserts, the hospital’s trauma center and the U.S. Army Institute of Surgical Research, which is also located at the hospital, “cannot possibly sustain the trauma skills of every trauma, general and specialty surgeon assigned to the hospital” with their joint total of 4,000 trauma admissions a year.
“The Army needs civilian centers to sustain a ready medical force,” Nessen says. The military has established a handful of these partnerships, but they are primarily for trauma surgeons and they often take months to negotiate as idle surgeons languish in sleepy base hospitals.
Nessen also says the military must train surgical teams collectively before they’re deployed and keep them together during subsequent overseas assignments so that they function effectively as a unit. As matters stand, he says, members who may never have met must figure out how to provide coordinated care to severely injured patients under battlefield conditions, essentially starting over every time they deploy into a conflict zone.
Making sure that nurses and surgical techs are fully trained and prepared is as important as having competent surgeons, Nessen says. In some forward surgical teams, the techs have not held surgical instruments for months or years. “These teams cannot be adequately trained without trauma surgeon leadership,” Nessen says.
Nessen’s colleagues say putting such thoughts on paper, in a system that prizes loyalty and penalizes those who air their criticisms of the system, can be risky.
“This is as honest as I’ve ever seen a leader,” says one high-ranking military surgeon who reviewed the assessment. Like most active-duty surgeons, he agreed to speak on the condition of anonymity to avoid retribution from superiors. Nessen declined to comment via email from Iraq.
The surgeons’ dissatisfaction, evident in their responses to a U.S. News survey, has led to a growing exodus of senior trauma and general surgeons who fear that staying in the military will cripple their careers because they spend so little time in the operating room.
Retired Col. Kyle Remick, a West Point graduate and trauma surgeon with more than two decades of Army service including multiple deployments in conflict zones, told U.S. News he applauds Nessen’s appraisal of the crisis unfolding in Army combat casualty care.
Remick, now practicing trauma and critical care surgery at Cooper University Medical Center in Camden, New Jersey, says he left the Army in October out of frustration over the military’s failure to address surgeons’ concerns.
“We all want the higher level military medical leadership, especially the highest ranking officers, to understand the issues that we’re facing and to put some effort into battlefield care – especially combat casualty care,” Remick says.
He adds that providing routine healthcare service members and their families back home is important, but “it’s not the reason we wear the uniform.”
U.S. Army and Navy surgeons attend a training course at the Naval Medical Center Portsmouth on Aug.1. A new report critiques the state of military surgery in the U.S. Kris R. Lindstrom/U.S. Navy/DVIDS
