Forward Surgical Team Experience (FSTE) Is Associated With Increased Confidence With Combat Surgeon Trauma Skills

Forward Surgical Team Experience (FSTE) Is Associated With Increased Confidence With Combat... Abstract Introduction Little is known regarding the confidence of military surgeons prior to combat zone deployment. Military surgeons are frequently deployed without peers experienced in combat surgery. We hypothesized that forward surgical team experience (FSTE) increases surgeon confidence with critical skill sets. Methods We conducted a national survey of military affiliated personnel. We used a novel survey instrument that was piloted and validated by experienced military surgeons to collect demographics, education, practice patterns, and confidence parameters for trauma and surgical critical care skills. Skills were defined as crucial operative techniques for hemorrhage control and resuscitation. Surveyors were blinded to participants, and surveys were returned electronically via REDCap database. Data were analyzed with SPSS using appropriate models. Significance was considered p < 0.05. Results Of 174 distributed surveys, 86 were completed. Nine individuals failed to characterize their FSTE, thus leaving a sample size of 77. At the time of first deployment, 78.4% were alone or with less experienced surgeons and 53.2% had less than 2 yr of post-residency practice. The respondents’ confidence in damage control techniques and seven other trauma skills increased relative to FSTE. After adjusting for years of practice, number of trauma resuscitations performed per month and pre-deployment training, there remained a significant positive association between FSTE and confidence in damage control, thoracic surgery, extremity/junctional hemorrhage control, trauma systems administration, adult critical care and airway management. Conclusions Training programs and years of general surgery practice do not replace FSTE among military surgeons. Pre-deployment training that mimics FST skill sets should be developed to improve military surgeon confidence and outcomes. Level of Evidence Prognostic and Epidemiologic, Level IV. INTRODUCTION Ambroise Paré famously said, “He who practices surgery must to go to war.” This has been supplemented by the corollary from Ramasamy et al.1 that “He who desires to go to war, must first learn war surgery.” However, the optimal method for learning war surgery and sustainment of combat surgery skills remains undetermined. A set of skills necessary for combat surgeons have been defined in the literature.1–3 These skills translate to different theaters and include damage control operations and resuscitation techniques, vascular surgery, thoracic and orthopedic surgery, burn surgery and emergency airway and most importantly the ability to integrate well as part of a highly functioning team.1,2 While these skills are useful for surgeons at all levels throughout the continuum of combat surgical care, they are of paramount importance to the isolated surgeon functioning in an austere environment. These forward surgical teams (FST) at service-specific Role 2 facilities provide the first level of resuscitative surgical care within the theater of combat operations. Dependent upon the operational environment, these FSTs may provide initial surgical care to the bulk of the combat injured and utilize critical combat surgery skills on a daily basis. Combat surgical skills have been honed by the experience of many who have deployed, brought back what they learned, studied the systems and practices, and taught others. Over the past 13 plus years, an amazing amount of medical and surgical knowledge has been gained from the experience in Iraq and Afghanistan. This experience translated into better results. Even as more severely injured patients were presenting to combat hospitals the case fatality rate continued to decline.4 The U.S. case fatality rate for the combat injured now sits at the lowest level for any major conflict in history.4 This institutional knowledge and experience must be retained and augmented to best prepare our medical forces who care for the injured. We sought to answer the questions: “How to best train military surgeons prior to deployment?” and the related question of “What is the best paradigm for maintenance of the combat surgery skill set?” Our hypothesis was that the greater the number of deployments to a FST or a Role 2 facility, the more confidence in combat surgical skills; that this combat surgical experience would supercede pre-deployment training or years of experience. In essence, the key to confidence in combat surgical skills would be more combat surgical experience itself. METHODS We conducted a nation-wide survey of self-identified military affiliated personnel in conjunction with the Eastern Association for the Surgery of Trauma (EAST) Military Ad Hoc Committee. The survey was created and approval obtained from the University of Pennsylvania Institutional Review Board and the EAST Research-Scholarship Section. Informed consent was obtained from all participants. The survey instrument was a novel tool created and validated by multiple experienced military surgeons in an iterative fashion. The questionnaire was distributed to EAST members with self-identified military affiliation. It was administered by e-mail and researchers were blinded to the identities of the respondents. Completed surveys were databased in REDCap. FST experience (FSTE) was examined. This was defined as deployment as a surgeon to any Role 2 facility in the theater of military operations. The specific skills examined were directly related to hemorrhage control and resuscitation and were drawn from the previously published literature on the optimal operative skill set for combat surgeons (Table I).3 Table I. Combat Surgical Skills Examined as Part of the Survey. The Specific Skills Examined Were Directly Related to Hemorrhage and Resuscitation and Were Drawn from the Previously Published Literature on the Optimal Operative Skill Set for Combat Surgeons. Combat Surgical Skills Damage control techniques Damage control surgery Thoracic surgery Orthopedic surgery Vascular surgery Control of junctional hemorrhage Emergency airway management Adult critical care Trauma system administration Combat Surgical Skills Damage control techniques Damage control surgery Thoracic surgery Orthopedic surgery Vascular surgery Control of junctional hemorrhage Emergency airway management Adult critical care Trauma system administration Table I. Combat Surgical Skills Examined as Part of the Survey. The Specific Skills Examined Were Directly Related to Hemorrhage and Resuscitation and Were Drawn from the Previously Published Literature on the Optimal Operative Skill Set for Combat Surgeons. Combat Surgical Skills Damage control techniques Damage control surgery Thoracic surgery Orthopedic surgery Vascular surgery Control of junctional hemorrhage Emergency airway management Adult critical care Trauma system administration Combat Surgical Skills Damage control techniques Damage control surgery Thoracic surgery Orthopedic surgery Vascular surgery Control of junctional hemorrhage Emergency airway management Adult critical care Trauma system administration Data were analyzed using SPSS version 22. Categorical data were described as counts (percentages) and continuous data were represented as medians (interquartile ranges) and means (standard deviations) as appropriate. Likert and visual analog scales were used to generate data on the general practice patterns of the study participants and describe their comfort and confidence with various trauma and surgical critical care skills. Because of the ordinal nature of the exposure of interest (number of FST deployments), the Jonckneere trend test was used for univariate comparisons. Skewed data were normalized using reflections and square root transformations (data not shown), and multiple variable regressions were performed with the transformed data in order to adjust for confounding variables. Missing data were excluded, and statistical significance was considered p < 0.05. RESULTS Of the 174 surveys distributed 86 were completed. Of those 77 were eligible for this analysis; 9 had to be excluded because the FSTE was not characterized. The demographics of the cohort are described in Table II. There was representation of all three branches of military service with medical personnel. The majority of respondents completed fellowship training, 93.5%, and the majority of these completed a Trauma/Critical Care fellowship. Table II. Demographics of the Survey Cohort Demographics N (95% CI) Years of medical practice 13.0 (8.0–21.0) Years of military service 15.0 (10.5–22.5) Branch of service  Army 39 (50.6%)  Navy 18 (23.4%)  Air Force 15 (19.5%)  Army and Navy 3 (3.9%)  Army and Air Force 2 (2.6%) Fellowship training  Trauma/critical care 60 (77.9%)  Vascular 1 (1.3%)  Other surgical subspecialty 3 (3.9%)  None 5 (6.5%)  Trauma and vascular 3 (3.9%)  Trauma and other surgical subspecialty 4 (5.2%)  Vascular and other surgical subspecialty 1 (1.3%) Primary practice environment  Civilian academic 43 (56.6%)  Military academic 15 (19.7%)  Other military 1 (1.3%)  Community teaching 12 (15.8%)  Community non-teaching 5 (6.6%) Average number of monthly traumas Operations Resuscitations  0–2 16 (20.8%) 9 (11.7%)  3–5 23 (29.9%) 9 (11.7%)  6–10 21 (27.3%) 13 (16.9%)  11–25 13 (16.9%) 23 (29.9%)  25+ 2 (2.6%) 21 (27.3%)  I do not regularly practice trauma 2 (2.6%) 2 (2.6%) Demographics N (95% CI) Years of medical practice 13.0 (8.0–21.0) Years of military service 15.0 (10.5–22.5) Branch of service  Army 39 (50.6%)  Navy 18 (23.4%)  Air Force 15 (19.5%)  Army and Navy 3 (3.9%)  Army and Air Force 2 (2.6%) Fellowship training  Trauma/critical care 60 (77.9%)  Vascular 1 (1.3%)  Other surgical subspecialty 3 (3.9%)  None 5 (6.5%)  Trauma and vascular 3 (3.9%)  Trauma and other surgical subspecialty 4 (5.2%)  Vascular and other surgical subspecialty 1 (1.3%) Primary practice environment  Civilian academic 43 (56.6%)  Military academic 15 (19.7%)  Other military 1 (1.3%)  Community teaching 12 (15.8%)  Community non-teaching 5 (6.6%) Average number of monthly traumas Operations Resuscitations  0–2 16 (20.8%) 9 (11.7%)  3–5 23 (29.9%) 9 (11.7%)  6–10 21 (27.3%) 13 (16.9%)  11–25 13 (16.9%) 23 (29.9%)  25+ 2 (2.6%) 21 (27.3%)  I do not regularly practice trauma 2 (2.6%) 2 (2.6%) Table II. Demographics of the Survey Cohort Demographics N (95% CI) Years of medical practice 13.0 (8.0–21.0) Years of military service 15.0 (10.5–22.5) Branch of service  Army 39 (50.6%)  Navy 18 (23.4%)  Air Force 15 (19.5%)  Army and Navy 3 (3.9%)  Army and Air Force 2 (2.6%) Fellowship training  Trauma/critical care 60 (77.9%)  Vascular 1 (1.3%)  Other surgical subspecialty 3 (3.9%)  None 5 (6.5%)  Trauma and vascular 3 (3.9%)  Trauma and other surgical subspecialty 4 (5.2%)  Vascular and other surgical subspecialty 1 (1.3%) Primary practice environment  Civilian academic 43 (56.6%)  Military academic 15 (19.7%)  Other military 1 (1.3%)  Community teaching 12 (15.8%)  Community non-teaching 5 (6.6%) Average number of monthly traumas Operations Resuscitations  0–2 16 (20.8%) 9 (11.7%)  3–5 23 (29.9%) 9 (11.7%)  6–10 21 (27.3%) 13 (16.9%)  11–25 13 (16.9%) 23 (29.9%)  25+ 2 (2.6%) 21 (27.3%)  I do not regularly practice trauma 2 (2.6%) 2 (2.6%) Demographics N (95% CI) Years of medical practice 13.0 (8.0–21.0) Years of military service 15.0 (10.5–22.5) Branch of service  Army 39 (50.6%)  Navy 18 (23.4%)  Air Force 15 (19.5%)  Army and Navy 3 (3.9%)  Army and Air Force 2 (2.6%) Fellowship training  Trauma/critical care 60 (77.9%)  Vascular 1 (1.3%)  Other surgical subspecialty 3 (3.9%)  None 5 (6.5%)  Trauma and vascular 3 (3.9%)  Trauma and other surgical subspecialty 4 (5.2%)  Vascular and other surgical subspecialty 1 (1.3%) Primary practice environment  Civilian academic 43 (56.6%)  Military academic 15 (19.7%)  Other military 1 (1.3%)  Community teaching 12 (15.8%)  Community non-teaching 5 (6.6%) Average number of monthly traumas Operations Resuscitations  0–2 16 (20.8%) 9 (11.7%)  3–5 23 (29.9%) 9 (11.7%)  6–10 21 (27.3%) 13 (16.9%)  11–25 13 (16.9%) 23 (29.9%)  25+ 2 (2.6%) 21 (27.3%)  I do not regularly practice trauma 2 (2.6%) 2 (2.6%) At the time of first deployment combat surgeons were young, average age 36, and often solo or paired with even less experienced partners. At the time of the first FSTE, 53.2% of the surgeons had less than 2 yr post-residency training experience and 78.4% were solo or paired with less experienced surgeons. Only 22.1% of the surgeons were paired with another surgeon who had prior combat surgery experience. Increased FSTE resulted in increased confidence in measured skills. Figure 1 demonstrates the whisker boxplot for confidence scores for Damage Control Techniques. The cohort was divided into four groups based on number of FSTEs: none, one, two, or three or more. The median score did increase with increasing number of FSTEs. This increase reached statistical significance after two or more FSTEs. Additionally, the dispersion of scores narrowed as the number of FSTEs increased. This increased confidence was seen in a variety of surgical skills and persisted when adjusted for years of practice, number of trauma resuscitations, and number of training programs attended prior to deployment (Table III). FIGURE 1. View largeDownload slide Confidence score distributions tor damage control technique skill set compared by number of FSTEs. Whiskers represent minimum and maximum values. Box represents median with 25th and 75th percentiles. Dots represent statistical outliers. FIGURE 1. View largeDownload slide Confidence score distributions tor damage control technique skill set compared by number of FSTEs. Whiskers represent minimum and maximum values. Box represents median with 25th and 75th percentiles. Dots represent statistical outliers. Table III. Unadjusted and Adjusted p-Value for Increased Confidence Scores Compared Between No Prior FSTE and Any Prior FSTE. Association Between FSTE and Surgical Skill Set Confidence Skill Sets Unadjusted p-value Adjusted p-value* Damage control techniques 0.009 0.011 Damage control resuscitation 0.027 0.002 Thoracic surgery 0.028 0.039 Orthopedic surgery 0.041 0.122 Iliac artery control for junctional hemorrhage <0.001 <0.001 Emergency airway management 0.032 0.047 Adult critical care 0.039 0.010 Trauma system administration 0.029 <0.001 Association Between FSTE and Surgical Skill Set Confidence Skill Sets Unadjusted p-value Adjusted p-value* Damage control techniques 0.009 0.011 Damage control resuscitation 0.027 0.002 Thoracic surgery 0.028 0.039 Orthopedic surgery 0.041 0.122 Iliac artery control for junctional hemorrhage <0.001 <0.001 Emergency airway management 0.032 0.047 Adult critical care 0.039 0.010 Trauma system administration 0.029 <0.001 *Model adjusted for years of practice, number of trauma resuscitations performed per month and number of training programs attended prior to deployment. Table III. Unadjusted and Adjusted p-Value for Increased Confidence Scores Compared Between No Prior FSTE and Any Prior FSTE. Association Between FSTE and Surgical Skill Set Confidence Skill Sets Unadjusted p-value Adjusted p-value* Damage control techniques 0.009 0.011 Damage control resuscitation 0.027 0.002 Thoracic surgery 0.028 0.039 Orthopedic surgery 0.041 0.122 Iliac artery control for junctional hemorrhage <0.001 <0.001 Emergency airway management 0.032 0.047 Adult critical care 0.039 0.010 Trauma system administration 0.029 <0.001 Association Between FSTE and Surgical Skill Set Confidence Skill Sets Unadjusted p-value Adjusted p-value* Damage control techniques 0.009 0.011 Damage control resuscitation 0.027 0.002 Thoracic surgery 0.028 0.039 Orthopedic surgery 0.041 0.122 Iliac artery control for junctional hemorrhage <0.001 <0.001 Emergency airway management 0.032 0.047 Adult critical care 0.039 0.010 Trauma system administration 0.029 <0.001 *Model adjusted for years of practice, number of trauma resuscitations performed per month and number of training programs attended prior to deployment. DISCUSSION The wars in Afghanistan and Iraq have been some of the best studied from a medical perspective. Numerous advances have come from the diligent work of cataloging, examining and refining lessons learned. The development of damage control resuscitation techniques, improved field combat casualty care, refinement of casualty evacuation principles, expanded pre-deployment training, as well as the dissemination of clinical practice guidelines have all contributed to the success in the care of patients injured on the battlefield.2,5 Historically, the method for obtaining experience in combat surgery was by performing combat surgery itself. Past conflicts suffered from inattention of continued training of care for the combat injured with a loss of lessons learned from prior experience.6 This resulted in a repeat of the learning curve from conflict to conflict for combat surgeons and combat surgical teams. The question remains how best to retain and pass on this experience. Reproducing the combat surgery experience prior to the first time an injured patient arrives at a facility is a key element to training future combat surgery teams. Prior to deployment, all combat surgical teams should have a clinical experience that mimics the FSTE. Training models should be studied to find the ideal fit for this goal. It is possible that this experience may be best found at high volume trauma centers with a substantial percentage of penetrating firearm injuries.7 Lessons learned during wartime have been applied in civilian trauma settings and have proved effective.8,9 The flow of knowledge between the civilian and military has always been a two-way street.8,10 It may be time for more of our civilian trauma centers to prepare military surgical teams for combat surgery.7,11 A multitude of models currently exist for pre-deployment training.12–17 Short weeklong or less courses exist such as the U.S. Military Emergency War Surgery Course, the American College of Surgeons Advanced Surgical Skills for Exposure in Trauma (ASSET) course or the U.K.’s Military Operational Surgical Training. More extensive training is also employed via field training military exercises in both the USA and the UK.18 Other training models incorporate longer term team experiences of a month or more such as the Centers for Sustainment of Trauma and Readiness Skills (C-STARs) program in the U.S. Air Force at centers in Baltimore, St Louis, and Cincinnati.16 The U.S. Army and U.S. Navy also have relationships with civilian training hospitals located in Miami and Los Angeles, respectively. Which of these training models is optimal for pre-deployment training has yet to be determined. This study is limited by the self-reporting nature of the survey instrument. Confidence in a particular procedure or skill set is a subjective measure and cannot be easily linked to patient outcomes. Finally, a sampling bias may exist in that the majority of those surveyed had completed a trauma/critical care fellowship at the time of the survey; while the majority of the surgeons that fill FST billets are general surgeons and non-trauma general surgery subspecialists functioning in the role of combat surgeon. Although most of those completing the survey deployed early in their careers prior to fellowship, it is difficult to ascertain the impact of the fellowship training on their combat surgery confidence levels. The aim of this study was to provide preliminary data to guide future investigations. This study does provide the foundation for exploring and developing both existing and novel training methods to better prepare combat surgical teams. CONCLUSION Training programs and years of general surgery practice do not replace FSTE among military surgeons. Pre-deployment training that mimics FST skill sets should be developed to improve military surgeon confidence and outcomes. Conflict of Interest Drs D.J.M. and C.W.S previously served as surgeons in the U.S. Navy. Dr Polk currently serves as a surgeon in the U.S. Navy, there are no financial conflicts of interest to report. This paper was presented at the European Congress for Trauma and Emergency Surgery, May 10, 2015. References 1 Ramasamy A , Hinsley DE , Edwards DS , Stewart MPM , Midwinter M , Parker PJ : Skill sets and competencies for the modern military surgeon: lessons from UK military operations in Southern Afghanistan . Injury 2010 ; 41 : 453 – 459 . Google Scholar CrossRef Search ADS PubMed 2 Eastridge BJ , Mabry RL , Seguin P , et al. : Death on the battlefield (2001-2011): implications for the future of combat casualty care [correction published in J Trauma Acute Care Surg. 2013;74(2):706] . J Trauma Acute Care Surg 2012 ; 73 ( 6 suppl 5 ): S431 – S437 . Google Scholar CrossRef Search ADS PubMed 3 Tyler JA , Ritchie JD , Leas ML , et al. : Combat readiness for the modern military surgeon: data from a decade of combat operations . J Trauma Acute Care Surg 2012 ; 73 ( 1 ): S64 – S70 . Google Scholar CrossRef Search ADS PubMed 4 Rasmussen TE , Gross KR , Baer DG : Where do we go from here? Preface. US Military Health System Research Symposium . J Trauma Acute Care Surg 2013 ; 75 ( 2 Suppl 2 ): S105 – 6 . Google Scholar CrossRef Search ADS PubMed 5 Blackbourne LH , Baer DG , Eastridge BJ , et al. : Military medical revolution: prehospital combat casualty care . J Trauma Acute Care Surg 2012 ; 73 ( 6 Suppl 5 ): S372 – 7 . Google Scholar CrossRef Search ADS PubMed 6 Trunkey DJ : Excelsior Surgical Society Edward D Churchill Lecture. Changes in combat casualty care . J Am Coll Surg 2012 ; 214 ( 6 ): 879 – 91 . Google Scholar CrossRef Search ADS PubMed 7 Schwab CW : Winds of war: enhancing civilian and military partnerships to assure readiness: a White Paper . J Am Coll Surg 2015 ; 221 : 235 – 254 . Google Scholar CrossRef Search ADS PubMed 8 Schwab CW : Crises and war: stepping stones to the future . J Trauma Acute Care Surg 2007 ; 62 : 1 – 16 . Google Scholar CrossRef Search ADS 9 Elster E , Butler F , Rasmussen T : Implications of combat casualty care for mass casualty events . JAMA 2013 ; 310 ( 5 ): 475 – 476 . Google Scholar CrossRef Search ADS PubMed 10 Pruitt BA : The symbiosis of combat casualty care and civilian trauma care: 1914–2007 . J Trauma 2008 ; 64 : S4 – S8 . Google Scholar CrossRef Search ADS PubMed 11 Eibner C : Maintaining Military Medical Skills During Peacetime: Outlining and Assessing a New Approach . Santa Monica, CA, Rand Corporation, 2008 . Available at: www.rand.org. https://www.rand.org/pubs/monographs/MG638.html; accessed April 24, 2016. 12 Hight RA , Salcedo ES , Martin SP , Cocanour CS , Utter G , Galante JM : Level I academic medical center integration as a model for sustaining combat surgical skills: the right surgeon in the right place for the right time . J Trauma Acute Care Surg 2015 ; 78 : 1176 – 1181 . Google Scholar CrossRef Search ADS PubMed 13 McCunn M , York GB , Hirshon JM , Jenkins DH , Scalea TM : Trauma readiness training for military deployment: a comparison between a U.S. trauma center and an Air Force theater hospital in Balad, Iraq . Mil Med 2011 ; 176 : 769 – 776 . Google Scholar CrossRef Search ADS PubMed 14 Schreiber MA , Holcomb JB , Conaway CW , Campbell KD , Wall M , Mattox KL : Military trauma training performed in a civilian trauma training center . J Surg Res 2002 ; 104 : 8 – 14 . Google Scholar CrossRef Search ADS PubMed 15 Schulman CI , Graygo J , Wilson K , Robinson DB , Garcia G , Augenstein J : Training forward surgical teams: do military-civilian partnerships work? US Army Med Dep J 2010 ; Oct-Dec : 17 – 21 . 16 Thorson CM , Dubose JJ , Rhee P , et al. : Military trauma training at civilian centers: a decade of advancements . J Trauma Acute Care Surg 2012 ; 73 ( 5 ): S483 – S489 . Google Scholar CrossRef Search ADS PubMed 17 Tyler JA , Clive KS , White CE , Beekley AC , Blackbourne LH : Current US military operations and implications for military surgical training . J Am Coll Surg 2010 ; 211 : 658 – 662 . Google Scholar CrossRef Search ADS PubMed 18 Eardley WGP , Taylor DM , Parker PJ : Training Tomorrow’s Military Surgeons: Lessons from the Past and Challenges for the Future . JR Army Med Corps 2009 ; 155 ( 4 ): 249 – 252 . Google Scholar CrossRef Search ADS Author notes The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any agency of the U.S. government. © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Forward Surgical Team Experience (FSTE) Is Associated With Increased Confidence With Combat Surgeon Trauma Skills

Military Medicine , Volume Advance Article (7) – Jun 28, 2018

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Abstract

Abstract Introduction Little is known regarding the confidence of military surgeons prior to combat zone deployment. Military surgeons are frequently deployed without peers experienced in combat surgery. We hypothesized that forward surgical team experience (FSTE) increases surgeon confidence with critical skill sets. Methods We conducted a national survey of military affiliated personnel. We used a novel survey instrument that was piloted and validated by experienced military surgeons to collect demographics, education, practice patterns, and confidence parameters for trauma and surgical critical care skills. Skills were defined as crucial operative techniques for hemorrhage control and resuscitation. Surveyors were blinded to participants, and surveys were returned electronically via REDCap database. Data were analyzed with SPSS using appropriate models. Significance was considered p < 0.05. Results Of 174 distributed surveys, 86 were completed. Nine individuals failed to characterize their FSTE, thus leaving a sample size of 77. At the time of first deployment, 78.4% were alone or with less experienced surgeons and 53.2% had less than 2 yr of post-residency practice. The respondents’ confidence in damage control techniques and seven other trauma skills increased relative to FSTE. After adjusting for years of practice, number of trauma resuscitations performed per month and pre-deployment training, there remained a significant positive association between FSTE and confidence in damage control, thoracic surgery, extremity/junctional hemorrhage control, trauma systems administration, adult critical care and airway management. Conclusions Training programs and years of general surgery practice do not replace FSTE among military surgeons. Pre-deployment training that mimics FST skill sets should be developed to improve military surgeon confidence and outcomes. Level of Evidence Prognostic and Epidemiologic, Level IV. INTRODUCTION Ambroise Paré famously said, “He who practices surgery must to go to war.” This has been supplemented by the corollary from Ramasamy et al.1 that “He who desires to go to war, must first learn war surgery.” However, the optimal method for learning war surgery and sustainment of combat surgery skills remains undetermined. A set of skills necessary for combat surgeons have been defined in the literature.1–3 These skills translate to different theaters and include damage control operations and resuscitation techniques, vascular surgery, thoracic and orthopedic surgery, burn surgery and emergency airway and most importantly the ability to integrate well as part of a highly functioning team.1,2 While these skills are useful for surgeons at all levels throughout the continuum of combat surgical care, they are of paramount importance to the isolated surgeon functioning in an austere environment. These forward surgical teams (FST) at service-specific Role 2 facilities provide the first level of resuscitative surgical care within the theater of combat operations. Dependent upon the operational environment, these FSTs may provide initial surgical care to the bulk of the combat injured and utilize critical combat surgery skills on a daily basis. Combat surgical skills have been honed by the experience of many who have deployed, brought back what they learned, studied the systems and practices, and taught others. Over the past 13 plus years, an amazing amount of medical and surgical knowledge has been gained from the experience in Iraq and Afghanistan. This experience translated into better results. Even as more severely injured patients were presenting to combat hospitals the case fatality rate continued to decline.4 The U.S. case fatality rate for the combat injured now sits at the lowest level for any major conflict in history.4 This institutional knowledge and experience must be retained and augmented to best prepare our medical forces who care for the injured. We sought to answer the questions: “How to best train military surgeons prior to deployment?” and the related question of “What is the best paradigm for maintenance of the combat surgery skill set?” Our hypothesis was that the greater the number of deployments to a FST or a Role 2 facility, the more confidence in combat surgical skills; that this combat surgical experience would supercede pre-deployment training or years of experience. In essence, the key to confidence in combat surgical skills would be more combat surgical experience itself. METHODS We conducted a nation-wide survey of self-identified military affiliated personnel in conjunction with the Eastern Association for the Surgery of Trauma (EAST) Military Ad Hoc Committee. The survey was created and approval obtained from the University of Pennsylvania Institutional Review Board and the EAST Research-Scholarship Section. Informed consent was obtained from all participants. The survey instrument was a novel tool created and validated by multiple experienced military surgeons in an iterative fashion. The questionnaire was distributed to EAST members with self-identified military affiliation. It was administered by e-mail and researchers were blinded to the identities of the respondents. Completed surveys were databased in REDCap. FST experience (FSTE) was examined. This was defined as deployment as a surgeon to any Role 2 facility in the theater of military operations. The specific skills examined were directly related to hemorrhage control and resuscitation and were drawn from the previously published literature on the optimal operative skill set for combat surgeons (Table I).3 Table I. Combat Surgical Skills Examined as Part of the Survey. The Specific Skills Examined Were Directly Related to Hemorrhage and Resuscitation and Were Drawn from the Previously Published Literature on the Optimal Operative Skill Set for Combat Surgeons. Combat Surgical Skills Damage control techniques Damage control surgery Thoracic surgery Orthopedic surgery Vascular surgery Control of junctional hemorrhage Emergency airway management Adult critical care Trauma system administration Combat Surgical Skills Damage control techniques Damage control surgery Thoracic surgery Orthopedic surgery Vascular surgery Control of junctional hemorrhage Emergency airway management Adult critical care Trauma system administration Table I. Combat Surgical Skills Examined as Part of the Survey. The Specific Skills Examined Were Directly Related to Hemorrhage and Resuscitation and Were Drawn from the Previously Published Literature on the Optimal Operative Skill Set for Combat Surgeons. Combat Surgical Skills Damage control techniques Damage control surgery Thoracic surgery Orthopedic surgery Vascular surgery Control of junctional hemorrhage Emergency airway management Adult critical care Trauma system administration Combat Surgical Skills Damage control techniques Damage control surgery Thoracic surgery Orthopedic surgery Vascular surgery Control of junctional hemorrhage Emergency airway management Adult critical care Trauma system administration Data were analyzed using SPSS version 22. Categorical data were described as counts (percentages) and continuous data were represented as medians (interquartile ranges) and means (standard deviations) as appropriate. Likert and visual analog scales were used to generate data on the general practice patterns of the study participants and describe their comfort and confidence with various trauma and surgical critical care skills. Because of the ordinal nature of the exposure of interest (number of FST deployments), the Jonckneere trend test was used for univariate comparisons. Skewed data were normalized using reflections and square root transformations (data not shown), and multiple variable regressions were performed with the transformed data in order to adjust for confounding variables. Missing data were excluded, and statistical significance was considered p < 0.05. RESULTS Of the 174 surveys distributed 86 were completed. Of those 77 were eligible for this analysis; 9 had to be excluded because the FSTE was not characterized. The demographics of the cohort are described in Table II. There was representation of all three branches of military service with medical personnel. The majority of respondents completed fellowship training, 93.5%, and the majority of these completed a Trauma/Critical Care fellowship. Table II. Demographics of the Survey Cohort Demographics N (95% CI) Years of medical practice 13.0 (8.0–21.0) Years of military service 15.0 (10.5–22.5) Branch of service  Army 39 (50.6%)  Navy 18 (23.4%)  Air Force 15 (19.5%)  Army and Navy 3 (3.9%)  Army and Air Force 2 (2.6%) Fellowship training  Trauma/critical care 60 (77.9%)  Vascular 1 (1.3%)  Other surgical subspecialty 3 (3.9%)  None 5 (6.5%)  Trauma and vascular 3 (3.9%)  Trauma and other surgical subspecialty 4 (5.2%)  Vascular and other surgical subspecialty 1 (1.3%) Primary practice environment  Civilian academic 43 (56.6%)  Military academic 15 (19.7%)  Other military 1 (1.3%)  Community teaching 12 (15.8%)  Community non-teaching 5 (6.6%) Average number of monthly traumas Operations Resuscitations  0–2 16 (20.8%) 9 (11.7%)  3–5 23 (29.9%) 9 (11.7%)  6–10 21 (27.3%) 13 (16.9%)  11–25 13 (16.9%) 23 (29.9%)  25+ 2 (2.6%) 21 (27.3%)  I do not regularly practice trauma 2 (2.6%) 2 (2.6%) Demographics N (95% CI) Years of medical practice 13.0 (8.0–21.0) Years of military service 15.0 (10.5–22.5) Branch of service  Army 39 (50.6%)  Navy 18 (23.4%)  Air Force 15 (19.5%)  Army and Navy 3 (3.9%)  Army and Air Force 2 (2.6%) Fellowship training  Trauma/critical care 60 (77.9%)  Vascular 1 (1.3%)  Other surgical subspecialty 3 (3.9%)  None 5 (6.5%)  Trauma and vascular 3 (3.9%)  Trauma and other surgical subspecialty 4 (5.2%)  Vascular and other surgical subspecialty 1 (1.3%) Primary practice environment  Civilian academic 43 (56.6%)  Military academic 15 (19.7%)  Other military 1 (1.3%)  Community teaching 12 (15.8%)  Community non-teaching 5 (6.6%) Average number of monthly traumas Operations Resuscitations  0–2 16 (20.8%) 9 (11.7%)  3–5 23 (29.9%) 9 (11.7%)  6–10 21 (27.3%) 13 (16.9%)  11–25 13 (16.9%) 23 (29.9%)  25+ 2 (2.6%) 21 (27.3%)  I do not regularly practice trauma 2 (2.6%) 2 (2.6%) Table II. Demographics of the Survey Cohort Demographics N (95% CI) Years of medical practice 13.0 (8.0–21.0) Years of military service 15.0 (10.5–22.5) Branch of service  Army 39 (50.6%)  Navy 18 (23.4%)  Air Force 15 (19.5%)  Army and Navy 3 (3.9%)  Army and Air Force 2 (2.6%) Fellowship training  Trauma/critical care 60 (77.9%)  Vascular 1 (1.3%)  Other surgical subspecialty 3 (3.9%)  None 5 (6.5%)  Trauma and vascular 3 (3.9%)  Trauma and other surgical subspecialty 4 (5.2%)  Vascular and other surgical subspecialty 1 (1.3%) Primary practice environment  Civilian academic 43 (56.6%)  Military academic 15 (19.7%)  Other military 1 (1.3%)  Community teaching 12 (15.8%)  Community non-teaching 5 (6.6%) Average number of monthly traumas Operations Resuscitations  0–2 16 (20.8%) 9 (11.7%)  3–5 23 (29.9%) 9 (11.7%)  6–10 21 (27.3%) 13 (16.9%)  11–25 13 (16.9%) 23 (29.9%)  25+ 2 (2.6%) 21 (27.3%)  I do not regularly practice trauma 2 (2.6%) 2 (2.6%) Demographics N (95% CI) Years of medical practice 13.0 (8.0–21.0) Years of military service 15.0 (10.5–22.5) Branch of service  Army 39 (50.6%)  Navy 18 (23.4%)  Air Force 15 (19.5%)  Army and Navy 3 (3.9%)  Army and Air Force 2 (2.6%) Fellowship training  Trauma/critical care 60 (77.9%)  Vascular 1 (1.3%)  Other surgical subspecialty 3 (3.9%)  None 5 (6.5%)  Trauma and vascular 3 (3.9%)  Trauma and other surgical subspecialty 4 (5.2%)  Vascular and other surgical subspecialty 1 (1.3%) Primary practice environment  Civilian academic 43 (56.6%)  Military academic 15 (19.7%)  Other military 1 (1.3%)  Community teaching 12 (15.8%)  Community non-teaching 5 (6.6%) Average number of monthly traumas Operations Resuscitations  0–2 16 (20.8%) 9 (11.7%)  3–5 23 (29.9%) 9 (11.7%)  6–10 21 (27.3%) 13 (16.9%)  11–25 13 (16.9%) 23 (29.9%)  25+ 2 (2.6%) 21 (27.3%)  I do not regularly practice trauma 2 (2.6%) 2 (2.6%) At the time of first deployment combat surgeons were young, average age 36, and often solo or paired with even less experienced partners. At the time of the first FSTE, 53.2% of the surgeons had less than 2 yr post-residency training experience and 78.4% were solo or paired with less experienced surgeons. Only 22.1% of the surgeons were paired with another surgeon who had prior combat surgery experience. Increased FSTE resulted in increased confidence in measured skills. Figure 1 demonstrates the whisker boxplot for confidence scores for Damage Control Techniques. The cohort was divided into four groups based on number of FSTEs: none, one, two, or three or more. The median score did increase with increasing number of FSTEs. This increase reached statistical significance after two or more FSTEs. Additionally, the dispersion of scores narrowed as the number of FSTEs increased. This increased confidence was seen in a variety of surgical skills and persisted when adjusted for years of practice, number of trauma resuscitations, and number of training programs attended prior to deployment (Table III). FIGURE 1. View largeDownload slide Confidence score distributions tor damage control technique skill set compared by number of FSTEs. Whiskers represent minimum and maximum values. Box represents median with 25th and 75th percentiles. Dots represent statistical outliers. FIGURE 1. View largeDownload slide Confidence score distributions tor damage control technique skill set compared by number of FSTEs. Whiskers represent minimum and maximum values. Box represents median with 25th and 75th percentiles. Dots represent statistical outliers. Table III. Unadjusted and Adjusted p-Value for Increased Confidence Scores Compared Between No Prior FSTE and Any Prior FSTE. Association Between FSTE and Surgical Skill Set Confidence Skill Sets Unadjusted p-value Adjusted p-value* Damage control techniques 0.009 0.011 Damage control resuscitation 0.027 0.002 Thoracic surgery 0.028 0.039 Orthopedic surgery 0.041 0.122 Iliac artery control for junctional hemorrhage <0.001 <0.001 Emergency airway management 0.032 0.047 Adult critical care 0.039 0.010 Trauma system administration 0.029 <0.001 Association Between FSTE and Surgical Skill Set Confidence Skill Sets Unadjusted p-value Adjusted p-value* Damage control techniques 0.009 0.011 Damage control resuscitation 0.027 0.002 Thoracic surgery 0.028 0.039 Orthopedic surgery 0.041 0.122 Iliac artery control for junctional hemorrhage <0.001 <0.001 Emergency airway management 0.032 0.047 Adult critical care 0.039 0.010 Trauma system administration 0.029 <0.001 *Model adjusted for years of practice, number of trauma resuscitations performed per month and number of training programs attended prior to deployment. Table III. Unadjusted and Adjusted p-Value for Increased Confidence Scores Compared Between No Prior FSTE and Any Prior FSTE. Association Between FSTE and Surgical Skill Set Confidence Skill Sets Unadjusted p-value Adjusted p-value* Damage control techniques 0.009 0.011 Damage control resuscitation 0.027 0.002 Thoracic surgery 0.028 0.039 Orthopedic surgery 0.041 0.122 Iliac artery control for junctional hemorrhage <0.001 <0.001 Emergency airway management 0.032 0.047 Adult critical care 0.039 0.010 Trauma system administration 0.029 <0.001 Association Between FSTE and Surgical Skill Set Confidence Skill Sets Unadjusted p-value Adjusted p-value* Damage control techniques 0.009 0.011 Damage control resuscitation 0.027 0.002 Thoracic surgery 0.028 0.039 Orthopedic surgery 0.041 0.122 Iliac artery control for junctional hemorrhage <0.001 <0.001 Emergency airway management 0.032 0.047 Adult critical care 0.039 0.010 Trauma system administration 0.029 <0.001 *Model adjusted for years of practice, number of trauma resuscitations performed per month and number of training programs attended prior to deployment. DISCUSSION The wars in Afghanistan and Iraq have been some of the best studied from a medical perspective. Numerous advances have come from the diligent work of cataloging, examining and refining lessons learned. The development of damage control resuscitation techniques, improved field combat casualty care, refinement of casualty evacuation principles, expanded pre-deployment training, as well as the dissemination of clinical practice guidelines have all contributed to the success in the care of patients injured on the battlefield.2,5 Historically, the method for obtaining experience in combat surgery was by performing combat surgery itself. Past conflicts suffered from inattention of continued training of care for the combat injured with a loss of lessons learned from prior experience.6 This resulted in a repeat of the learning curve from conflict to conflict for combat surgeons and combat surgical teams. The question remains how best to retain and pass on this experience. Reproducing the combat surgery experience prior to the first time an injured patient arrives at a facility is a key element to training future combat surgery teams. Prior to deployment, all combat surgical teams should have a clinical experience that mimics the FSTE. Training models should be studied to find the ideal fit for this goal. It is possible that this experience may be best found at high volume trauma centers with a substantial percentage of penetrating firearm injuries.7 Lessons learned during wartime have been applied in civilian trauma settings and have proved effective.8,9 The flow of knowledge between the civilian and military has always been a two-way street.8,10 It may be time for more of our civilian trauma centers to prepare military surgical teams for combat surgery.7,11 A multitude of models currently exist for pre-deployment training.12–17 Short weeklong or less courses exist such as the U.S. Military Emergency War Surgery Course, the American College of Surgeons Advanced Surgical Skills for Exposure in Trauma (ASSET) course or the U.K.’s Military Operational Surgical Training. More extensive training is also employed via field training military exercises in both the USA and the UK.18 Other training models incorporate longer term team experiences of a month or more such as the Centers for Sustainment of Trauma and Readiness Skills (C-STARs) program in the U.S. Air Force at centers in Baltimore, St Louis, and Cincinnati.16 The U.S. Army and U.S. Navy also have relationships with civilian training hospitals located in Miami and Los Angeles, respectively. Which of these training models is optimal for pre-deployment training has yet to be determined. This study is limited by the self-reporting nature of the survey instrument. Confidence in a particular procedure or skill set is a subjective measure and cannot be easily linked to patient outcomes. Finally, a sampling bias may exist in that the majority of those surveyed had completed a trauma/critical care fellowship at the time of the survey; while the majority of the surgeons that fill FST billets are general surgeons and non-trauma general surgery subspecialists functioning in the role of combat surgeon. Although most of those completing the survey deployed early in their careers prior to fellowship, it is difficult to ascertain the impact of the fellowship training on their combat surgery confidence levels. The aim of this study was to provide preliminary data to guide future investigations. This study does provide the foundation for exploring and developing both existing and novel training methods to better prepare combat surgical teams. CONCLUSION Training programs and years of general surgery practice do not replace FSTE among military surgeons. Pre-deployment training that mimics FST skill sets should be developed to improve military surgeon confidence and outcomes. Conflict of Interest Drs D.J.M. and C.W.S previously served as surgeons in the U.S. Navy. Dr Polk currently serves as a surgeon in the U.S. Navy, there are no financial conflicts of interest to report. This paper was presented at the European Congress for Trauma and Emergency Surgery, May 10, 2015. References 1 Ramasamy A , Hinsley DE , Edwards DS , Stewart MPM , Midwinter M , Parker PJ : Skill sets and competencies for the modern military surgeon: lessons from UK military operations in Southern Afghanistan . Injury 2010 ; 41 : 453 – 459 . Google Scholar CrossRef Search ADS PubMed 2 Eastridge BJ , Mabry RL , Seguin P , et al. : Death on the battlefield (2001-2011): implications for the future of combat casualty care [correction published in J Trauma Acute Care Surg. 2013;74(2):706] . J Trauma Acute Care Surg 2012 ; 73 ( 6 suppl 5 ): S431 – S437 . Google Scholar CrossRef Search ADS PubMed 3 Tyler JA , Ritchie JD , Leas ML , et al. : Combat readiness for the modern military surgeon: data from a decade of combat operations . J Trauma Acute Care Surg 2012 ; 73 ( 1 ): S64 – S70 . Google Scholar CrossRef Search ADS PubMed 4 Rasmussen TE , Gross KR , Baer DG : Where do we go from here? Preface. US Military Health System Research Symposium . J Trauma Acute Care Surg 2013 ; 75 ( 2 Suppl 2 ): S105 – 6 . Google Scholar CrossRef Search ADS PubMed 5 Blackbourne LH , Baer DG , Eastridge BJ , et al. : Military medical revolution: prehospital combat casualty care . J Trauma Acute Care Surg 2012 ; 73 ( 6 Suppl 5 ): S372 – 7 . Google Scholar CrossRef Search ADS PubMed 6 Trunkey DJ : Excelsior Surgical Society Edward D Churchill Lecture. Changes in combat casualty care . J Am Coll Surg 2012 ; 214 ( 6 ): 879 – 91 . Google Scholar CrossRef Search ADS PubMed 7 Schwab CW : Winds of war: enhancing civilian and military partnerships to assure readiness: a White Paper . J Am Coll Surg 2015 ; 221 : 235 – 254 . Google Scholar CrossRef Search ADS PubMed 8 Schwab CW : Crises and war: stepping stones to the future . J Trauma Acute Care Surg 2007 ; 62 : 1 – 16 . Google Scholar CrossRef Search ADS 9 Elster E , Butler F , Rasmussen T : Implications of combat casualty care for mass casualty events . JAMA 2013 ; 310 ( 5 ): 475 – 476 . Google Scholar CrossRef Search ADS PubMed 10 Pruitt BA : The symbiosis of combat casualty care and civilian trauma care: 1914–2007 . J Trauma 2008 ; 64 : S4 – S8 . Google Scholar CrossRef Search ADS PubMed 11 Eibner C : Maintaining Military Medical Skills During Peacetime: Outlining and Assessing a New Approach . Santa Monica, CA, Rand Corporation, 2008 . Available at: www.rand.org. https://www.rand.org/pubs/monographs/MG638.html; accessed April 24, 2016. 12 Hight RA , Salcedo ES , Martin SP , Cocanour CS , Utter G , Galante JM : Level I academic medical center integration as a model for sustaining combat surgical skills: the right surgeon in the right place for the right time . J Trauma Acute Care Surg 2015 ; 78 : 1176 – 1181 . Google Scholar CrossRef Search ADS PubMed 13 McCunn M , York GB , Hirshon JM , Jenkins DH , Scalea TM : Trauma readiness training for military deployment: a comparison between a U.S. trauma center and an Air Force theater hospital in Balad, Iraq . Mil Med 2011 ; 176 : 769 – 776 . Google Scholar CrossRef Search ADS PubMed 14 Schreiber MA , Holcomb JB , Conaway CW , Campbell KD , Wall M , Mattox KL : Military trauma training performed in a civilian trauma training center . J Surg Res 2002 ; 104 : 8 – 14 . Google Scholar CrossRef Search ADS PubMed 15 Schulman CI , Graygo J , Wilson K , Robinson DB , Garcia G , Augenstein J : Training forward surgical teams: do military-civilian partnerships work? US Army Med Dep J 2010 ; Oct-Dec : 17 – 21 . 16 Thorson CM , Dubose JJ , Rhee P , et al. : Military trauma training at civilian centers: a decade of advancements . J Trauma Acute Care Surg 2012 ; 73 ( 5 ): S483 – S489 . Google Scholar CrossRef Search ADS PubMed 17 Tyler JA , Clive KS , White CE , Beekley AC , Blackbourne LH : Current US military operations and implications for military surgical training . J Am Coll Surg 2010 ; 211 : 658 – 662 . Google Scholar CrossRef Search ADS PubMed 18 Eardley WGP , Taylor DM , Parker PJ : Training Tomorrow’s Military Surgeons: Lessons from the Past and Challenges for the Future . JR Army Med Corps 2009 ; 155 ( 4 ): 249 – 252 . Google Scholar CrossRef Search ADS Author notes The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any agency of the U.S. government. © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Military MedicineOxford University Press

Published: Jun 28, 2018

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