The contribution of nurses to combat casualties crosses the broad spectrum of combat operations, from care to injured US and Coalition soldiers, sailors, marines, and airmen to care of enemy combatants to care of innocent bystanders. These nurses have provided technically excellent care, under austere conditions, while maintaining the standards of a safe environment of care. Their depth of compassion and empathy for all in need is truly remarkable. This issue of the Journal of Trauma Nursing demonstrates yet another facet of nursing excellence accomplished during this conflict-enhancement of the profession of nursing by dissemination of information through peer-reviewed publication of their research and performance improvement efforts. In a time of war, this is no small achievement and is appropriately recognized by this publication of a supplement dedicated solely to military nursing, a first for this Journal.
Conflict and war are as old as time itself. Students of military history find countless volumes of information about previous conflicts, dating well back to ancient times. This history provides lessons on every aspect of war including logistics, tactics, strategy, as well as medical care. The evolution of medical care systems supporting combat operations can be traced as far back as at least the Greeks and the Romans, with well-documented advances in the wars of the 20th century (World War I, World War II, and Vietnam War). Now, springing from lessons learned in Operations Iraqi Freedom and Operation Enduring Freedom, we are on the cusp on another landmark advance in combat casualty care.
War creates a crucible for rapid advances in medicine, particularly trauma care, by bringing together a combination of volume of injury and complexity of injury with pressure as a catalyst-the pressure to do your best for men and women sacrificing their life for our freedom. But these advances often cannot be rigorously tested in the environment of war and must be further refined in the better controlled civilian sector. Thus, advances in trauma care are intertwined between the civilian and military sectors. The development of the current system of trauma care found across the United States and many other regions of the developed world can be traced to improvements in care developed in the Vietnam War. These advances were validated in the civilian sector and further refined and enhanced in the civilian sector during the period of relative peace after the Vietnam War. This has resulted in a well-defined system of trauma care established by the Committee on Trauma of the American College of Surgeons.
Military trauma surgeons, trained in the principles and processes established by the Committee on Trauma, recognized the opportunity to improve combat casualty care in Operations Iraqi Freedom and Operation Enduring Freedom by taking the trauma system concepts, now well documented in the civilian sector, back to the military environment. As it became apparent in early 2003 that this conflict was moving into a phase of sustained operations with increasing casualty figures, key military trauma surgeons began the process to integrate these system concepts to the medical plan. These trauma surgeons, with the help of many others, worked with the surgeon's general of the Army, Navy, and Air Force to establish a Joint Theater Trauma System (JTTS) with an integrated Joint Theater Trauma Registry (JTTR). Seeking to ensure that the system moves "the right patient to the right care, at the right place at the right time," the JTTS deployed its first official cell of personnel to the combat theaters in March 2005. Since that time, there has been a continuous presence in theater of a team dedicated to population of the JTTR and maintenance of the JTTS. This team originally consisted of 5 trauma coordinators, 1 trauma nurse manager, and 1 surgeon director and has recently seen the addition of trauma registrars. There have been many advances in care implemented during the course of this conflict, and most, if not all, can be attributed to JTTR data and actions of the JTTS leadership.
The next steps in the implementation of the JTTS are institutionalization and expansion. To institutionalize the JTTS, its concepts and details of execution will be documented and submitted to military leaders for incorporation as doctrine. This will prevent the loss of corporate memory as key leaders retire or leave the system and ensure the advances in trauma system development remain to enhance care in future conflicts. Expansion of the JTTS to a worldwide platform will be another key element to improve care to all combat casualties.
In this current conflict, casualties are evacuated from primarily 1 geographic area of the world-Southwest Asia. However, because American interests are worldwide, the responsibility of the Department of Defense to protect these interests is also worldwide. Because US military forces may be involved in armed conflict in any place where American interests are jeopardized, a worldwide trauma system should be developed to ensure optimal patient care at any point on the globe. Creating a network of integrated trauma centers functioning in a common trauma system would ensure this optimal patient care.
Development of a tiered system of trauma centers placed at key nodes throughout the world is clearly the next step in the development of the JTTS. The definition and characteristics of such a tiered system are well described in the book Resources for Optimal Care of the Injured Patient published by the Committee on Trauma of the American College of Surgeons. This document has provided a framework for the JTTS development to date and, with some modifications for the unique requirements of the military system, could characterize the formation of a worldwide Department of Defense trauma system. Using this model, the desired worldwide coverage could be attained by integrating key existing military hospitals into the JTTS. Existing facilities that could be included in the worldwide JTTS might include the Army hospital in Korea (level 3), the Army medical center in Hawaii (level 1 or 2), the Air Force hospital in Alaska (level 3), the Army hospital in Germany (verified ACS level 2 in 2007), and military hospitals in mainland United States (San Diego, Seattle, San Antonio, and Washington, DC-all as level 1 facilities). Further expansion of the system could include verification/designation of those facilities providing surgical care in a deployed setting.
The tactical and strategic missions of a military hospital vary according to the threat to US interests in their area and priorities of the Department of Defense. In light of this, any such system of integrated trauma centers must accommodate for these changes in mission. For example, a military hospital today might be treating a very small number of patients with trauma and justify resources only of a level 3 trauma center but could easily become a receiving platform for casualties a short time later and justify the resources of a level 2 trauma center. As the JTTS develops, it will need to develop doctrine that describes how to determine the level of resources required and what factors should be considered in upgrading or downgrading the trauma center.
The idea of a worldwide system of integrated military trauma centers is in its infancy, but thanks to advances in this current conflict that are directly attributable to establishing the JTTR and the JTTS, this idea is gaining strength in the military community. This supplement of the Journal of Trauma Nursing is clear evidence that military nursing has risen to meet the professional challenges imposed by this conflict. The alliance between military nursing and the Society of Trauma Nurses that is evident in this supplement should continue to grow and mature. Working together, military nursing and the Society of Trauma Nurses can provide important contributions to the development of a worldwide military trauma system and help bring this idea to reality.