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Lessons Learned From the Military

Koestner, Amy MSN, RN

doi: 10.1097/

President, Society of Trauma Nurses

Corresponding Author: Amy Koestner, MSN, RN, Borgess Trauma Service, 1535 Gull Rd, Ste 005, Kalamazoo, MI 49048 (



It is an honor to write my final president's message in the Journal of Trauma Nursing issue dedicated to recognizing the military contributions that advance the management of trauma care and the development of trauma systems. Lessons learned from the battlefield have a long history of providing improvements in trauma care in civilian medical management.

The 20th century is rich with advancements that have been transformed from the battlefield to trauma centers across the country. World War I established an organized systematic triage approach to trauma care. The Korean War brought the concept of transporting wounded soldiers by helicopter to mobile surgical hospitals on the front line.1,2 The Vietnam War refined helicopter transport system to these field hospitals and influenced postwar federally funded programs that placed helicopters in the United States to assess the impact of air medical transport in the civilian practice in regard to mortality and morbidity.3 Within a few years of the war, St Anthony in Denver, Colorado, started the first hospital-based air medical service in the United States.4 Today there are more than 500 rotor wing services in the United States transporting severely injured patients to trauma centers.4

The Vietnam efforts were also focused on advanced specialty training for field medics, which translated into development of the paramedic role in civilian practice. Many of the lessons learned from Vietnam provided the foundation for trauma team development and the establishment of prehospital protocols including the concept of triaging patients to the appropriate level of care versus the closest hospital. More recent military operations such as the conflicts in the Gulf War, Afghanistan, and Iraq have demonstrated new unique challenges in caring for these injured soldiers and civilians. The current battlefields not only produce the more traditional catastrophic injuries due to penetrating wounds, burns, and complex musculoskeletal injuries but also challenges of blast injuries sustained from improvised explosive devices.1,2,5,6

Unlike earlier conflicts, these blast injuries have resulted in increased incidence of traumatic brain injures and devastating musculoskeletal injuries. They have brought new challenges to robust trauma care in theater and rapid transport to a higher level of care.5 These transports are carried out by the Critical Care Air Transport Team. Literally, the Critical Care Air Transport Team provides state-of-the-art critical care from the battlefield to echelon 4 trauma centers and on to US-based military centers. There have been advancements with early access of ultrasound, damage control surgery, factor VII, and other clotting agents that have further influenced trauma care in trauma centers around the world.

In the world of trauma, there is collaboration and influence from the civilian sector. Collaborative trauma training has been developed between civilian trauma centers and the armed forces to provide intense trauma training and experience at high volume US trauma centers prior to deployment. Military nurses are exposed to managing severely injured patients in an organized systematic approach that can be adapted to the battlefield and other echelon centers. In 2002, Advanced Trauma Care for Nurses was added to the armamentarium of nurses prior to tour of duty deployment.

Civilian trauma care has provided the military services with resources to assist in further system development. Civilian trauma centers have developed robust trauma registries and performance improvement programs. Although the military presents some uniqueness to its “system,” the civilian centers' experience can be applied across many fronts.

In 2007, Landstuhl Regional Medical Center became the first verified level II trauma center outside the United States. Part of the challenge in the military setting was the establishment of the trauma registry to track patients' care elements throughout their treatment phase. Development of a performance improvement process provided further challenges as patient moved from various levels of care in multiple countries. Experienced trauma surgeons and trauma nurses worked in a collaborative effort to develop a foundation of data points unique to the military environment to capture essential aspects of care.

As a civilian trauma program manager, I truly cannot appreciate the leadership skill necessary to integrate the current combat practice of multiple branches of the military together in a cohesive systematic approach to care that can be adapted by all. Many trauma centers struggle to obtain common ground among specialty physicians to establish a standard approach to the patient in a stable environment, let alone in an austere one.

Development of a performance improvement process that addressed guideline compliance and deviations from standards was critical component in evaluating and validating care as this process moved forward.7

Collaborative efforts from the Society of Trauma Nurses civilian leadership and military leadership produced the development of a Military-Trauma Outcomes & Performance Improvement Course. This course was developed to address the specific needs of the military and provide established tools to assist with assessing performance improvement issues and establishing avenues to facilitate loop closure.

Our nursing history remains rich with examples of nursing leaders that provided a foundation for trauma care. One of history's most famous nurses is Florence Nightingale. She is well-known for her contributions to improving care and decreasing the mortality during the Crimean War. Florence Nightingale went beyond bedside care and recognized the environmental factors of war and their influence on wound healing and death. She championed many of the principles that directed nursing practice even today. Her collaborations with physicians, administrators, and policy makers created structure that guides both military and civilian trauma nurses today.8

As I look at the achievement of trauma nurses today and how we have formed bridges to collaborate and share our knowledge, experience, and expertise to ensure that trauma patients are provided quality care whether they be victims of war or common citizens, it6 takes a special dedication and courage to be a nurse serving in the armed forces today. I salute trauma nurses who work to provide the best care to military personnel while often placing themselves at personal risk. Your efforts are recognized and truly make a difference.

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1. Hoff W, Schwab C. Trauma system development in North America. Clin Orthop Relat Res. 2004;422:17–22.
2. Tracy E. Combining military and civilian trauma systems: the best of both worlds. Top Emerg Med. 2005;27(3):170–175.
5. Blood C, Puyana J, Pitlyk P, et al. An assessment of the potential for reducing future combat deaths through medical technologies and training. J Trauma. 2002;53(6):1160–1165.
6. Zietzer M, Brooks J. In the line of fire: traumatic brain injury among Iraq war veterans. AAOHN J. 2008;56(8):347–353.
7. Trunkey D. In search of solutions. J Trauma. 2002;53(6):1189–1191.
8. Gill C, Gill G. Nightingale in scutari: her legacy reexamined. Clin Infect Dis. 2005;40:1799–1805.
© 2008 Lippincott Williams & Wilkins, Inc.