Hippocrates said “war is the only proper school of the surgeon,” and as military surgeons who have deployed, we instinctively know this to be true. When you go to war, you mature your personal surgical skills at an accelerated pace. Oftentimes, experience gained during a single combat deployment is enough to inform the care of civilian trauma patients over an entire career due to the sheer volume and variety of injuries seen in even a short period of war. Similarly during war, the US Military’s medical infrastructure by necessity becomes laser focused on providing an optimal trauma care system throughout the continuum from point of injury and initial lifesaving care in the combat theater all the way back to restoration and rehabilitation of function in the United States (or allied countries).

But where does that leave current trainees and younger surgeons who may not have the opportunity to hone their skills and gain this concentrated experience during war? This is indeed an important question to ask at this juncture, and this point in history is not the first time this question has been raised. However, despite best intentions, history reveals little success at maintaining a combat surgery focus when political and societal will to support this effort wanes in between wars. To this point after World War I, Doctor (Col) Edward D Churchill is noted to have proclaimed, “Surgeons in a current war never begin where the surgeons in the previous war left off; they always go through another long learning period.” This chapter, indeed this entire book, is dedicated to the challenge of preventing this from happening yet again.

The purpose of military-civilian collaboration in our current reality of continued conflict, not only abroad but also at home, is to pass along lessons learned to ensure surgeons are prepared for combat in foreign lands and to ensure surgeon readiness in support of national preparedness on the home front. In this chapter, we will discuss several of these recent and ongoing efforts in military-civilian collaboration.

There is a notable historic precedent for civilian participation in the care of the injured during war. Particularly memorable is the leadership of the aforementioned Dr. (Col) Edward D. Churchill who volunteered during World War II and served as the chief surgical consultant in the North Africa and Mediterranean theaters. In this capacity, he led a deployed surgical unit from Harvard Medical School, making significant clinical contributions including advocacy for the use of whole blood.

Several generations later at the turn of the millennium , we found ourselves involved in war again but this time in Afghanistan and Iraq. Early on in 2003, three members of the American College of Surgeons National Ultrasound Faculty (Dr. David Wherry, Dr. Jon Perlstein, and Dr. M. Margaret Knudson) were granted permission to conduct the first Ultrasound for Surgeons course outside the United States at Landstuhl Regional Medical Center (LRMC) in Germany. At that time, the facility at LRMC was ramping up personnel and resources to care for an increasingly large number of combat casualties returning from Iraq and Afghanistan. Visualizing the extent and complexity of this effort firsthand, they realized a need for senior civilian mentorship and recommended a program to send senior civilian surgeons to collaborate and mentor the military trauma program at LRMC.

Dr. C. William Schwab, then president of the American Association for the Surgery of Trauma (AAST) , and Dr. Wayne Meredith, then chair of the American College of Surgeons Committee on Trauma (ACS-COT), supported the concept of sending senior civilian surgeons to LRMC, in both a teaching and an observer role. The idea also gained positive support through military leadership at the time, namely, Lt. Gen P. K. Carlton, retired Surgeon General of the Air Force and former Air Force Governor of the ACS; Dr. Charles Rice, then President of the Uniformed Services University; and Dr. Ben Eiseman, RADM (retired). Thus, the Senior Visiting Surgeons (SVS) Program was established in 2006 through a combined effort of the AAST and the ACS-COT. The objective of the program was to provide a 2–4-week tour for senior civilian trauma surgeon mentors at LRMC. Dr. C. William Schwab, the first SVS, arrived in Germany in August 2006. The real-time presence of senior-level trauma surgeon expertise provided the surgeons and the whole trauma team at LRMC access to some of the most experienced and respected surgeons in the United States. These senior leaders participated in clinical care of injured service members, contributed to education of junior surgeons and trauma staff, served as side-by-side clinical mentors, and provided expert opinion during performance improvement activities.

An early report on this collaboration by Moore and colleagues offered several examples demonstrating immediate benefit. Grand rounds introduced to military surgeons the novel technique of pre-peritoneal pelvic packing as a damage control technique for exsanguinating pelvic hemorrhage. ICU protocols at LRMC were adapted from the National Institutes of Health Inflammation and the Host Response to Injury research effort. Finally, this early SVS effort in improving the quality of trauma care delivered by the facility assisted LRMC in attaining verification as a Level II trauma center from the ACS-COT in 2007.

Within a short time, surgeons from the Society of Vascular Surgeon, orthopedic societies, and neurosurgical societies were also participating in this program as senior mentors. A review and survey of participants of this program through 2013 revealed 192 participating surgeons. Seventy-eight participated in one tour at LRMC, 13% participated in two tours, and three surgeons participated in more than four tours each. Overall, SVS surgeons participated in two to five operations per week with the most prevalent being debridement of wounds and burn care. Of significant note, Dr. M. Margaret Knudson was able to extend this relationship by volunteering for a tour with the Air Force Theater Clearing Hospital in Balad, Iraq. Several other key civilian leaders in trauma surgery were able to journey beyond Landstuhl and spend time at combat medical facilities in Iraq or Afghanistan (Fig. 48.1). In 2014, a final review of the SVS program also emphasized military-civilian translatable lessons learned and advice for the utilization of the SVS program in times of reduced military operations. Collaboration in the development of clinical practice guidelines (CPGs) included techniques for complex wound management, venous thromboembolism prevention, and principles of damage control resuscitation and surgery. At the top of the list for suggestions for continued use of the SVS program during peacetime included SVS mentor visits to military hospitals and rotations for military surgery residents at civilian trauma centers. The full list of recommendations is shown in Table 48.1.

Lastly, the authors recommended continued collaboration in three important areas. First, military surgeons should maintain their combat readiness in busy civilian trauma centers during peacetime to ensure preparedness to deploy and to be optimally prepared to care for the very first injured American. Second, military and civilian trauma leaders should collaborate in the development of the optimal clinical care and trauma system response for mass casualty events caused by natural or man-made disasters . Lastly, in between wars, critical military combat casualty care research should proceed without interruption and with funding appropriate to an aggressive urgency to be prepared for the next war and to be ready for a mass casualty event on the home front.

In 2014, stakeholders from the US Military and the American College of Surgeons met to discuss and solidify a critical partnership focused on education and training, systems of care, and research and quality improvement. With the successful creation and maturation of the Joint Trauma System (JTS) , the experience and lessons learned by military combat surgeons stationed at the Uniformed Services University and at other training programs, and robust wartime research guided in real time by the Department of Defense’s Combat Casualty Care Research Program, there arose a need to preserve and protect these medical lessons, advances, and experience that were forged by the blood, sweat, and tears of the US and coalition service members injured in battle. The creation of the Military Health System Strategic Partnership with the American College of Surgeons grew out of a shared ethos of both organizations, centered on education, trauma systems, and quality improvement (Fig. 48.2).