Shortly after the attacks on the United States on September 11, 2001, the military responded with significant combat operations in Afghanistan and then Iraq. As general and trauma surgeons, we were among the most heavily deployed of the military medical specialties and maintained a sustained high operational tempo for over a decade and one that continues to this day. The authors of this chapter have all had the relatively unique experience of serial deployments from the earliest phases of combat operations, through the “surges” in both Iraq and Afghanistan, and continuing now during the relatively quieter and lower volume phases of these operations. What became readily apparent to all of us during our initial deployments was that we had put in place all of the individual elements of a standard military combat casualty care system, but we lacked a true robust and overarching “trauma system” like we have seen in civilian trauma care in the United States. There was no routine patient-level data collection and no trauma registry , no identification and analysis of adverse events (complications, deaths, errors in management), no real-time data analysis or system-wide efforts at process and/or quality improvement, and no one person or organization with responsibility for this key aspect of trauma care. The system was effective, care was provided, and patients were processed through the continuum efficiently, but it was readily apparent that there were problems that needed to be addressed. We saw things like incomplete (or omitted) fasciotomies, failures to apply damage control surgery principles, primary closure of contaminated combat wounds, adverse events occurring during patient transfer between facilities, and poor communication/coordination of care along the continuum from the point of injury to the Role 4 (Landstuhl) and 5 (United States) facilities. Fortunately, this missing element was identified and led to the establishment, introduction, and growth of a robust in-theater trauma system that included routine data collection and entry into a custom trauma registry , vigorous QI/PI processes and oversight, the development of evidence-based clinical practice guidelines for combat trauma care , and the coordination of communication and information exchange across all echelons of battlefield care. This chapter describes that process, the key elements of this incredibly important endeavor, and the current status and future plans for this system.

One of the benefits of providing medical care in a combat zone is the freedom from many of the administrative hassles, burdensome regulations/policies, and endless paperwork that has come to characterize modern medicine and surgery. Asking a trauma surgeon at a busy forward deployed Role 2 or Role 3 facility to stop and fill out a data sheet for abstraction into a trauma registry can be (and was) a tough sell, particularly if the downstream benefits of that administrative task are not readily apparent. However, the immediate impact of this trauma system and the improvements in care that were seen became quickly obvious to even the most cynical providers and have even now been used by civilian experts as a model of a “learning health system.” As a deployed provider, you are now a key and important part of that system. We implore you to support it, champion it, and most importantly ensure that it continues to be utilized, enhanced, and improved. We should never again go to war without a true robust trauma system in place and on the ground from day 1 of combat operations.

Trauma care requires a myriad of disciplines, sites of care (both within health-care facilities and outside health-care facilities), and planning for trauma care. A system is necessary to ensure the multiple individuals are trained, material resources are available, and the various resources are arrayed to ensure optimal care. In general terms a system is “a regularly interacting or interdependent group of items forming a unified whole.” The concept of a trauma system can more readily be understood by an analogy to another commonly referenced system.

A regional transportation system offers a reasonable example of a system. Transportation systems coordinate logistics of the numerous component elements required to move people and goods utilizing multiple modes of transport in order to optimize efficiency and value. It is intuitive that an area with a planned transportation system with oversight would provide better service than an area with an ad hoc arrangement of travel in a region. Key to oversight is leadership with an understanding of transportation and the region.

The origins of trauma systems in the US civilian experience can be dated back to a report in 1966 from the National Academy of Sciences. The title “Accidental Death and Disability: The Neglected Disease of Modern Society” clearly described the problems with trauma care as it existed in more than 50 years ago [3]. Although not specifically identified as a system in this report, this recommendation for the development of organizations of community councils on emergency medical services to link to a national trauma association sought to remedy the lack of coordination of trauma care. The current stateside model of regional advisory councils for trauma (endorsed by the individual states) with the regional advisory council leaders interacting with their State Committees on Trauma and the American College of Surgeons Committee on Trauma through their regional leadership can be clearly seen in the recommendations in the 1966 report.

Trauma systems became incorporated into stateside trauma care in earnest in the 1980s and 1990s. The impact of a functioning trauma system on outcomes became clear in the late 1990s. Mature trauma systems were felt to decrease morbidity and mortality between 15% and 20% [4]. Of note, the use of the National Trauma Data Bank as championed by the American College of Surgeons Committee on Trauma served as a way to obtain data. Also, the need for a trauma registry had been identified in the 1966 report.

The military experience of rudimentary trauma systems dates back centuries. Larrey and Letterman are examples of military medical leaders who recognized the capabilities needed for casualties were not available at the point of injury. The evacuation of casualties off the battlefield to a higher level of care, even though only a short distance away, demonstrated the recognition of interactions in an organized fashion.

The distinction between the earliest battlefield casualty evacuation programs and trauma systems which were employed in the early years of operations in Iraq and Afghanistan is related primarily to the agility to change based upon outcomes. Information describing outcomes in near real-time fashion only became available as effective data capture, analysis, and application occurred. For all practical purposes, the data capture in near real-time fashion only occurred since 2000. No doubt improvements in practice, materiel, and array of trauma assets have occurred for as long as there has been war. A hallmark of a trauma system is the organization and incorporation of this learning concept .

A report by Mullins and colleagues [4] identified the benefits of trauma systems in the late 1990s. When war developed in response to the September 11 attack on the World Trade Center and Pentagon, the concepts of trauma systems had yet to be incorporated into the US military medical planning. COL (accepted Army abbreviation) John Holcomb, Commander of the US Army Institute of Surgical Research, traveled to Iraq for a survey of trauma care. The survey was conducted in May 2003, 2 months after onset of hostilities. He identified no trauma system existed in Iraq. Medical planning had indeed been conducted, but in many circumstances, the planning was service specific. COL Holcomb, LtCol (corrected rank with accepted US Air Force abbreviation at time cited) Don Jenkins (US Air Force), and LTC (accepted US Army abbreviation) Brian Eastridge (US Army Reserve) proposed the establishment of a theater trauma system for the entire battlespace. The proposal to establish a Joint Theater Trauma System for the US Central Command (CENTCOM) area of responsibility was approved by Col Doug Robb, CENTCOM Command Surgeon .

Critical to the success of the Joint Theater Trauma System (JTTS) was assigning the Director of the JTTS directly responsible to the CENTCOM Surgeon. By doing so, the JTTS Director served as the CENTCOM Surgeon’s advisor on combat casualty care. For issues in the CENTCOM area of responsibility that could not be resolved locally by the JTTS Director, the CENTCOM Surgeon would provide direction. This command oversight was imperative in the complex environment of a theater of operations. Over the subsequent decade-plus of sustained combat operations in Iraq and Afghanistan, the JTTS achieved unparalleled success in data collection, real-time data analysis, and robust evidence and data-based quality/process improvement initiatives. The implementation of the JTTS, now known as the Joint Trauma System (JTS ) as it encompasses care along the entire continuum and not just “in theater,” is widely credited for achieving improved battlefield survival despite an increase in the average injury severity.

The benefits of the JTTS were recognized by leaders of the military health system. To ensure the US military does not go to war in the future without a trauma system, the Department of Defense Instruction (dated 28 September 2016) established a Combatant Command Trauma System (CTS) modeled after the JTTS [5].

The Combatant Command Trauma System (CTS) is to be modeled after the Joint Theater Trauma System (JTTS). No doubt the CTS will adapt to fit the relevant battle space and contingency. However, the JTTS as deployed in Iraq and Afghanistan will serve as a frame of reference as each Combatant Command develops its own trauma system. The CTS of Pacific Command will look much different than the JTTS of Central Asia Command of 2001–2015. And the CTS of Central Asia Command in 2025 will look much different than the JTTS of Central Asia Command of 2001–2015. The CTS is to be scalable to contingency requirements. The CTS may also maintain operations between contingencies to sustain capability for rapid expansion and adaptation based upon the Combatant Command’s requirements. In the face of the variations in region and contingencies, to follow will be general guidelines for personnel and roles to be considered during contingencies. CTS members may be of active or reserve component of all three services.