Basil A. Pruitt

Decreasing killed in action and died of wounds rates in combat wounded.

Abstract : Combat Demographics From retrospective analysis, the majority of potentially survivable injuries resulting in death on the battlefield and after reaching a surgical facility are caused by hemorrhage. In combat, hemorrhage is the cause in 83% to 87% of all such potentially survivable deaths. Of these deaths, approximately 50% are attributed to noncompressible hemorrhage from penetrating truncal injury (Fig. 1). Therefore, the primary target for making a significant impact on death in combat, both before (killed in action [KIA]) and after reaching a deployed surgical facility (died of wounds [DOW]), is to address noncompressible hemorrhage from penetrating truncal injury. Because of the potential for prolonged evacuation time during combat operations and the relatively limited options available for treatment of truncal penetrating injury before admission to a surgical facility, the prehospital phase of evacuation offers the greatest opportunity to mitigate the hemorrhagic sequels of battlefield injury.

Malpractice risk and cost are significantly reduced after tort reform

BACKGROUNDnRising medical malpractice premiums have reached a crisis point in many areas of the United States. In 2003 the Texas legislature passed a comprehensive package of tort reform laws that included a cap at

An historical perspective on advances in burn care over the past 100 years.

250,000 on noneconomic damages in most medical malpractice cases. We hypothesized that tort reform laws significantly reduce the risk of malpractice lawsuit in an academic medical center. We compared malpractice prevalence, incidence, and liability costs before and after comprehensive state tort reform measures were implemented.nnnSTUDY DESIGNnTwo prospectively maintained institutional databases were used to calculate and characterize malpractice risk: a surgical operation database and a risk management and malpractice database. Risk groups were divided into pretort reform (1992 to 2004) and post-tort reform groups (2004 to the present). Operative procedures were included for elective, urgent, and emergency general surgery procedures.nnnRESULTSnDuring the study period, 98,513 general surgical procedures were performed. A total of 28 lawsuits (25 pre-reform, 3 postreform) were filed, naming general surgery faculty or residents. The prevalence of lawsuits filed/100,000 procedures performed is as follows: before reform, 40 lawsuits/100,000 procedures, and after reform, 8 lawsuits/100,000 procedures (p < 0.01, relative risk 0.21 [95% CI 0.063 to 0.62]). Virtually all of the liability and defense cost was in the pretort reform period:

The Symbiosis of Combat Casualty Care and Civilian Trauma Care: 1914-2007

595,000/year versus

Preparing the surgeon for war: present practices of US, UK, and Canadian militaries and future directions for the US military.

515/year in the postreform group (p < 0.01).nnnCONCLUSIONSnImplementation of comprehensive tort reform in Texas was associated with a significant decrease in the prevalence and cost of surgical malpractice lawsuits at one academic medical center.

The role and value of surgical critical care, an essential component of Acute Care Surgery, in the Affordable Care Act: A report from the Critical Care Committee and Board of Managers of the American Association for the Surgery of Trauma

The accelerated pace of clinical and laboratory research over the past century and application of the research findings to patient care have resulted in unprecedented survival of burned patients in all age groups. Resuscitation based on an understanding of the nature and magnitude of the multisystem response to injury now prevents burn shock; effective topical antimicrobial chemotherapy and early excision prevent wound toxemia and sepsis; biologic and bioengineered dressings compensate for the missing skin; and broad spectrum metabolic support regimens prevent exhaustion and accelerate convalescence. Rehabilitation programs have also been developed to restore physical function and permit the burn patient to reenter society as a productive individual.

Vietnam (1972) to Afghanistan (2014): The state of military trauma care and research, past to present

Abstract : Over the past 93 years, experience in the care of combat casualties and biomedical research activities by the U.S. military, focused on the problems occurring in combat casualties, have contributed significantly to overall surgical progress. Treatment refinements developed during wartime and research findings generated during conflict and the interbellum periods have been transferred to the civilian community to improve the care of all trauma patients. Similarly, technological developments and research findings generated in civilian laboratories have been readily integrated into military trauma care. Advances in wound care include effective topical antimicrobial chemotherapy for burns and other problem wounds, and the use of infection monitoring and surveillance systems to facilitate infection control in the ICU. Refinements of fluid resuscitation have essentially eliminated acute renal failure as a complication in combat casualties and have identified the hazards of excessive resuscitation (which are of considerable current interest). Civilian trauma patients have benefited by the transfer of prophylactic hemodialysis, the use of high pressure interrupted flow-positive pressure lung-protective ventilation, and the development of full-spectrum metabolic support regimens. The organization and delivery of civilian trauma care has been materially enhanced by adopting and adapting the military use of helicopters for patient transport and the establishment of trauma and burn centers within hierarchical regional trauma systems. This article reviews the advances in combat casualty care and civilian trauma care that have occurred from 1914 through 2007, and the symbiotic quality of the relationship between the two systems of care. The review encompasses World War I, World War II, the Korean War, the Vietnam War, advances in burn care, Operations Desert Shield/Desert Storm, and Operations Enduring Freedom and Iraqi Freedom.

Pathophysiology, research challenges, and clinical management of smoke inhalation injury

T Armed Forces of the United States and their North Atlantic Treaty Organization (NATO) partners continue to be engaged around the world in regions of conflict. Consequently, combat casualty care is a central focus of the military medical community. Accordingly, present deployment requirements demand the sustaining of a significant number of ready and capable trauma surgical providers to optimize outcome for injured combat casualties. Preparing a surgeon for war requires the development and maintenance of skill sets unique to the combat environment. Although modern graduate medical education (GME) surgical training provides civilian trauma case experience with a wide range of experience, it does not adequately prepare graduates of these programs for the injury patterns specific to the battlefield environment. Even among more senior surgical providers, the civilian practice does not adequately prepare the surgeon for combat experiences. Vascular trauma, as a particular example, constitutes a significant portion of the injuries observed in the setting of warfare; yet, the acquisition of the open surgical skills necessary to effectively manage these injuries continues to be considerably challenged both by recent changes in surgical training case volume and the increased use of endovascular techniques. Each branch of the US Armed Services, as well as Canadian and UK NATO partners, has established predeployment training efforts designed to prepare surgeons for dealing effectively with combat-injured. In the United States, these programs began with programs initiated at Ben Taub General Hospital in 1999 and have continued to evolve. Present efforts are highly varied, however, in their constructs and conduct between US branches and NATO partners. There is also evidence to suggest that these programs are not effectively used by deploying surgeons, at least among US military providers. A recent survey of 137 active-duty US military surgeons from all three services revealed that only 44% had attended any form of combat-related trauma predeployment course. The authors have examined the present trauma surgical readiness practices of the US Military Medical Corps, both active and reserve components as well as those of our Canadian and UK NATO partners. Members of each of those medical services have described the present requirements for their surgical community. Capabilities and challenges of each unique community are examined. In final consideration of these efforts, we provide potential options for further optimization of surgical readiness efforts for both present and future conflicts.

Reflection: Evolution of the Field over Seven Decades

Heidi L. Frankel, MD, Karyn L. Butler, MD, Joseph Cuschieri, MD, Randall S. Friese, MD, Toan Huynh, MD, Alicia M. Mohr, MD, Miren A. Schinco, MD, Lena M. Napolitano, MD, L.D. Britt, MD, MPH, Raul Coimbra, MD, PhD, Martin A. Croce, MD, James W. Davis, MD, Gregory J. Jurkovich, MD, Ernest E. Moore, MD, John A. Morris, Jr., MD, Andrew B. Peitzman, MD, Basil A. Pruitt, MD, Grace S. Rozycki, MD, MBA, Thomas M. Scalea, MD, and J. Wayne Meredith, MD, Baltimore, Maryland

one front and one battle: Civilian professional medical support of military surgeons

As the United States approaches the terminal phases of the 13-year war in Afghanistan, it is appropriate to take stock of the current state of military trauma care and research and compare that with what existed during the terminal stages of the lengthy conflict in the Republic of Vietnam (RVN) 41 years ago. Like all major transitions in history, relevant observations can bemade and lessons learned by considering the evolution and improvements in the organization and delivery of combat casualty care that have occurred during the years between thewar in the RVN and the wars in Afghanistan and Iraq (Figs. 1Y2). That review has identified the genesis ofmany aspects of currentmilitary trauma care and illuminated the maturation of care over the past four decades that has improved the outcomes of injured war fighters. Improvement in military trauma care can be related to changes in personnel resources, development of a joint service trauma system, and the application of knowledge and material solutions generated by a military-specific trauma research program.