Military Surgical Training Evolves Through Civilian Partnerships

Alex Jahangir, M.D., left, with Daniel Stinner, M.D.
Military Surgical Training Evolves Through Civilian Partnerships
Alex Jahangir, M.D., left, with Daniel Stinner, M.D.
With military trauma cases declining, a new program addresses gaps in readiness and research.

Despite significant unrest and deployment of U.S. troops in various regions of the world, the number of trauma cases treated at military treatment facilities (MTFs) has declined both in deployed environments and stateside – the opposite trend of that seen at civilian trauma centers (CIV CENs) in the U.S., where trauma cases have remained steady or increased.

With fewer high-level trauma cases, the U.S. military medical system faces a challenge when it comes to training surgeons and maintaining surgical skills, as well as conducting clinical trials, says Lieutenant Colonel Daniel Stinner, M.D., assistant professor of orthopaedic surgery at Vanderbilt University Medical Center and an active-duty Army officer.

“We need more training on trauma surgical cases to ensure that a surgeon has the appropriate knowledge and skillsets to take into the deployed environment.”

“We need more training on trauma surgical cases to ensure that a surgeon has the appropriate knowledge and skillsets to take into the deployed environment,” Stinner said. “Research in the past looked at the case volume of trauma patterns; trauma volume isn’t enough to sustain training and experience.”

Stinner is leading a new partnership between Vanderbilt and Fort Campbell, a U.S. Army installation located 50 miles from Nashville, that will address the shortfall in available cases through one of the army’s first military-civilian collaborations to implement a surgical cross-training initiative between CIV CENs and MTFs.

Re-envisioning Trauma Training

There is a growing body of research that demonstrates the importance of military and civilian partnerships for military surgeons to maintain complex trauma skills. Two such studies were published in Military Medicine in 2017, one of which included work done with the Major Extremity Trauma Research Consortium (METRC), an initiative funded by the U.S. Department of Defense.

The studies compared the number and types of extremity injuries treated at CIV CENs and MTFs and evaluated the viability of cross-training programs at CIV CENs to address current priorities for combat casualty care. Stinner was a co-author on both papers. “Although the studies focused on specific orthopaedic trauma cases deemed essential to combat casualty care, similar results have been shown for general surgery,” he said.

Stinner spends four days per week at Vanderbilt and one day at Fort Campbell’s Blanchfield Army Community Hospital to assist in orthopaedic trauma care and education. The army will be sending a surgical team to Vanderbilt soon, and efforts are underway to bring trauma surgeons and surgical teams from Blanchfield to Vanderbilt for training. Ultimately, it is hoped that entire military surgical teams will function as full-time faculty and work together in CIV CENs.

“The Army is moving toward formalized military-civilian partnerships because they’ve realized the need to train military surgeons and surgical teams where they can be exposed to high-level trauma care,” said Alex Jahangir, M.D., director of the Division of Orthopaedic Trauma at Vanderbilt University Medical Center. “As the only Level 1 trauma center in the region, Vanderbilt provides a wide range of complex trauma cases in addition to intensive surgical education.”

“Furthermore, because of our long history of partnership with Fort Campbell and the U.S. Army, as well as a strong commitment from the leadership of VUMC, our ability to partner with Fort Campbell and become one of the first models of military-civilian collaborations emphasizing trauma care is a natural next step in our relationship,” Jahangir said.

“Because of our long history of partnership with Fort Campbell and the U.S. Army, as well as a strong commitment from the leadership of VUMC, our ability to partner with Fort Campbell and become one of the first models of military-civilian collaborations emphasizing trauma care is a natural next step in our relationship.”

Innovations in Trauma Recovery

Another benefit of the partnership is that it will provide more cases for research. Stinner is the principal investigator on two multi-site trials testing new protocols for orthopaedic recovery. “A trauma patient’s challenges don’t end with the acute phase of treatment,” he said. “Most patients require rehabilitation and post-acute services to optimize recovery and reintegration back into military service and everyday life.”

The Rehabilitation Enhanced by Partial Arterial Inflow Restriction (REPAIR) Study will test restricted blood flow in individuals recovering from a traumatic diaphyseal fracture of the femur. Early Advanced Weight Bearing for Peri-articular Knee and Pilon Injuries (AlterG) will explore the use of an anti-gravity treadmill in patients with distal femur, proximal tibia and distal tibia fractures. “These are both novel interventions for increasing a patient’s weight-bearing ability,” Stinner said. “The goal is to help them heal faster and return to work (or military duty) faster with better functional muscle mass.”

The Final Test: Military Deployment

Stinner just returned from his second combat deployment to Afghanistan. The military-civilian partnership with Vanderbilt prepared him well for his deployment. “My surgical case complexity, frequent exposure to acute trauma, and the daily operational tempo at Vanderbilt was essential to a successful deployment,” he said.

Stinner will have approximately 16 months between military deployments and will use this time to work to improve his ability to care for combat injuries in the deployed environment and train others to do the same. “We’ve been fortunate to work out this appointment at Vanderbilt,” Stinner said. “These types of partnerships are changing the way we do military medical training, ensuring we remain at the forefront of combat casualty care.”