Military data supporting damage control resuscitation has altered civilian practice

November 23, 2015

A new study that surveyed Trauma Medical Directors (TMD's) at 245 trauma centers has found that damage control resuscitation (DCR) practices that originated in military settings have been widely adapted in civilian practices across the United States. The study, "Military to civilian translation of surgical battlefield innovations in surgical trauma care," is published in the December issue of Surgery.

The study found that the majority (67.8 percent) of responding TMD's indicated routine use of a blood product ratio of 1:1:1 (packed red blood cells: frozen fresh plasma: platelets). Usage of this ratio, which emulates the natural ratio of components in whole blood, has been shown to increase patient survival rates. Usage of the ratio originated in military settings, where whole blood is typically more readily available. Additionally, more than 95% of responding TMD's had adopted a written massive transfusion protocol (MTP). Military influence was directly credited in the majority of cases. TMD's reported that military data supporting DCR has significantly altered civilian practice at their institutions and that this strategy is now strongly practiced in large and small trauma centers alike.

This study is published just months after the Institute of Medicine has established an ad hoc committee, intended to understand the "military trauma care's learning health system and its translation to the civilian sector."

"Historically, many improvements in trauma care have been observed during war and innovations made on the battlefield due to the large and concentrated number of severely injured patients," explained Colonel Lorne Blackbourne, former commander of the U.S. Army Institute Of Surgical Research and last author of the study. "The objective of this work in particular was to gauge the extent to which recent battlefield innovations used in the conflicts in Iraq/Afghanistan have been adapted to civilian practice. The U.S. military is honored to make even a small contribution to the improvement in civilian trauma care-from which the U.S. military has gained immense advancements due to the tireless efforts in research in civilian trauma during the times of peace."

"Historically, improvements in operative trauma care have been driven by war and innovations on the battlefield," explained Colonel Lorne Blackbourne, commander of the U.S. Army Institute of Surgical Research and last author of the study. "The objective of this work in particular was to gauge the extent to which recent battlefield innovations used in the conflicts in Iraq/Afghanistan have shaped civilian practice."

To determine which interventions to include, the study's authors gathered an expert physician/surgeon panel, consisting of representatives from both military and civilian trauma and the emergency medical field. Using a modified Delphi method, the panel collectively identified four types, or domains, of interventions for which the military had published significant clinical data: (1) DCR (2) tourniquet use, (3) use of hemostatic agents, and (4) prehospital interventions, including intraosseous catheter access and needle thoracostomy.

Based on panel recommendations, a 47-question survey was designed and administered to TMD's at 630 trauma centers across the country to assess the relevance and function of each of the four domains. Of these, 245 responded. TMD's reported high civilian use of DCR; but only mixed adoption of the other three interventions corresponded to expressed concerns regarding the extent of concomitant civilian research to support military research and experience.

"It's clear that civilian researchers have a significant role to play in terms of conducting research that builds trauma surgeon awareness of military techniques and their translation to civilian settings," said Adil Haider, MD, MPH, Kessler Director of the Center for Surgery and Public Health at Brigham and Women's Hospital, lead author of the study. "Governing bodies and supporting agencies like the IOM also have an important role to play in terms of fostering partnerships between military and civilian trauma centers. The sharing of best practices and dissemination of findings will be essential as we look to broaden the evidence base for battlefield innovations not just to improve care for frontline soldiers in future combat operations, but to improve civilian trauma care as well."
Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 4.2 million annual patient visits and nearly 46,000 inpatient stays, is the largest birthing center in Massachusetts and employs nearly 16,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagement and educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Brigham Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, more than 1,000 physician-investigators and renowned biomedical scientists and faculty supported by nearly $600 million in funding. For the last 25 years, BWH ranked second in research funding from the National Institutes of Health (NIH) among independent hospitals. BWH continually pushes the boundaries of medicine, including building on its legacy in transplantation by performing a partial face transplant in 2009 and the nation's first full face transplant in 2011. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies and the Women's Health Initiative as well as the TIMI Study Group, one of the premier cardiovascular clinical trials groups. For more information, resources and to follow us on social media, please visit BWH's online newsroom.

Brigham and Women's Hospital

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