Joint Trauma System

In this episode of Frontline Surgery: Mastering Military Trauma Care, host Dr. Joshua Dilday is joined by Dr. Jennifer Gurney, Chief of the Joint Trauma System (JTS), and Dr. Mike Van Gent, Chief of the Defense Committee on Trauma, to discuss the JTS and how it shapes combat casualty care from the point of injury through recovery. The conversation unpacks the JTS operational cycle of act, learn, and adjust, how clinical practice guidelines are developed and continuously updated, and why documentation and performance improvement are not bureaucratic exercises, but life-saving ones.

The episode makes a direct case for why early-career military surgeons need to understand the JTS before they deploy, not after. From weekly Thursday PI calls to real-time trauma log reviews to the growing library of nearly 90 CPGs, the JTS is the infrastructure behind every good outcome on the battlefield. As Dr. Gurney puts it: if you take care of combat casualties and you write it down, you are already part of the system.

Literature Mentioned:
JTS CPG: Damage Control Resuscitation
JTS CPG: Damage Control Resuscitation in Prolonged Field Care
JTS CPG: Prehospital Blood Transfusion

Transcript

SPEAKER_00 0:01

When we entered the conflicts in Iraq and Afghanistan, service members died because we didn't have a data-driven, leadership-invested trauma system. We had stuff, we didn't have a joint trauma system.

SPEAKER_03 0:12

It's another version of Phone Afriend, but also, you know, a bunch of subject matter experts that have are either currently doing it or have done it for a long time that are there to help, you know, this the coalition of the well-hand.

SPEAKER_02 0:26

Enter the world of military trauma surgery with frontline surgery, where we bring you expert insights and real-world scenarios to help surgeons stay ready.

SPEAKER_01 0:35

Brought to you by the AST Military Committee. Join us as we engage in conversations with field experts, examine critical battlefield scenarios, and uncover the strategies that keep surgeons ready for anything.

SPEAKER_02 0:47

Stay prepared and stay sharp with Frontline Surgery, where every episode provides key insights into mastering military trauma care. Well, welcome to Frontline Surgery, Mastering Military Trauma Care. Again, I'm Joshua Dilde, and to review, this series is designed to prepare early career military surgeons for the realities of deployed trauma care and the systems that support it. And that's what we're focusing on today's episode. This episode focuses on the Joint Trauma System, or the JTS, organization that has fundamentally shaped modern military trauma care internationally. From evidence clinical practice guidelines to trauma system performance improvement. The JTS has become the backbone of combat casualty care in an increasingly important bridge between military and civilian trauma systems. And because of that, we're joined by the leaders of the JTS. We've got repeat guests, multiple repeat guests, frontline surgery, Mike Van Gent, the Chief of the Defense Committee on Trauma. Guys, thank you so much for joining us. Welcome for the first time for Mike and repeat guest, Colonel Gurney. Thank you for joining us on Frontline Surgery today.

SPEAKER_00 1:55

Thank you, Joshua Dilde. Thanks for your incredible leadership with this podcast that's doing so well. Appreciate all the work that you and the AST has done. And welcome, MVC.

SPEAKER_03 2:06

Yeah, thanks, Josh. Thank you very much. It's a pleasure to be here. Appreciate it.

SPEAKER_02 2:10

Well, thank you guys for joining us. Now, for every episode, we always start with a clinical scenario. And because this is focusing on the joint trauma system, we're still going to start with that scenario, but we're going to dive into what the JTS can do when all that dust settles. So for the for the listeners and everyone on the podcast, just imagine we're in a deployed forward surgical element. It's a high operational tempo. You've got a severely injured casualty, multi-system blast injuries, comes in in profound hypovolemic shock. Team rapidly activates everything from massive transfusion protocols, TXA is given, damage control principles have followed, and we're able to prepare the patient for evacuation. We're doing high fives, we're doing good AERs, everyone's kind of on that rise that that high of good combat casuality care successfully delivered. But now we're starting to discuss the case. What went well, what could have gone better, and how will this inform future care? So, Colonel Gurney, with that scenario in mind, and now that after that scenario is finished, this process of learning and adapting and standardizing care seems to be central to the joint trauma system. And one of the reasons it was implemented. So for those early in the career, what exactly is the joint trauma system and why does it matter for scenarios like this?

SPEAKER_00 3:24

Yeah, thanks, Dr. Dilday. So I think it's worth starting out by saying that when we initially deployed into CentCome operations in 2002, we had no trauma system. So, you know, what is a trauma system? I think understanding that and the fact that we had no trauma system, and it was surgeons, it was surgeons like the ones listening to this podcast that, you know, recognized that we had stuff. We had role twos, we had role threes, we had Medavax, we had people, but we didn't have a way to integrate that care, a data-driven way, a way that is fostered with leadership, strong communication, you know, data-driven to improve the care from point of injury through survival. So if you think about the scenario that you gave, you know, during that, during that continuum of care and with the AAR, lessons learned are captured and they're written down. You know, most fundamentally, they're written down in the medical record, right? The TC3 card, the trauma resuscitation record, the op note, the anesthesia note. That eventually gets back to the joint trauma system and that data is analyzed thoroughly through our operational cycle, which is essentially act, trauma care is delivered, learn, you write stuff down, you do AARs, and then adjust, you know, feedback through clinical practice guidelines. And so I think the, you know, three points I would make is that one, when we entered the conflicts in Iraq and Afghanistan, service members died because we didn't have a data-driven, leadership-invested trauma system. We had stuff, we didn't have a joint trauma system. Surgeons, through a lot of efforts with support from support from the different services, established this data-driven trauma system and really the the registry. Our registry is foundational to that. And, you know, so um I want to just say two other things and then turn over to Van Gent because the DECOT Defense Committee on Trauma is really instrumental in how this ultimately gets continued to be implemented, promulgated, codified, and like, you know, things are driven out to the services. So performance improvement. So, you know, what we do every day in MM conferences, this is why surgeons, I think, developed the JTS, is because we're used to this culture of looking at what we do and figuring out how we could do better. Act, learn, adjust, or deliver trauma care, write it down, it goes into a registry, analyze it, adjust. And we've kind of rebranded that, you know, going back to how important it is to communicate with operational commanders who we ultimately work for. You know, we've got two roles as military surgeons. We're surgeons, and we also are, you know, well, I don't want to say that you're not all leaders, but we have to, we're also officers. We're all officers, and we've got to, you know, communicate back to the line. So we've kind of rebranded this idea of performance improvement. And we say, we do medical performance optimization, which is the same thing. It's using data from clinical care to identify and close gaps from point of injury through discharge along the entire.mil PF spectrum. And if you're a new military surgeon and you're listening to this, you say, what the hell is.milPF? Yeah, don't worry, we said that too. But dot mil PF is how change happens in the military. It's doctrine, organization, training, material, leadership, policy, uh uh, personnel, dot dot mil PF. Now I'm getting, so if I wasn't on a podcast, I'd get them all right away. You know, policy, the golden hour policy, organization, how teams are organized, how we deploy doctrine, uh, everything from the battlefield underwear that we had at one point, just really informing, using data to inform these gaps. You know, we didn't have eye protection when we initially wanted to send come. We saw a lot of eye injuries, eye protection was implemented. You know, we didn't have a policy for rapid transport. So all those things come from what we do as providers, as surgeons. We write stuff down, we document, it's painful, it gets into the systems, we am analyze it, and that's this MPO process. Van Gen, MVG, is the chief of the DCOT Defense Committee on Trauma, which are our three committees. And really, when you think about how this gets implemented at the tactical and operational level, it's those guys. So, MVG, turning it over to you if you to add on to that.

SPEAKER_03 7:27

Yeah, thanks. I agree with everything you said, and I think really the committees uh kind of serve two functions in my mind. One of them being, you know, the subject matter expert kind of pool of folks that are pushing protocols, pushing SOPs. And really uh, you know, the second function of like listening to the community, you know, we've got all these ears out that as things are needed to do, you know, to change uh, you know, across the whole spectrum of care, we're able to kind of funnel that in and kind of help uh kind of change the system, if you will. And that's you know, that can be just as simple as, you know, this doesn't make sense in T Triple C to, hey, we don't have the right equipment for some of this stuff, or we don't have the right personnel and some of these locations that we're kind of needing them from. So it's just a it's another version of Phone a friend, but also, you know, a bunch of subject matter experts that have are either currently doing it or have done it for a long time that are there to kind of help the coalition of the willing, if you will.

SPEAKER_02 8:29

And thank you for explaining. And I gotta say, I mean, even having a familiarity with the joint trauma system, the way, the way I sometimes understand this or think about this is it's so high level. You've talked about experts in this and in quality across multiple platforms and for decades of data. But for someone who is now on their going to their first deployment, why does the JTS matter to that surgeon? If I'm preparing and someone says something about the JTS, does this have anything to do with me who's actively taking care of that patient? Or is that all back in the States and going to be evaluated later? What do we need to know about this real time as a surgeon seeing that patient?

SPEAKER_00 9:10

Yeah, you know, to start with that, uh it's uh, and for the young surgeons deploying, I hope you all know about the JTS before you deploy. I was probably on my fifth deployment before I even really understood what the JTS was. You know, I knew um, I knew there was very valuable research coming out, but I really didn't understand our role in it. You know, one thing that we always say at our DCOP meetings and at other things is if you take care of combat casualties and if you write it down and if you're participating in performance improvement, you are part of the joint trauma system. So thank you for your continued commitment to the JTS and how we improve combat casualty care. You know, one other thing, the reason it matters is if we look at what's happening right now with Operation Epic Fury, we're pretty much reviewing every one of those cases. So, in addition to what happens on the data side, our performance improvement nurses are reviewing every single case. We review the cases. Our chief of PI, Major Carter Kaminsky, he's reviewing cases. We're all reviewing those cases and looking for lessons learned from how we deliver care and trying to feed that back as quickly as possible. So it matters because it comes down to high-quality care for our service members. And that's one thing that we bring to the organization through, you know, communication, document, like the documentation is absolutely a crucial part of it. But also there are PI reviews that happen every single Thursday. We have a call, and I remember the first one uh in 2005 when I was a chief resident at Walter Reed. We just had a, we have a call every Thursday morning, same time, 7 a.m. Central Time, 8 a.m. Eastern Time. So it's in the afternoon for if you're in CENTCCOM deployed, and we review cases, and that closes the loop. That also lets the surgeons in the uh who are deployed know what's happening with the patients, and it helps give the story for the surgeons at the role four O CONUS at launch school and roll four CONUS in the States, understand, you know, the whole continuum of care. This process of MPO or performance improvement should every surgeon should care about because it's how we get better. And um, it's how we, you know, in the end, it's all about saving more lives, adapting and adjusting what we can to improve our CPGs and TC3 guidelines. And um, you know, Mike, I'm old, you're young, but you know, how would you answer that for like the young surgeons, you know, how they'd be impacted by the JTS tactically?

SPEAKER_03 11:41

Yeah, great question. Young-ish surgeon, I guess. You know, I don't, I haven't cut my teeth as as long as you have, I guess. But yeah, I think my first experience with really looking at those CPGs, like Josh was saying, you know, and having that in the first time in a tent of like, there's a ton of knowledge base that, you know, others have kind of gone, you know, and done before me was a little bit reassuring from that standpoint. But Josh, you you hit it on the on the nail there of really that being huge benefit. But the benefit I didn't realize was the reach back potential for both, you know, the downrange calls for the PI questions, but also knowing that I have a point of contact to call if I need to talk to somebody. Like I haven't seen this before, I don't know what to do with our advisor line or just just flat out the networks that you kind of build throughout the JTS. I mean, I think most of us in this organization are are available to to people 24-7. And I'd like to think that you know they feel comfortable calling us when they need a hand, but especially that advisory line of of calling and knowing they're gonna be able to talk to you know an expert pretty quickly.

SPEAKER_02 12:57

Yeah, that's you mentioned the CPGs, and and we and I had mentioned those as well, because I really want to talk about that because I think that's a really forward-facing element of the JTS. But uh Colonel Gurney, you mentioned something I just want to clarify. You're saying that the JTS can give real-time feedback to combat casualty care to a surgeon within uh a few weeks, if even sooner, of that uh case. You're telling me that the JTS is actively changing and updating and regulated and improving combat casualty care, not just after the incident, but in real time during that same deployment. Is that correct? I just want to clarify.

SPEAKER_00 13:36

Yeah, I mean, so there's two ways that we get data. One is from what people document. And ideally, if our electronic documentation tools that are coming forward, because we're we're living in an electronic world, solutions are electronic, right? So if we can get that data faster, we'll be able to rapid cycle the trauma care delivery, goes into the registry, gets analyzed, come up with guidelines. But in addition to that, we have an entire team of amazing PI nurses. I mean, you know, while surgeons lead the trauma system, really the backbone of a trauma system are what our nurses do. And they are reviewing cases as soon as we get them. So for the deployed teams, and Josh, you remember this on your deployment. Your teams send a trauma log every single week, right? And we get those trauma logs. And I always, you know, if I have a chance, I'll try and write back just thanking people for sending those trauma logs. From that, our nurses go right into TMDS and they start reviewing those cases. And those are the cases that we try and get on the upcoming Thursday calls. So, so not, you know, I mean, immediate, no. We can't do anything immediate, one day maybe with uh, you know, different electronic tools and AI and everything else. But pretty short term, we can give feedback to the field. I think that's one of our most valuable things. It's really implementing that PI. Now we say MPO, medical performance optimization, but we know it as surgeons, as PI. It's implementing that PI process as soon as we can across the entire global continuum of care, which is what makes us unique. You know, PI processes happen in hospitals and surgery services and trauma services, but we try and do it across the global continuum of care, from point of injury to when they get back at Walter Reed. And I just want to credit our nurses who work tirelessly to review each one of those records, look at where there's PI fallouts. They talk about it with our chief of PI and us. We will either do a secondary review or we'll reach out to the downrange team. So it's pretty close to real-time feedback. Now, that aggregate information, the data, right, that we can analyze and look at best practices. I mean, you know, just as a reminder to the young guys on the net, we didn't, when I first deployed, didn't go with the tourniquet. We were using crystalloid instead of whole blood. We weren't doing balanced resuscitation. We certainly weren't, we were using walking blood bank whole blood, but low tide role whole blood was implemented in the system at the end of 2016. All this stuff is data-driven medical performance optimization. And we know that it improves survivability. Now, how we scale that for Lisco and how we're able to be rapid, it's one of the reasons one of our hugest efforts at the JTS right now is full modernization of our registry processes and data processes. Because while people are absolutely crucial to this and our PI nurses, we also must leverage technology in order to understand faster, understand the care we're delivering faster, decide faster, and then ultimately act faster. That's how we save lives on the future battlefield.

SPEAKER_02 16:40

And a lot of that is seen in evidence in these documented clinical practice guidelines. Now, from the Defense Committee on Trauma, I I have to say, when I was first looking at these CPGs, I just assumed that it was the same thing that we knew. Should I shunt or should I do a definitive repair? Should I do damage scroll or not? But as I'm looking at these, the breadth of these are extensive, including there's a CPG. Correct me if I wrong, I'm pretty sure there's a CPG on how to write a CPG, which I I think is a little ironic, but it's I I think it really is case in point on how the breadth of knowledge that these CPGs can cover. Can you guys talk about how in-depth these CPGs are in terms of what they cover, especially for stuff that is not really inherent to a deployed surgeon to begin with? And then the process that goes into that, how how much work is done to make sure that these CPGs are truly always up to date and delivering important uh stateside and international need for these surgeons and teams.

SPEAKER_00 17:36

MVG can talk about the work. I mean, he's really helped streamline our CPG process and turn it into a machine, so uh, which we're all really grateful for.

SPEAKER_03 17:45

Yeah, thanks. Um, yeah, great question. Definitely one of the lines, yeah, I guess, of the work that I do at the JTS is trying to push this stuff forward. So, from the standpoint of like what goes into it, I mean, it's a ton of hours. A lot of it, you know, we try to do as uh data driven as possible. You know, like Colonel Gurney was saying, you know, really looking at the registry to kind of inform some of our CPGs. Uh, not everyone is gonna be able to do that, obviously, but we certainly try to apply, you know, our data that we kind of gather from that standpoint to kind of push these recommendations forward. Uh, but yeah, I mean, we are, you know, at the mercy of volunteers to help with a lot of these all throughout the the enterprise itself, but through the committees as well. So if you look, a lot of these lead authors and you know the major drivers are folks in the community, whether in the committees or outside of the committees, but really driving those changes, they're subject matter experts in you know, a lot of these uh these areas uh that we're asking them to kind of write on. But yeah, they're extensive, like to your point, Josh. And I think this has um evolved over the last few years as wartime has kind of slowed down as we haven't been in conflict. So if you'll look over the years, um, you know, a lot of these CPGs are getting a little bit longer because we're trying to get these lessons learned documented. Um so, you know, we're we're picking the brains of the Colonel Gurneys out out in the enterprise because I don't have the breadth of experience that she does. And then, you know, the generation behind us certainly doesn't, you know, unfortunately or fortunately, right? So trying to get those lessons learned built into those CPGs, it makes them a little bit longer, but it also gives a lot of background and you know, kind of the institutional knowledge like we talked about to kind of pass that torch onto the the next teams. But yeah, the lead authors will typically that process, lead authors will, you know, we'll send out an update, you know, request, you know, they'll take a crack at it, and then we'll get, you know, we've got an adjudication team to kind of look through all these things, make sure it makes sense from a flow perspective, but also, you know, talking with the PI team and the registry team to make sure we're all synced from we're not hearing, you know, we're we're not kind of capturing some of the issues that the current downrange round downrange teams are uh kind of seeing. And then also are we capturing that within the registry if these are important metrics and outcomes that we need to be tracking? So that whole process uh kind of functions that way. But also we've got our ears open to anything that we might need in the future. Dried plasma is a hot topic right now, for instance. Uh so coming out with guidance to kind of help teams, you know, really know when to give this, when not to give it, how to, you know, how to actually transfuse the dried plasma. And that's just one example. Colonel Garney, you have anything to add on to that?

SPEAKER_00 20:34

For the surgeons, like for young surgeons, one thing you guys can be doing, young or old surgeons, all surgeons, even non-surgeons. But you know, our CPGs are great educational tools. You know, like so we have some slides and we're trying to improve on those that link to every CPG. So there should be, you know, downrange education that's happening one, two, or three times a week, where your team meets and you review a clinical practice guideline. You know, the more you know them, we have, you know, dozens and dozens around 80 something, or maybe even 90 something. Some of them are non-trauma, you know, clinical practice guidelines, but the opportunity to review those as a team. One thing I find interesting is getting to interact with the international community. Many international surgeons and international surgical teams know more about our CPGs than some of our own teams. Uh, you know, so the JTS, while everybody in the military who has any chance of deploying should know that we are the reference body for trauma care, we're a data-driven organization that improves casualty outcomes, we're joint, we're across the services. Not everybody knows about it, and we don't, it's not codified in training. But if you go overseas and you work with foreign countries, I mean, there there are people that know our CPGs, you know. I guarantee you that most of those surgeons know our clinical practice guidelines. I would put them up against any US surgeon. They use our clinical practice guidelines. So they're kind of our currency, really, you know. And so we've made this huge effort. And, you know, I'm really grateful to Mike and to our nurses and to all the people. We've got lots of people, Matt Tadlock, Romeil Howe, Val Sam's, many others that, you know, work on these CPGs. They take, like Mike said, a huge amount of time. We've added infotra infographics. We've added, we call Bling My CPG, a.mil Pf table at the end to be able to, you know, really kind of if you're a unit commander, if you're a nurse or a surgeon or whoever commands the, you know, Ford surgical teams, depending on the service, depending on the team, you can go to the.mil Pf. What do we need, what do you need for this CPG for doctrine? What is how does this look like from an organization, from a training, from a leadership? And then thanks to our team at Medlog, super grateful for these guys. Scott Coons is one of them, and I'm sure I'm forgetting other names. They've taken each one of those CPGs and said, okay, this is the class eight that you need to order. And we should thank Ken Leffler publicly. Mike, you know, he's worked so hard on that and the infographics. But you know, like this is this is the stuff that you need to order. So if you, if it's a burn CPG, this is the class eight that you need. So we've really tried to make the CPGs kind of um, in a way, a center of gravity for those clinical entities, and a huge amount of work has gone into that. And like Mike was saying, you know, also we knew that there was this gap, that we said things like, okay, timing of antibiotics is important, but we weren't necessarily capturing that in the registry. So we couldn't judge our performance on it. So we've linked our performance metrics to what goes into the registry. And all that cycle, that cycle of medical performance optimization or, you know, PI, PI cycle is crucial to how we get better. The reason we also need this is how many unknowns do we have on the future battlefield? I would say plenty. But whether it's C-burn events, different weapons, the reaction to thermobaric weapons, different drone injury patterns. We have to be able to understand faster, decide faster, act faster. That cycle, our operational cycle to save lives, we can't wait months or years to figure things out. We have to accelerate everything and be data-driven and then try and get that out in clinical practice guidelines. So a lot of what we're doing, it's not super sexy, but these performance metrics and using data to drive this, it's a lot of work. And, you know, Mike leads that and gets that out to the, you know, DCOTs and to the authors. It's a lot of work, but it's worth it. You know, this work, this work is foundational to accelerating saving lives on the battlefield and uh and the battlefields that have the unknowns. And there's lots of unknowns. Um, you know, and I I just want to foot stomp, like for each one of those CPGs that providers open, you know, downrange. One, we want feedback. We want feedback. We have a mailbox to get feedback and just the amount of work that goes into it. It is uh, you know, people see that list of authors or they see things. Each one of those CPGs is, you know, cumulative hundreds of hours of work. We take a lot of pride and it's a lot of effort. And, you know, this is the first time Mike is really the first person that we've had to, you know, as his role as the chief of the DCOT, you know, to like really have this laser focus on CPGs, which before that was always kind of like an ad hoc responsibility. I think we've gotten more task organized, Van Gent, you know, with you uh uh and and Kathy in that position, Kathy Roble. I want to thank her. She herds all the cats. You know, and we want feedback from the providers. I think it's crucial. I mean, it's it's part of our data-driven trauma system. I know I go on and on about that, but if you think about the threat for large-scale combat operations and even what we're seeing in Epic Fury, all this planning and preparing, we've seen so many things break down. And uh capturing that data, doing the performance improvement, and ultimately improving our guidelines. I mean, in the end, it is about saving lives, but like we talked about on other podcasts, it's also about improving operational effectiveness, having a well-informed data-driven trauma system. We can link that to lethality of the force and operational effectiveness, which ideally helps us win the war, get people home, and maybe have a period of peace.

SPEAKER_02 26:11

That's a great phrase. And that's honestly where we're gonna segue to the ending. Uh, but before we do, uh I'm gonna switch gears just from my hat. I gotta say our team reviewed a CPG every week. That was part of what we did downrange. And I will say that not to be a little too tongue-in-cheek, but these CPGs really put the practicality in the clinical practice guidelines, linking the steps for quality measurements, leaking the opportunity to need to know what's documented so that these CPGs can not only be used for in real-time care, but also be used to capture and make sure the quality that that care continues the excellence that uh United States military medicine is known for. And even so, the joint trauma system, it's more than a collection of guidelines. And the listeners, hopefully, you know when we have episodes, uh, we link the relative CPGs within the show notes of these episodes because we really believe strongly from the double AC frontline surgery side how important the JTS and its work from quality management, from the improvement process to the CPGs, to the international exposure, to the stateside collaborations, all of that. It is driving the continuity of excellence to combat casualty care. And we can't endorse JTS strongly enough. And in fact, a lot of our authors come from those uh lead or a lot of our podcast uh speakers come from the author list of those respective CPGs. So we know that those are already a good quality product, but we want to bring them on. And the JTS is more than just this collection of guidelines, it's a healthcare system, it's a mission to ensure that every casualty benefits not from the skill of the individual surgeon or the skill from the trauma system 20 years ago, but from the collective experience of the entire trauma system in real time. Thank you so much from the leadership of joint trauma system, the leadership of Defense Committee on Trauma. Thank you for joining us today on frontline surgery, mastery in military trauma care. We've personally were excited to do this episode because we believe that understanding the JTS is essential for every military surgeon. It connects bedside care to system-wide readiness, and importantly, as Colonel Gurner mentioned, future survivability. These lessons learned today shape the outcomes as tomorrow's battlefield. And as we say and end every episode, until next time, stay sharp, stay ready.

SPEAKER_01 28:17

Thank you for tuning into this episode of Frontline Surgery. We hope today's discussion has provided valuable insights into military trauma care.

SPEAKER_02 28:25

Be sure to join us next time for more expert perspectives and battlefield ready knowledge. Until then, stay ready.