United States General Accounting Office

GAO Report to Congressional Committees

April 1998 MEDICAL

READINESS

Efforts Are Underway

for DOD Training in

Civilian Trauma

Centers

GAO/NSIAD-98-75

GAO United States

General Accounting Office

Washington, D.C. 20548

National Security and

International Affairs Division

B-279215 

April 1, 1998

The Honorable Strom Thurmond

Chairman

The Honorable Carl Levin

Ranking Minority Member

Committee on Armed Services

United States Senate

The Honorable Floyd Spence

Chairman

The Honorable Ike Skelton

Ranking Minority Member

Committee on National Security

House of Representatives

This report responds to Section 744 of the National Defense Authorization Act for Fiscal Year

1996, requiring us to evaluate the effectiveness of the Department of Defense’s (DOD)

demonstration program that would provide trauma care training for military medical personnel

through one or more public or nonprofit hospitals. Specifically, we (1) determined the status of

the demonstration program and DOD’s actions to meet the legislative provisions, (2) identified

other initiatives aimed at training military personnel in trauma care, and (3) identified key

issues that DOD should address if it decides to expand its trauma care training program. This

report contains recommendations to the Secretary of Defense.

We are sending copies of this report to the Secretaries of Defense, the Army, the Navy, and the

Air Force and the Commandant of the Marine Corps. We will also make copies available to

others on request.

Please contact me at (202) 512-5140 if you or your staff have any questions concerning this

report. Major contributors to this report are listed in appendix III.

Mark E. Gebicke

Director, Military Operations

 and Capabilities Issues
Executive Summary

Purpose Military medical personnel have almost no chance during peacetime to

practice their battlefield trauma care skills. As a result, physicians both

within and outside the Department of Defense (DOD) believe that military

medical personnel are not prepared to provide trauma care to severely

injured soldiers in wartime, which could result in the loss of lives and

limbs. Because DOD must be better prepared to deliver trauma care during

wartime, Congress enacted legislation in 1996 requiring DOD to implement

a demonstration program that would provide trauma care training for

military medical personnel through one or more public or nonprofit

hospitals. This report responds to a requirement in that legislation that GAO

evaluate the effectiveness of the demonstration program. Specifically, GAO

(1) determined the status of the demonstration program and DOD’s actions

to meet the legislative provisions, (2) identified other initiatives aimed at

training military personnel in trauma care, and (3) identified key issues

that DOD should address if it decides to expand its trauma care training

program.

Background DOD and GAO reports on medical operations during the Gulf War questioned

the military’s ability to meet its wartime medical mission, particularly in

providing trauma care to the predicted number of casualties. These

reports highlighted that many military medical personnel, including

physicians, nurses, and corpsmen, had either never treated trauma

patients or had no recent experience. For example, only 2 of 16 surgeons

on a Navy hospital ship had recent trauma surgical experience. Military

medical personnel receive readiness training in both military and medical

combat casualty skills. However, these courses are taught through

classroom instruction and field exercises and do not include actual

hands-on training with injured patients.

Since most military treatment facilities provide health care to active duty

personnel and their beneficiaries and do not receive trauma patients,

military medical personnel cannot maintain combat trauma skills during

peacetime by working in these facilities. In contrast, civilian trauma

centers are specialized hospital facilities with immediately available health

care providers and equipment to care for severely injured trauma patients,

such as those with penetrating stab or gunshot wounds. Most combat

injuries are penetrating wounds resulting from bullets from small arms and

fragments from explosive munitions. A 1995 Congressional Budget Office

report stated that 98 percent of the cases treated at one civilian trauma

center matched those casualty-related diagnoses on the military’s list of

Page 2 GAO/NSIAD-98-75 Medical Readiness
Executive Summary

battlefield injuries, whereas only 5 percent of the primary diagnoses that

military personnel treat match battlefield injuries.

Section 744 of the National Defense Authorization Act for Fiscal Year 1996

required the Secretary of Defense to implement a demonstration program

to evaluate the feasibility of providing shock trauma training for military

medical personnel through public or nonprofit hospitals. Specifically, the

act required DOD to implement a demonstration program at a civilian

center not later than April 1, 1996, and submit reports describing the scope

and activities of the program to Congress not later than March 1, 1997, and

March 1, 1998. In addition, the act required that the agreement between

DOD and the civilian center include a provision that the center will provide

health care services to DOD beneficiaries that are at least equal to the value

of the services provided by the military personnel training in the center.

In August 1996, the Office of the Assistant Secretary of Defense for Health

Affairs, which is responsible for DOD’s health care system, formed the

Combat Trauma Surgical Committee to help develop guidance on

improving trauma medical readiness training. In February 1997, the

Committee issued a report recommending trauma care training standards

for military surgeons, which included both hands-on experience and

continuing education. The service Surgeons General approved the

recommendations as a first step toward developing a trauma care training

program for military personnel.

In April 1997, DOD chose Naval Medical Center Portsmouth, Virginia, to

lead the demonstration program. Naval Medical Center Portsmouth signed

an agreement with Eastern Virginia Medical School to provide training for

Navy surgeons at Sentara Norfolk General Hospital in Norfolk, Virginia.

The program, which is currently limited to general surgeons, was initiated

in November 1997 and expected to run through March 1998.

Results in Brief It is too early to assess the effectiveness of DOD’s demonstration program

because it has only been in place since November 1997. As of March 1,

1998, only four surgeons had completed their training rotations. Also, DOD

has not finished the evaluation tool it is developing to assess the program’s

effectiveness. Due in part to the program’s late start, DOD’s actions to

implement the program have not been fully consistent with the legislative

provisions. DOD missed the April 1996 implementation milestone and

issued a report on its proposed demonstration program to Congress 

5 months late. Further, DOD did not seek an agreement with the civilian

Page 3 GAO/NSIAD-98-75 Medical Readiness
Executive Summary

center to provide health care to DOD beneficiaries that is at least equal in

value to the services provided by the military trainees, as specified in the

legislation. DOD officials believed that such an arrangement might have

jeopardized the willingness of hospital officials to enter into the program.

GAO identified several other initiatives that might be used in assessing the

feasibility of training military personnel in civilian trauma centers. Unlike

the current demonstration program, these other initiatives have not limited

their training to general surgeons. Rather, these programs have extended

training to orthopedic surgeons, medics, corpsmen, general medical

officers, nurses, and physicians. Individual surgeons, military medical

treatment facilities, and combat units appear to have initiated these

programs to fill the void left by the lack of any DOD or servicewide program

for trauma care training. The collective experiences of these programs,

together with those of the demonstration program, could provide DOD

valuable information in determining the feasibility and effectiveness of

training military medical personnel in civilian trauma centers.

DOD will need to address several issues, none of which appear to be

insurmountable, if it decides to expand its trauma care training program.

Questions have arisen over physician licensure requirements, but state

licensure was an issue in only one of six programs that GAO examined. Two

additional issues concern whether (1) civilian trauma centers have the

capacity to train large numbers of military personnel and (2) military

trainees can obtain sufficient experience, since they will compete for

training opportunities with the centers’ own personnel. The first issue

cannot be addressed because DOD has not yet estimated the number and

type of medical personnel that might require trauma training. DOD could

deal with the second issue by selecting civilian centers that are

understaffed because of their large caseloads. In the longer term, better

information will be needed on wartime medical requirements, the

personnel requiring trauma care training and their priority for such

training, and the desired frequency of refresher training. The biggest

challenge DOD may face is determining how best to balance the need for

wartime medical training with the substantial needs of its peacetime

health care system.

Page 4 GAO/NSIAD-98-75 Medical Readiness
Executive Summary

Principal Findings

DOD’s Demonstration

Program Is Not Fully

Consistent With Legislative

Provisions

Because implementation of the demonstration program was delayed, it is

too early to determine its effectiveness. Data from the program is limited

because, as of March 1, 1998, only four surgeons had rotated through the

program. In addition, no evaluation tool has been completed to capture the

data needed to assess the program’s effectiveness. The implementation

and evaluation of the demonstration program are the responsibilities of

the head of the Department of Surgery at Naval Medical Center

Portsmouth. This official has many other competing demands and has not

been provided any administrative support personnel to assist with the

program.

Although the legislation stated that the demonstration program was to be

implemented not later than April 1, 1996, Health Affairs did not select the

demonstration site until April 1997, and the first rotation did not begin

until November 1997. In addition, the law required reports on the program

to Congress on March 1, 1997, and March 1, 1998. DOD’s first report was not

issued until July 24, 1997, and the second report had not been issued as of

March 13, 1998. According to Health Affairs and service officials, the delay

in implementing the program was due to Health Affairs (1) shifting

responsibility for the program between offices, (2) taking time to assess

whether two existing military trauma centers could be used to fulfill the

legislative mandate for a demonstration program, (3) establishing the

Combat Trauma Surgical Committee to develop the minimum training

requirements for trauma surgery, and (4) waiting until another ongoing

training program at the civilian center was completed.

The agreement between Naval Medical Center Portsmouth and Eastern

Virginia Medical School does not contain a provision that the school or

hospital would provide in-kind services to military personnel and other

DOD beneficiaries, as required by the law. Navy officials believed that, if

they had asked for an in-kind service agreement, the medical school would

not have agreed to provide the training. Eastern Virginia Medical School

officials confirmed that an in-kind service arrangement would not have

been acceptable because neither the school nor the hospital receives any

financial benefit from this training arrangement and they have adequate

resources without the Navy trainees to provide needed trauma care.

Page 5 GAO/NSIAD-98-75 Medical Readiness
Executive Summary

DOD’s demonstration program only provides trauma care training for

general surgeons. The program does not include trauma training for the

other medical personnel who would also be expected to take care of the

wounded servicemembers, including those who would be the first ones to

treat combat casualties on the battlefield. Under the program, general

surgeons from the Naval Medical Center Portsmouth are on call every

other 24-hour period for 3 weeks at Sentara Norfolk General Hospital’s

trauma center. The surgery staff at Eastern Virginia Medical School

provides and directs the trauma service at the center and supervises the

military trainees when they are on call. Participating surgeons said that the

trauma training they received in the program was worthwhile, but they

reserved judgment on the effectiveness of the program.

Health Affairs had no minimum criteria for selecting the site for a

demonstration program other than identifying military treatment facilities

that already had affiliations with civilian trauma centers. The Navy

suggested Naval Medical Center Portsmouth for the demonstration

program because of its affiliations with a local trauma center and medical

school. This affiliation consisted of Navy general surgery residents training

at the hospital and two trauma-trained Navy surgeons being on call at the

local trauma center 3 to 4 nights a month. Although other urban centers

might have a greater penetrating trauma training caseload, Sentara Norfolk

General Hospital’s caseload provided an adequate amount of hands-on

trauma care cases.

Other Programs Attempt to

Provide Wartime Trauma

Skills Training

DOD does not capture data on existing local cooperative programs between

the military and civilian trauma centers. Individual physicians, military

medical treatment facilities, and combat units initiated programs or

established affiliations with civilian trauma centers even though not

required to do so by DOD. For example, the Third Marine Aircraft Wing

trains its corpsmen and general medical officers at Martin Luther King,

Jr./Drew Medical Center, an inner-city trauma center in south Los Angeles

that treats over 2,500 trauma patients a year, including about 1,200

penetrating trauma cases. The benefit of this program is that it trains those

medical personnel that would be the first ones to treat and stabilize

combat casualties. The local programs that GAO identified have generally

tended to be short-lived because they have been based on personal

initiative rather than on a DOD requirement. Nevertheless, these programs

appear to have yielded valuable experiences that could be useful in

assessing the feasibility and effectiveness of training military medical

personnel in civilian trauma centers.

Page 6 GAO/NSIAD-98-75 Medical Readiness
Executive Summary

DOD also provides limited trauma care training in its two trauma centers at

Brooke Army and Wilford Hall Medical Centers in San Antonio, Texas.

Each center receives about 800 trauma patients per year, about 20 to

25 percent of which are penetrating trauma cases. The benefit of providing

trauma care in these military facilities is that they can train all members of

the team expected to take care of combat casualties and not just general

surgeons. However, hands-on training opportunities at these facilities are

limited because of the small number of trauma patients.

Issues Related to Wartime

Trauma Care Training Have

Surfaced

GAO identified several issues that DOD will need to address if it decides to

expand trauma care training for military personnel, but these issues do not

appear to be insurmountable. For example, many military medical officials

are concerned that they may need a second medical license to train in

civilian centers and that they would have to incur the cost of the license.

However, some states are allowing military personnel to obtain a training

license or register with the state, at no or nominal cost, to train in civilian

centers.

Another issue concerns the ability of the civilian centers to train large

numbers of military medical personnel. DOD is in the process of updating

its wartime medical force structure requirements. Currently, the total

number of active duty military medical personnel is about 100,000. DOD’s

assessment will determine the number and types of personnel that will be

needed to meet DOD’s wartime requirements. However, until this

assessment is completed, the number of personnel who need to be trained

in trauma care cannot be determined.

According to some military and civilian officials, civilian hospitals that

offer military trainees the most beneficial training are generally teaching

hospitals with trauma centers that provide total care for the most severely

injured patients. However, since these hospitals have programs that also

train civilian physicians in trauma care, the military trainees may have to

compete with the civilian trainees for hands-on trauma procedures and

decision-making opportunities. The directors from three large trauma

centers in Los Angeles, Houston, and Baltimore stated that the large

number of trauma patients at many inner-city trauma centers would enable

both the civilian staff and the military trainees to get more than enough

hands-on experience.

A longer term issue is the need for an overall strategy and plan to address

the need for trauma care training. The recommendations in the

Page 7 GAO/NSIAD-98-75 Medical Readiness
Executive Summary

February 1997 report of Health Affairs’ Combat Trauma Surgical

Committee provide a starting point for DOD to begin developing such a

plan. However, clear objectives and milestones to build a comprehensive

plan must be in place. For example, it is important for DOD to complete its

ongoing assessment of wartime medical requirements, determine which

personnel require trauma care training, prioritize the personnel to be

trained, and determine the frequency with which training will be required.

DOD currently has no system to identify those personnel that will receive

trauma care training. The Combat Trauma Surgical Committee

recommended that individual trauma care training should be tracked so

that trained personnel could be quickly identified if a crisis should arise.

Two systems—the Centralized Credentials and Quality Assurance System

and the Defense Medical Human Resource System—could be used for this

purpose. However, the first system has limitations, and the second system

is still being developed.

Another wartime medical training issue is how such training might be

handled in the reserves, but this issue was not addressed by the Combat

Trauma Surgical Committee. Also, DOD has focused its attention to date

only on providing trauma care training to active duty general surgeons. In

the longer term, it will also be important to examine the training needs of

other medical personnel.

DOD’s biggest challenge may be in providing wartime trauma care training

while meeting the substantial demands of its peacetime health care

system. DOD’s primary medical mission is to provide health care to

1.6 million active duty beneficiaries to fulfill its wartime operational

objectives. In addition, DOD provides health care to 6.6 million other

military-related eligible beneficiaries, such as active duty dependents and

retirees and their dependents. Trauma care training will unavoidably

compete for resources with the health care services DOD must provide to

these beneficiaries.

Recommendations Additional data is needed to evaluate the feasibility and effectiveness of

providing trauma care training to military personnel in civilian centers.

Because the authority for the demonstration program at Sentara Norfolk

General Hospital expires on March 31, 1998, GAO recommends that the

Secretary of Defense consider negotiating a new agreement for a similar

program. GAO also recommends that the Secretary (1) expedite DOD’s

efforts to establish an evaluation tool to assist in an assessment of the

Page 8 GAO/NSIAD-98-75 Medical Readiness
Executive Summary

feasibility and effectiveness of training military personnel in civilian

trauma centers and (2) broaden the scope of the evaluation to include

other individual programs that have provided trauma care training to

general surgeons as well as other medical personnel.

If DOD determines that the trauma care training concept is feasible and

decides to expand such training in civilian trauma care centers, GAO

recommends that the Secretary of Defense develop a long-term strategic

plan that establishes goals and identifies actions and appropriate

milestones for achieving these goals. This plan should (1) establish criteria

for selecting locations for trauma care training that would maximize the

experiences of military trainees, (2) identify which medical personnel

should receive trauma care training and the frequency of such training,

and (3) develop a mechanism to identify those military medical personnel

who are likely to deploy early in a conflict so that they can receive priority

for medical wartime trauma care training. In addition, this plan should

address the training needs of both the active and reserve components.

Agency Comments In official oral comments on a draft of this report, DOD generally concurred

with GAO’s recommendations. DOD noted that it has determined that the

trauma care training concept is feasible for general surgeons and is

currently evaluating the concept for other military medical personnel. DOD

further stated that it is addressing GAO’s concerns. Specifically, it plans to

(1) negotiate a new agreement with Sentara Norfolk General Hospital to

provide trauma care training, (2) facilitate development of an evaluation

tool to help assess the effectiveness of trauma care training and include

other individual trauma care training programs beyond the demonstration

program in its evaluation, and (3) establish panels to determine trauma

care sustainment training needs for all military medical personnel and not

only general surgeons. Finally, DOD stated that, in February 1998, the

Combat Trauma Surgical Committee reconvened to coordinate with the

services in developing, coordinating, and implementing trauma care

training strategy for both the active and reserve components.

DOD also stated that it has specific concerns regarding (1) additional costs

for licensure and credentialing of providers, (2) costs for additional

civilian trauma training opportunities, and (3) sustainment costs of what

will have to become a new readiness mission. GAO recognizes that cost is a

factor that DOD must consider in selecting civilian training locations. GAO

notes that the extent to which DOD might incur additional costs depends on

the specific site selected.

Page 9 GAO/NSIAD-98-75 Medical Readiness
Contents

Executive Summary 2

Chapter 1 

Introduction

12

Gulf War Studies Highlighted the Need to Improve Trauma Care

Training

12

Diverse Medical Teams Provide Wartime Trauma Care 13

Medical Personnel Receive Readiness Training 14

DOD Organizations Play a Role in Trauma Care 15

Objectives, Scope, and Methodology 16

Chapter 2 

DOD’s Demonstration

Program Proceeds 

at a Slow Pace

18

Legislative Mandate Provides Reporting Requirements 18

Navy Designated to Lead DOD’s Demonstration Program 18

Program Implementation Is Not Fully Consistent With Legislative

Provisions

20

Effectiveness of Program Is Not Yet Known 24

Chapter 3 

Individual Programs

Attempt to Satisfy

Wartime Trauma

Training Needs

28

Individual Programs Establish Affiliations With Civilian Centers

for Trauma Training

28

Sustainment Training in DOD Trauma Centers Is Limited 34

Chapter 4 

DOD Faces

Challenges in

Providing Trauma

Care Training

36

State Licensure Has Not Been a Significant Obstacle 36

Trainee Competition With Other In-house Programs Could Limit

Hands-on Experience

38

No Strategy Exists for Providing Trauma Care Training 38

Competing Demands Placed on Health Care System Can Limit

Medical Readiness Training

42

Chapter 5 

Conclusions and

Recommendations

44

Recommendations 45

Agency Comments and Our Evaluation 45

Appendixes Appendix I: Battlefield Diagnoses and Peacetime Health Care 48

Appendix II: Organizations Visited or Contacted 50

Page 10 GAO/NSIAD-98-75 Medical Readiness
Contents

Appendix III: Major Contributors to This Report 52

Tables Table 3.1: Individual Military Trauma Training Programs in

Civilian Facilities

29

Table 4.1: Active Duty Medical Personnel by Type of Health Care

Provider and Service for Fiscal Year 1997

40

Table I.1: Top Five Wounded-in-Action Injuries,

Nonbattlefield-Related Injuries, and Diseases Expected in

Wartime and Top Five Peacetime Diagnoses in Fiscal Year 1997

49

Figure Figure 2.1: Timeline of Major Events for Public Law 104-106 21

Abbreviations

CHAMPUS Civilian Health and Medical Program 

of the Uniformed Services

DOD Department of Defense

GAO General Accounting Office

Page 11 GAO/NSIAD-98-75 Medical Readiness
Chapter 1 

Introduction

Warfighters need to be confident that military medical personnel can take

care of them if they are wounded on the battlefield. However, Gulf War

reports pointed out that medical personnel were unprepared to provide

combat casualty care. These reports questioned the Department of

Defense’s (DOD) ability to meet its wartime medical mission, particularly in

providing care to the predicted number of casualties. A major area of

concern was that many military medical personnel lacked sufficient

training or experience in wartime skills, such as trauma care.

Few military medical personnel receive hands-on training for trauma care,

which includes treating actual patients who have incurred severe injuries.

Instead, most medical readiness training is provided through formal

classroom instruction and field exercises. In peacetime, medical personnel

have little chance to practice their battlefield trauma care skills because

most patient care provided in military treatment facilities bears little

resemblance to injuries treated in wartime. For example, the most

common wounded-in-action injury is an open penetrating wound, whereas

the most common peacetime diagnosis is a single live birth. In fact, none

of the 50 most frequent peacetime diagnoses at military medical centers

match a wounded-in-action condition. Appendix I describes the top five

wounded-in-action injuries, nonbattlefield injuries, and diseases and the

top five diagnoses seen in military treatment facilities in fiscal year 1997.

Gulf War Studies

Highlighted the Need

to Improve Trauma

Care Training

DOD lessons learned after the Gulf War highlighted that many medical

personnel had little to no experience in taking care of severely injured

patients. For example, of the 16 surgeons on the Navy hospital ship 

USNS Mercy, only 2 had recent trauma surgical experience. Also, none of

the over 100 corpsmen at a surgical support company had ever seen actual

advanced trauma life support given to a trauma patient. In addition, an

Army report highlighted that surgical teams identified to complement the

rapid movement of troops during the war and provide emergency surgical

services consisted of physicians who were not surgeons, such as

obstetrician/gynecologists. An Army trauma surgeon deployed to the area

believed that an obstetrician could not have provided lifesaving definitive

surgery.

In 1992 and 1993, we issued reports on medical readiness weaknesses

identified during the Gulf War.1

 These reports highlighted that some

1

Operation Desert Storm: Problems With Air Force Medical Readiness (GAO/NSIAD-94-58, Dec. 30,

1993), Operation Desert Storm: Improvements Required in the Navy’s Wartime Medical Program

(GAO/NSIAD-93-189, July 28, 1993), and Operation Desert Storm: Full Army Medical Capability Not

Achieved (GAO/NSIAD-92-175, Aug. 18, 1992).

Page 12 GAO/NSIAD-98-75 Medical Readiness
Chapter 1 

Introduction

medical personnel were not trained to take care of combat casualties. For

example, although Navy nurses and physicians who were deployed to the

war were described as experienced and competent, many of them had

never treated trauma patients, and most had not completed training in

combat casualty care. The prolonged buildup of forces over a 6-month

period allowed Navy personnel to perform medical training, such as

refresher resuscitative skills, mass casualty drills, and triage procedures.

Also, one report noted that a slot for an Army thoracic (chest) surgeon

was filled by a gynecologist who admitted that he was not qualified for the

position because he had never opened a human chest cavity.

A July 1995 Congressional Budget Office report on restructuring military

medical care, prepared at the request of the House Committee on National

Security, indicated that the military services may need to establish

affiliations with level I civilian trauma centers to improve wartime medical

training and broaden exposure to wounded-in-action injuries. Level I

centers provide total care for the most severely injured trauma patients.2

Many injuries seen in these centers are similar to the injuries seen in war.

Only 2 of DOD’s 115 military hospitals are level I trauma centers. These

centers are Brooke Army Medical Center and Wilford Hall Medical Center,

both located in San Antonio, Texas.

In March 1995, Congress held hearings on DOD wartime and peacetime

medical requirements, including medical readiness training weaknesses. In

February 1996, Congress enacted the National Defense Authorization Act

for Fiscal Year 1996 (P.L. 104-106). Section 744 of the act required that the

Secretary of Defense implement a demonstration program to evaluate the

feasibility of providing shock trauma training for military medical

personnel in civilian hospitals.

Diverse Medical

Teams Provide

Wartime Trauma Care

DOD has about 100,000 active duty medical personnel, including general

and other surgeons, nonsurgical physicians, physician assistants, nurses,

and enlisted medical personnel. Various teams of these personnel provide

medical care to wounded soldiers on the battlefield. The most critical time

for treatment of severe battlefield trauma is within the first hour of injury.

Historical data from past conflicts shows that medical treatment, including

nonsurgical, makes a significant contribution to the decrease in loss of

lives and limbs during this critical period.

2

Level II through IV centers provide less comprehensive trauma care than a level I center.

Page 13 GAO/NSIAD-98-75 Medical Readiness
Chapter 1 

Introduction

Initial care of a wounded soldier is provided by self-aid or a fellow soldier

administering first aid. The first medically trained team that responds to

battlefield injuries—known as first responders—includes enlisted medical

personnel, such as combat medics, field corpsmen, and independent duty

corpsmen, and a physician assistant or a physician. These personnel move

with the combat units they support and provide medical care limited to

emergency procedures that prevent death, such as establishing an airway,

controlling hemorrhaging, administering intravenous fluids, and stabilizing

wounds and fractures.

Forward surgical teams, which consist of physicians (especially surgeons),

nurses, and medical technicians, also provide care for those severely

injured on the battlefield. These teams provide emergency surgical

procedures that prevent death, loss of limb, or body function. The size of

the team is determined by the predicted number and type of casualties.

Medical Personnel

Receive Readiness

Training

Military physicians must meet basic civilian education and residency

requirements as well as military training requirements to provide medical

care during wartime. After 4 years of medical school, physicians receive

specialized training in graduate medical education or residency programs.

Residents in a surgical specialty are required to perform a rotation in

trauma and critical care to become board-certified general surgeons. This

rotation provides the resident experience with hands-on management and

treatment of severely injured trauma patients. Much of this trauma training

occurs in civilian facilities because DOD has only two level I trauma centers

that receive severe trauma patients. After physicians complete residency

training, no formal DOD or service hands-on training program exists for

sustaining trauma care skills. Although there is no requirement in the

civilian sector for continuing hands-on experience, the American College

of Surgeons suggests that surgeons treat about 50 severe trauma cases per

year to remain adequately trained in trauma care.3

Enlisted medical personnel, such as combat medics and field corpsmen,

receive initial medical readiness training in both basic military and life

support skills. The military skills courses teach technical, tactical, and

leadership training necessary for personnel to function as part of a

medical team in a war environment, and the basic life support course

teaches necessary medical skills. For example, the entry-level course for

Army medics includes about 150 hours of classroom training devoted to

3

The American College of Surgeons is a professional medical association founded in 1913 to improve

the care of surgical patients and the education of surgeons.

Page 14 GAO/NSIAD-98-75 Medical Readiness
Chapter 1 

Introduction

basic emergency medical skills and a field exercise at the conclusion of

the class. However, the medics do not receive hands-on trauma experience

at a hospital or on board an ambulance.

Before deployment, both military physicians and enlisted medical

personnel are required to take courses on combat casualty care, which

focuses on the military casualty management system and casualty care in a

battlefield environment. These courses consist of classroom instruction,

animal laboratories, and field training and include the principles of trauma

life support. These courses also do not provide hands-on exposure to

actual trauma patients.

DOD Organizations

Play a Role in Trauma

Care

The Office of the Assistant Secretary of Defense for Health Affairs is

responsible for the overall supervision of health and medical affairs within

DOD. In addition to issuing policy, Health Affairs controls and monitors the

services’ medical readiness programs and resources, including medical

training programs. Health Affairs has established a number of

organizations to help oversee medical readiness. For example, in

June 1996, Health Affairs formed the Defense Medical Readiness Training

and Education Council, which is responsible for developing joint medical

readiness training policy and overseeing the services’ medical training

programs, including trauma care.

In August 1996, Health Affairs organized the Combat Trauma Surgical

Committee to study policy options for sustaining wartime trauma surgery

capabilities. Current Committee members include trauma surgery

representatives from each service, Reserve Affairs, the Uniformed Services

University of the Health Sciences, the private sector, two military

treatment facilities that have affiliations with civilian trauma centers, and

DOD’s two military trauma centers. In February 1997, the Committee issued

a report recommending three categories of military trauma-trained

surgeons and trauma training standards, which included both hands-on

experience and continuing education. The service Surgeons General

approved the recommendations, and in May 1997, the Acting Assistant

Secretary of Defense for Health Affairs directed the services to develop

phased implementation plans for training active duty personnel in trauma

surgical skills.

The Surgeons General of the military services are responsible for policy

development, direction, organization, and management of the health

services system within their service. Each service has a medical

Page 15 GAO/NSIAD-98-75 Medical Readiness
Chapter 1 

Introduction

department that is responsible for providing medical readiness training

(i.e., the Army Medical Command, the Navy Bureau of Medicine and

Surgery, and the Air Force Medical Services). Each individual department

trains its medical personnel for their missions. However, the unit

commander is ultimately responsible for certifying that unit personnel

have medical readiness training.

The Deputy Director for Medical Readiness Division in the Joint Staff

Directorate for Logistics is responsible for reviewing medical portions of

the commanders in chief’s operation and contingency plans and Joint

Strategic Planning System documents to assess the adequacy, feasibility,

and suitability of medical plans, requirements, and resources. In 1997, the

Division sponsored five seminars to identify medical capabilities, training

issues, and technology needed to support future war-fighting missions

through 2010. The seminars focused on the management of wartime

casualties in theater, including the identification of core medical skills and

the subsequent training requirements.

Objectives, Scope,

and Methodology

Section 744 of the National Defense Authorization Act for Fiscal Year 1996

requires us to assess the effectiveness of DOD’s demonstration program in

providing shock trauma care training for military medical personnel

through one or more public or nonprofit hospitals. Specifically, we

(1) determined the status of the demonstration program and DOD’s actions

to meet the legislative provisions, (2) identified other initiatives aimed at

training military personnel in trauma care, and (3) identified key issues

that DOD should address if it decides to expand its trauma care training

program.

To obtain background information on DOD medical readiness and trauma

care training, we interviewed officials within many DOD and service

components and reviewed DOD directives, policies, and guidelines. Our

review focused on active component training because DOD focused the

demonstration program and its initial efforts on the active duty

component. In addition, active duty personnel provide most of the care in

military treatment facilities. Nevertheless, reserve personnel play a major

role in wartime medical care since they represent about 57 percent of all

military medical personnel. Also, we reviewed DOD reports and studies on

medical readiness training, DOD medical lessons learned reports from the

Gulf War, and other related reports and congressional testimonies on

military medical care. We examined military medical textbooks, medical

Page 16 GAO/NSIAD-98-75 Medical Readiness
Chapter 1 

Introduction

journals, and various other information sources for relevant data on

trauma care.

To assess the effectiveness of DOD’s demonstration program, we

(1) monitored the implementation of the program by Naval Medical Center

Portsmouth officials, (2) collected data on the program and the rotations

through the civilian trauma center at Sentara Norfolk General Hospital,

(3) interviewed the program’s trainees and Navy trauma-trained surgeon

and medical school officials, and (4) discussed legal issues regarding the

program with Navy judge advocate officials from both the Naval Medical

Center Portsmouth and the Navy Bureau of Medicine and Surgery.

To identify other initiatives aimed at providing military medical personnel

training in trauma care and determine the key issues that DOD faces in

providing military medical personnel training in wartime medical skills, we

interviewed officials from Health Affairs, military treatment facilities that

provide trauma care training or have training affiliations with civilian

trauma centers, and private trauma centers. We also interviewed military

medical personnel who trained in civilian trauma centers. In addition, we

consulted with officials from a professional medical association affiliated

with trauma care to learn their perspectives on military trauma care

training. We did not evaluate the feasibility of increasing the number of

military treatment facilities that receive trauma patients. However, DOD

officials noted that a substantial investment would be required to upgrade

a military treatment facility to a level I trauma center. Appendix II lists all

the federal, state, and private organizations we contacted.

We conducted our review from April 1997 to February 1998 in accordance

with generally accepted government auditing standards.

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Section 744 of the National Defense Authorization Act for 1996 mandated

the establishment of DOD’s demonstration program to evaluate the

feasibility of providing shock trauma training to military medical

personnel in one or more public or nonprofit hospitals. However, the

program does not fully meet all of the requirements of the mandate.

Further, the program will only have been in effect for 5 months, as of

April 1, 1998, and thus will need to be further developed before its

effectiveness can be fully determined.

Legislative Mandate

Provides Reporting

Requirements

Section 744 of the National Defense Authorization Act for Fiscal Year 1996

(P.L. 104-106, Feb. 10, 1996) requires DOD to implement a demonstration

program by April 1, 1996, to evaluate the feasibility of providing shock

trauma training for military medical personnel through one or more public

or nonprofit hospitals. The law also requires DOD to report on the status of

the demonstration program by March 1, 1997, and March 1, 1998, and us to

comment on the program’s effectiveness by May 1, 1998. Finally, the law

requires that agreements with hospitals include a provision that the

hospitals provide health care services to DOD beneficiaries that are at least

equal to the value of the services provided by the military personnel

training at the hospitals.

Navy Designated to

Lead DOD’s

Demonstration

Program

In April 1996, Health Affairs requested input from the services on existing

programs that could be used for the demonstration program to train

military general surgeons in a civilian trauma center. In April 1997, Health

Affairs designated Naval Medical Center Portsmouth in Virginia as the site

for the demonstration program because of its affiliation with Sentara

Norfolk General Hospital—a local trauma center—and Eastern Virginia

Medical School. This affiliation had consisted of Navy general surgery

residents training at the local trauma center and two Navy trauma-trained

surgeons on call at the civilian trauma center about 3 to 4 nights per

month. In addition, a Navy surgeon at Portsmouth had been involved in

the Combat Trauma Surgical Committee, which established the standards

for trauma surgery sustainment training. No other sites were proposed by

the Navy.

According to Health Affairs and service officials, other sites were

informally suggested but were deemed unacceptable because they were

either military treatment facilities, instead of civilian centers, or graduate

medical education programs, instead of sustainment training programs.

Other suggestions had limitations. For example, the Army initially

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suggested a trauma sustainment program based in Georgia but then did

not support it because the surgeon in charge of the program was deployed

to Bosnia for a year. The Air Force suggested Ben Taub General Hospital

in Houston; however, its current program for general surgeons only

consists of observation and no hands-on experience. Because of the

limitations of these and other possibilities, Health Affairs requested that

the Naval Medical Center Portsmouth conduct the DOD demonstration

program. In October 1997, the medical center signed an agreement with

Eastern Virginia Medical School to obtain sustainment trauma training for

Navy general surgeons at Sentara Norfolk General Hospital. The first

rotation began in November 1997.

Sentara Norfolk General Hospital, a nonprofit hospital, is the only level I

trauma center located in Norfolk, Virginia. It is also the primary teaching

hospital for Eastern Virginia Medical School. The hospital is a 664-bed

facility located on a large medical complex that includes Eastern Virginia

Medical School and a children’s hospital. In 1996, Sentara’s trauma center

saw 2,060 trauma and burn patients. The hospital is also part of a larger

regional health management organization, Sentara Health System, which

currently holds the DOD contract for TRICARE through which

approximately 40,000 enrollees eligible for the Civilian Health and Medical

Program of the Uniformed Services (CHAMPUS) receive health care services.

Eastern Virginia Medical School is a private school that does not own a

hospital but provides human resources to Sentara Norfolk General

Hospital and other hospitals in the area. The school has nearly 600

students in its degree programs as well as 300 residents and fellows and

300 faculty members. The surgery staff at Eastern Virginia Medical School

currently provides and directs trauma services at Sentara Norfolk General

Hospital. General surgery residents from Eastern Virginia Medical School

and Naval Medical Center Portsmouth also rotate at Sentara Norfolk

General Hospital for trauma care experience.

Naval Medical Center Portsmouth is a 360-bed facility that provides

medical services to active duty Navy, Marine Corps, Army, Air Force, and

Coast Guard personnel; their families; and other DOD beneficiaries. The

medical center is one of three major teaching hospitals in the Navy with

residency programs, including general surgery.

The head of the Department of General Surgery at Naval Medical Center

Portsmouth has specific responsibility for the demonstration program.

Under the program, a general surgeon from the medical center performs a

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3-week rotation at Sentara Norfolk General Hospital. The Portsmouth

official in charge of the program said that the program is operated at no

cost to the government because the hospital is within commuting distance

of the medical center. In addition, the Portsmouth official said the absence

of a surgeon from the medical center does not affect the center’s patient

workload because the general surgery department is well staffed.

During the rotation, a Navy general surgeon is to be on call every other

night at Sentara Norfolk General Hospital and, when possible, under the

supervision of a Navy trauma-trained surgeon. Currently, Naval Medical

Center Portsmouth has only one trauma-trained surgeon who is to be on

call at the hospital 3 to 4 nights a month. On the remaining nights, the

Navy trainee is to be under the direction of a civilian attending physician.

The trainee is to function as a trauma team leader and be responsible for

assessing patients and developing therapeutic and diagnostic plans. The

trainee is to receive hands-on experience in caring for trauma patients,

including stabilizing and resuscitating the patient by (1) inserting

intravenous lines for fluids, chest tubes for air in the chest cavity, or

endotracheal tubes for airway management and (2) performing surgery if

necessary. The trainee is also responsible for the management of the

patients after they leave the trauma room and enter the intensive care unit.

Program

Implementation Is Not

Fully Consistent With

Legislative Provisions

DOD’s implementation of the demonstration program does not fully meet

the legislative provisions authorizing the program for two reasons. First,

the program did not meet the congressionally mandated schedule. Second,

the program agreement does not include a provision that the civilian

center provide health care services to DOD beneficiaries that are at least

equal to the value of the services provided by military personnel training in

the center.

Demonstration Program Is

Behind Mandated Schedule

Public Law 104-106 directed DOD to implement its demonstration program

by April 1, 1996. However, DOD did not implement the program at Sentara

Norfolk General Hospital until November 1997. The law also specified that

DOD report to Congress on the scope and activities of the demonstration

program by March 1, 1997, and March 1, 1998. DOD issued its first report to

Congress on July 24, 1997. The report describes the activities leading up to

identifying the requirements for peacetime training of military surgeons,

describes the demonstration site, and states that DOD would monitor other

trauma training programs in military treatment facilities and with civilian

centers. DOD’s second report, due March 1, 1998, had not been issued as of

Page 20 GAO/NSIAD-98-75 Medical Readiness
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March 13, 1998. Figure 2.1 shows a timeline of major events from

enactment of the law to the actual start of the demonstration program.

Figure 2.1: Timeline of Major Events for Public Law 104-106

February 1996 

April 1996

July 1996

August 1996

February 1997

March 1997

April 1997

May 1997

July 1997

October 1997

November 1997

Date

Public Law 104-106 is enacted.

Uniformed Services University of Health Sciences tasked to determine trauma

surgical training skills necessary to maintain wartime readiness.

Combat Trauma Surgical Committee is organized to recommend trauma

training standards.

Combat Trauma Surgical Committee issues a report that recommends trauma care

sustainment training standards for general surgeons.

DOD trauma care report to Congress, required by March 1, is not submitted.

Health Affairs requests information from services on existing trauma training programs. 

Demonstration program implementation, required by April 1, does not occur.

Navy officially accepts demonstration program.

Health Affairs designates the Navy to conduct a demonstration program at

Naval Medical Center Portsmouth.

DOD submits its trauma care report to Congress.

Naval Medical Center Portsmouth signs memorandum of understanding with

Eastern Virginia Medical School.

First Navy surgeon begins training at Sentara Norfolk General Hospital.

Major Events

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DOD officials cited four main reasons for the delay in implementing the

program. First, Health Affairs officials explained that the delay was partly

due to shifting responsibility for the program between its offices. The

program started in the Clinical Services office because Health Affairs

thought trauma care training was a peacetime training issue. When Health

Affairs realized that trauma care training was actually a wartime medical

readiness training issue, it transferred responsibility for the program to its

Health Services Operations and Readiness office.

Second, Health Affairs was examining whether it could use in-house

trauma training programs at DOD’s two trauma centers—Brooke Army

Medical Center and Wilford Hall Medical Center—to fulfill the legislative

mandate. The officials stated that these two military centers could train

the whole trauma team and not just general surgeons. However, Health

Affairs realized that this training would not meet the requirement of the

law because the training would not take place in civilian trauma centers.

In addition, according to Brooke and Wilford Hall officials, their military

centers do not have the trauma volume to train military personnel that are

not already permanently assigned there.

Third, Health Affairs officials wanted to determine minimum training

standards for general surgeons before the start of the program. According

to DOD officials, consensus on the minimum number of cases and the

amount of time needed in training was difficult to reach. Agreeing and

publishing DOD’s recommendation for the minimum training standards for

trauma surgery took from August 1996, when the Combat Trauma Surgical

Committee was convened, to February 1997. According to a Committee

official, consensus took a long time because (1) no civilian standards

existed on how many cases per year a surgeon needs to manage to be

adequately trained in trauma and (2) the length of training that is both

reasonable and doable was difficult to determine, given DOD’s conflicting

medical missions.

Finally, DOD did not want the implementation of the demonstration

program to interfere with other Naval Medical Center Portsmouth trauma

training at the civilian center. Specifically, from May to October of each

year, senior surgical residents from Naval Medical Center Portsmouth

train for 3 months at Sentara Norfolk General Hospital. During this

rotation, the surgical residents function as trauma team leaders. The

official responsible for the demonstration program did not want to send

general surgeons for sustainment training at the hospital at the same time

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as senior surgical resident training because the number of cases that could

be managed by each group would be lessened.

The Deputy Assistant Secretary of Defense for Health Services Operations

and Readiness was not concerned about the late implementation of the

demonstration program because he believed that 6 months would be

adequate to determine the feasibility of training surgeons in a civilian

trauma center. Other service officials stated that they were not concerned

with the implementation deadline. These officials believed that it was

more important to take the necessary time to design the program correctly

rather than implement a program quickly just to meet the target date

specified in the legislation.

Demonstration Program

Does Not Include an

Exchange of Equal Value

of Services

The agreement between Naval Medical Center Portsmouth and Eastern

Virginia Medical School does not include an exchange of equal-value

services, as required by the law. Specifically, the law states that an

agreement shall require that the value of the services provided by a

hospital to members of the armed forces and other DOD beneficiaries

should be at least equal to the value of the services provided by military

medical personnel under the agreement.

The Navy did not propose equal value of services in its negotiations with

Eastern Virginia Medical School. The official at Naval Medical Center

Portsmouth that is responsible for the demonstration program believed

that, if he had asked for this arrangement, the program would not have

been initiated. Health Affairs officials said that they instructed Navy

officials to try to meet the conditions of the law but not to allow

negotiations on in-kind services to prevent the program from being

implemented. In addition, officials believed that the value of the services

provided by the military trainees was offset by the value of the training

provided by the medical school. Eastern Virginia Medical School officials

told us that an in-kind services arrangement would not be acceptable

because neither the school nor the hospital receives any significant

financial benefit from this arrangement. Officials also stated that the Navy

surgeon trainee is used as additional staff and does not reduce the medical

school’s staffing. Further, medical school officials stated that, if the Navy

had insisted on such an arrangement, the demonstration program at

Sentara would not have been acceptable.

We discussed the possibility of in-kind service arrangements with trauma

officials from four large level I trauma centers that provide training to

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at a Slow Pace

military medical personnel. Officials from two of the centers stated that

their hospital would be willing to consider an in-kind service arrangement

with DOD, especially if DOD included a military trauma-trained surgeon as

an attending physician. One of these centers currently provides room and

board to its military trainees. The other center is in the process of

negotiating an agreement in which 20 military trainees would receive room

and board. Officials from the other two centers stated that their facilities

would not consider providing in-kind services.

Effectiveness of

Program Is Not Yet

Known

It is still too early to determine the effectiveness of the demonstration

program in training medical personnel in trauma care. The program at

Sentara is limited to general surgeons, and only a few surgeons have

rotated through the program. Also, not enough data has been collected: a

training evaluation tool had not been completed as of January 1998, and an

interim data collection instrument captures very little data. In addition,

although the site chosen for the demonstration program provides valuable

training, it does not offer the volume of penetrating trauma cases other

urban centers may have afforded.

Program Is Limited to

General Surgeons

Although DOD’s demonstration program is to evaluate the feasibility of

training military medical personnel in public or nonprofit hospitals, the

program has provided training thus far only to general surgeons. The

program currently does not include training other military medical

personnel who are expected to be the first to treat combat casualties, such

as combat medics, corpsmen, and general medical officers. Health Affairs

officials acknowledged that personnel other than general surgeons need

trauma care training but stated that the training started with the surgeons

because they are considered the trauma leaders. The officials also believed

that civilian hospitals would more readily accept general surgeons because

of their credentials and licenses. In addition, DOD already had numerous

affiliations with civilian hospitals to provide graduate medical education to

military physicians. An official at Eastern Virginia Medical School

indicated that the DOD demonstration program could be expanded to

include personnel other than general surgeons. The official noted that the

school currently has physician assistant and surgical assistant training

programs that could incorporate training for military corpsmen.

Although the demonstration program has been limited to training general

surgeons, we found a number of unrelated programs that are training

medics and corpsmen in civilian trauma centers. For example, the Third

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at a Slow Pace

Marine Aircraft Wing in California trains corpsmen and general medical

officers at a level I trauma center in southern Los Angeles County.

Likewise, Army Special Operations Forces enlisted medical personnel

train at three civilian facilities located in Maryland, Colorado, and New

Mexico. The Army is also negotiating with a level I civilian trauma center

in Texas to provide training to a forward surgical team made up of general

surgeons, orthopedic surgeons, anesthesiologists, nurses, and medics.

Few Rotations Have Taken

Place

Only four surgeons will have completed their training rotations by the

March 1, 1998, congressional reporting date. The first trainee began his

3-week rotation in November 1997 and saw a total of 65 cases, including 

50 blunt trauma, 5 gunshot wounds, 3 stabbings, and 7 other injuries.4

 Of

the total number of cases, 20, or 31 percent, were categorized as severe.

The trainee performed surgery for six cases, including three penetrating

trauma cases. The five gunshot wounds and the three stab wounds are

penetrating injuries and are therefore similar to the type of combat

casualties that are expected on the battlefield. These penetrating trauma

cases represented 12 percent of the total number of cases.

As of January 1998, the Portsmouth official responsible for the

demonstration program stated that the feasibility of training military

surgeons in a civilian trauma center had been shown. However, he

believed that it would probably be another 6 months to 1 year, as

additional trainees rotate through the program, before the effectiveness of

the program could be determined. The trauma-trained surgeon and the

first two Navy trainees, who all had prior deployment experience in the

Gulf War, acknowledged that the training at Sentara Norfolk General

Hospital provided them with recent experience in treating trauma.

Although the surgeon and trainees reserved judgment on the overall

effectiveness of the program, they believed that the program built their

confidence level in treating severely injured patients.

Evaluation Tool Has Not

Been Completed

Naval Medical Center Portsmouth and Eastern Virginia Medical School

have been developing a training evaluation tool. This tool is expected to

capture data on the number and type of injuries managed and the

procedures performed. The Portsmouth official in charge of the

demonstration program has the responsibility for developing the

evaluation tool, but no administrative support personnel have been

provided to assist with the official’s additional duty.

4

As of January 27, 1998, data was only available for one trainee.

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As of January 1998, the evaluation tool had not been completed, and the

Portsmouth official did not know when it would be completed because of

other competing demands. In the interim, the official has been collecting

data on the number and types of cases managed by the trainees and

working on a database to compile this information along with the

procedures performed by the trainees. The official is also working on a

subjective questionnaire for trainees who have completed the program.

This questionnaire is to capture the trainees’ trauma experience level

before they began their rotation and assess the adequacy of the training

they received at Sentara Norfolk General Hospital.

DOD Did Not Consider the

Amount of Warlike Injuries

When Selecting the

Demonstration Site

According to an official in Clinical Services, Health Affairs did not

establish criteria for selecting a site for the demonstration program other

than identifying already established military trauma training programs

with civilian trauma centers. Health Affairs did not consider the amount of

penetrating trauma cases that these centers typically see. As a result, it is

not clear whether the site selected for the demonstration program will

provide as many penetrating trauma cases as other potential sites. About

90 percent of battlefield trauma is penetrating (e.g., bullets from small

arms and fragments from explosive munitions).

Although criteria for site selection was not established when Naval

Medical Center Portsmouth was chosen, DOD and civilian trauma officials

told us that trauma centers that receive more than 2,500 trauma cases per

year, with at least 30 percent from penetrating trauma, would provide the

most hands-on exposure to warlike injuries. In addition, these officials and

representatives of the American College of Surgeons’ Committee on

Trauma stated that an ideal trauma center would also be associated with

an academic center to show a commitment to trauma education, training,

and research. Trauma centers that frequently meet these criteria are large

inner-city level I centers whose personnel are frequently strained by the

large number of trauma cases. One DOD official believed that the civilian

center’s proximity to a military hospital and the presence of reserve or

retired military personnel at the civilian center should also be a factor in

selecting a site.

Sentara Norfolk General Hospital is a level I trauma center, associated

with a medical school, located within close proximity to a military

hospital, and staffed with active and retired military personnel. However,

the trauma center does not have the volume of penetrating trauma cases

as some other civilian level I trauma centers that train military medical

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personnel. Sentara had less than 400 penetrating trauma cases in 1996, but

other trauma centers that train military medical personnel had about 900

to 1,200 cases of penetrating trauma per year. For example, Martin Luther

King, Jr./Drew Medical Center received 1,188 cases of penetrating trauma

in 1996.

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Wartime Trauma Training Needs

Before the DOD demonstration program in November 1997, no overall DOD

or servicewide program existed to provide hands-on experience in treating

trauma patients. A number of individual programs have been established

with civilian trauma centers to fill the void left by the lack of DOD training

programs for trauma care. These individual programs generally involve

affiliations between physicians, military medical facilities, or combat units

and local civilian trauma centers. However, since the programs are mostly

local and based on personal initiatives within the individual services, they

are sometimes short-lived. The collective experiences of these programs,

coupled with those of the demonstration program, could provide DOD

valuable information in determining the feasibility and effectiveness of

training military medical personnel in civilian trauma centers. Finally,

although DOD operates two level I trauma centers, sustainment training at

these centers is limited.

Individual Programs

Establish Affiliations

With Civilian Centers

for Trauma Training

Because of the lack of DOD or servicewide programs for sustainment

trauma care training, a number of individual programs have been

established to provide such training. Table 3.1 lists the individual trauma

care training programs that we identified, followed by program

descriptions. All of the programs, except one, have been limited to military

medical personnel from a single service. The program at Ben Taub General

Hospital in Houston, Texas, plans to include military medical personnel

from all three services. Because individual programs are based on

personal initiatives, neither DOD nor the services maintain a central

clearing point or database of trauma training programs. Thus, there may

be additional local trauma care training programs beyond those that we

identified.

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Table 3.1: Individual Military Trauma

Training Programs in Civilian Facilities

Program Location

Type of personnel

trained Status

Regional Trauma

Network

Atlanta, Augusta, and

Savannah, Georgia;

Baltimore, Maryland;

and Nashville,

Tennessee

General and

orthopedic surgeons

Inactive

Military surgical teams

at Ben Taub General

Hospital

Houston, Texas Surgeons, other

physicians, nurses,

and medics

Planned

Third Marine Aircraft

Wing at Martin Luther

King, Jr./Drew Medical

Center

Los Angeles, California Corpsmen and

medical officers

Active

Third Marine Aircraft

Wing at Santa Ana Fire

Department

Santa Ana, California Corpsmen and

medical officers

Active

First Marine Division at

Scripps Hospital

San Diego, California Corpsmen Planned

Naval Medical Center

San Diego at Mercy

Hospital

San Diego, California General surgeons Suspended

Naval Hospital Oakland Oakland, California General surgeons Canceled

Army Special

Operations at civilian

centers

Denver, Colorado;

Gallup, New Mexico;

and Baltimore,

Maryland

Medics Active

Army Programs The first of two Army programs that train military medical personnel in

civilian trauma centers is the Regional Trauma Network. In 1993, Dwight

David Eisenhower Army Medical Center in Augusta, Georgia, initiated a

trauma training program for Army general and orthopedic surgeons in the

Southeast Regional Medical Command. The Chief of Trauma and Surgical

Critical Care at the center started this program because of the

unavailability of sustainment trauma training in most military treatment

facilities. Implementation of the program began in 1993 and was not

completed until 1996 because of the lack of local command support for the

program and funding for temporary duty and travel costs. Funding was

ultimately obtained from the Army Surgeon General.

This program was intended to give surgeons hands-on experience in

managing and treating critically injured trauma patients in one of five 

level I trauma centers. From January to September 1996, seven surgeons

trained in the five different trauma centers for 30 days, including two

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surgeons from deployments in Bosnia and Hungary. The cost for the seven

surgeons was less than $19,000, or about $2,665 per surgeon.1

 Many

participants stated that the training renewed their confidence for treating

seriously wounded patients.

Between September 1996 and January 1998, only one surgeon rotated

through the program. This rotation occurred in October 1997 at no cost to

the military because the surgeon was stationed within commuting distance

of the civilian trauma center. According to the surgeon in charge of the

program, no additional rotations have occurred mainly due to insufficient

funding for the trauma training and not the lack of available slots at the

civilian centers or the lack of military volunteers. The surgeon intends to

begin rotating a surgeon through a civilian center in April 1998.

The second program, which is still in the planning stages, is at Ben Taub

General Hospital in Houston, Texas. The hospital’s level I trauma center

receives approximately 2,800 trauma cases per year, including about 900

penetrating injuries. Since November 1997, the Army has been negotiating

with officials from the hospital to rotate forward surgical teams through

the trauma center. The teams consist of three general surgeons, one

orthopedic surgeon, two nurse anesthetists, one critical care nurse, one

operating room nurse, one emergency room nurse, three licensed

vocational nurses, three operating room technicians, four emergency

medical technicians (medics), and one administrator. The team also

includes a military trauma surgeon who would be given attending

privileges at the hospital and would coordinate and monitor the training.

Currently, two 30-day rotations are planned. An Army surgical team will

rotate through the center in April 1998 and an Air Force team in May 1998.

In addition, a Navy surgical team may rotate through the center in

June 1998. The Army, along with the Defense Medical Readiness Training

Institute, plans to develop an evaluation tool to capture travel costs,

opportunity costs (decreased patient workload at a military treatment

facility), and the benefits of training in a civilian trauma center.

According to an Army official, the Great Plains Army Medical Command

will provide funding for travel and any licensing fees for the Army team.

The physicians are not required to have a Texas license and can train

under the hospital’s institutional permit, which costs $50 per physician.

1

One surgeon commuted less than 2 miles to a civilian center at no cost, but the travel and temporary

duty costs for the surgeon from Hungary totaled $4,600.

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The nurses will need a current Texas nursing license, which costs between

$75 and $90. The hospital will provide room and board for the teams.

Marine Corps Programs In May 1997, the Third Marine Aircraft Wing at El Toro, California,

established a trauma training agreement with Martin Luther King, Jr./Drew

Medical Center in south Los Angeles. The hospital has a level I trauma

center that receives approximately 2,500 trauma cases per year. Under the

agreement, a Navy general medical officer and two hospital corpsmen, all

from the same squadron, will train for 30 days on one of the center’s

trauma teams.2

The first team completed its training in June 1997, and one team per month

was expected to train at the center through March 1998. The program has

been operating at no cost to the government. The trainees pay their own

travel expenses to and from the center, and the center provides free

housing, meals, and parking for the trainees.

The trainees complete after-action reports detailing their training

experience. According to these reports and interviews with the trainees,

their confidence and skill levels in trauma care improved because of the

training. For example, one rotation of trainees saw an average of two

gunshot wounds per night, and in one night six gunshot wound victims

arrived at the center. Under the direct supervision of the attending

physician or senior surgical resident, the corpsmen were allowed to

perform procedures, such as initial assessments of trauma patients for

injuries, intubations, chest tube placements, central line placements,

suture lacerations, and removal of bullets lodged under the skin.

Before the rotations, the corpsmen stated that their duties in military

treatment facilities did not include treating trauma patients. One corpsman

said that he never saw trauma patients while working in the emergency

department at the Naval Medial Center San Diego. His duties consisted of

drawing blood and starting simple intravenous lines. All of the corpsmen

stated that they had attended classroom training and field exercises on

how to treat combat casualties but had not performed hands-on

procedures with actual patients.

Because of the aircraft wing’s experience at the civilian trauma center,

officials at the First Marine Division at Camp Pendleton, California, are

negotiating with Scripps Memorial Hospital, a local level I trauma center in

2

Navy medical personnel provide health care services for the Marine Corps.

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Wartime Trauma Training Needs

San Diego, to provide trauma training for their corpsmen. According to the

Deputy Commander of the I Marine Expeditionary Force, if the trauma

training program is a success, the Force will consider expanding the

training to the medical personnel in the support group, which includes the

medical battalions and surgical teams.

Third Marine Aircraft Wing officials also negotiated an agreement with the

Santa Ana Fire Department to provide prehospital trauma training

experience. Corpsmen and general medical officers rotate with the

ambulance service for 30 days and act as emergency medical technicians.

During one rotation, a corpsman started numerous intravenous lines,

treated one person with severe burns over 60 percent of his body,

evaluated and treated gunshot patients from a multiple shooting, and

practiced spine stabilization procedures. The corpsman stated that he was

able to practice invaluable skills and refresh old training with hands-on

experience in an unusual, nonclinical, and unpredictable environment,

which will allow him to perform more efficiently in a combat scenario.

Navy Programs According to a Navy trauma-trained surgeon, five or six Navy surgeons

from the Oakland Naval Hospital obtained trauma sustainment training at

Highland General Hospital, Oakland, California, from 1991 to 1995. Under

this program, a Navy trauma-trained surgeon was assigned for 2 years as

the medical center’s Director of Trauma. Navy surgeons performed 30- to

90-day rotations as attending surgeons, with the trauma-trained surgeon

backing them up.

According to the trauma-trained surgeon, the lack of experience of the

surgeons deployed to the Gulf War was a major factor that allowed him to

convince the naval hospital of the need for this training. In January 1992,

the general surgery specialty advisor for the Navy recommended that a

similar program be set up at all four Navy teaching hospitals. However,

when Oakland Naval Hospital was closed, the program was discontinued.

According to Naval Medical Center San Diego officials, seven surgeons

from the Naval Medical Center San Diego received trauma sustainment

training at Mercy Hospital and Medical Center, also in San Diego, between

1992 and 1995. Five of these surgeons trained for 1 month, and two

surgeons trained for 2 months. The current chairman of the general

surgery department at the Navy medical center, appointed in the spring of

1995, has been hesitant to reestablish the program. He believes that, before

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Individual Programs Attempt to Satisfy

Wartime Trauma Training Needs

the program can be restarted a curriculum should be developed for the

training and all general surgeons should be required to obtain this training.

The commander of the Navy medical center does not want to implement

the agreement with Mercy Hospital and Medical Center because Mercy

Hospital requires each Navy surgeon to obtain a current California medical

license, even if the surgeon is licensed in another state. Military physicians

who are training in civilian facilities in California are not required to have

an active state medical license; they are only required to register with the

state. Registration is done at no cost to the physician, whereas a California

medical license can cost between $1,100 and $1,200. The Navy commander

believes that, if this training is going to be required, DOD should pay for his

staff to obtain a California medical license.

Army Special Operations

Command Programs

Enlisted medical personnel in the Army Special Operations Command

have been obtaining trauma sustainment training at the R. Adams Cowley

Shock Trauma Center in Baltimore since 1989. The Command also has

sustainment training agreements with Gallup Indian Medical Center in

New Mexico and Denver General Hospital in Colorado. In addition,

personnel obtain training at Brooke Army Medical Center and Wilford Hall

Medical Center in San Antonio, Texas.

From October 1995 to April 1997, 61 Army enlisted medical personnel

within the Command trained at the 5 centers at a cost of about $157,000,

which includes airfare, rental car, lodging, and meals. After-action reports

from some trainees indicated that the training provided the hands-on

experience they needed to be confident that they could care for injured

soldiers. For example, one trainee stated that he was able to see and do

things that he had only read and studied about in classroom training and

while working in a military treatment facility.

In April 1997, the Special Operations Command required all its enlisted

medical personnel from the Army, the Navy, and the Air Force to become

National Registry Emergency Medical Technician Paramedic trained and

certified.3

 As a result, sustainment training for the Army enlisted medical

personnel at the three civilian centers was temporarily put on hold while

resources were focused on getting all medical personnel certified.

Sustainment training resumed in September 1997.

3

The Special Operations Command is the headquarters command for the three services’ special forces.

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Sustainment Training

in DOD Trauma

Centers Is Limited

Through a unique relationship with the city of San Antonio, Texas, the

Army and the Air Force operate level I trauma centers at their medical

centers in the city. This affiliation allows civilian trauma patients to be

brought to these military hospitals for care.

Brooke Army Medical Center at Fort Sam Houston receives about

one-third of the city’s trauma patients. The center has been providing

trauma care for about 15 years and receives about 800 admissions per

year, 25 percent of which are penetrating trauma wounds. Wilford Hall

Medical Center at Lackland Air Force Base also receives about 800 cases

per year, about 20 percent of which are penetrating trauma.

DOD and service officials believe that these centers offer an advantage over

civilian trauma centers because they can train military surgeons and the

rest of the military trauma team, including other types of physicians,

nurses, and enlisted medical personnel. However, officials at the centers

stated that their low volume of trauma admissions and their current

staffing levels preclude them from providing sustainment training for

military medical personnel not already assigned to the centers. The

current physicians, residents, interns, and fellows are already competing

for limited hands-on trauma experiences. Medical personnel from the

Army Special Operations Command confirmed that they received little

hands-on training at Brooke and Wilford Hall compared with other civilian

centers because the military facilities did not have enough trauma patients

for the military staff already assigned there.

In addition, the city of El Paso, Texas, and the county-owned public

hospital there have invited William Beaumont Army Medical Center, also

in El Paso, to participate in a formal citywide trauma system. This system

would require that the medical center become a level I trauma center.

Currently, the center assists the community with civilian emergency

support and receives about 500 of the 2,000 trauma injuries per year in the

El Paso area.

The Army Surgeon General views the citywide trauma care system as an

opportunity to train surgical teams in trauma management. However, an

official at William Beaumont stated that, even with a level I designation,

the center cannot train military medical personnel beyond those already

assigned there because of the limited number of trauma patients the

center can receive. However, with additional funding of about $2.7 million

for start-up costs and annual funding of about $1.4 million, the official

believes that the center could be expanded to accept more trauma patients

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Wartime Trauma Training Needs

and therefore could train an additional 330 military medical personnel per

year in trauma.

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DOD Faces Challenges in Providing Trauma

Care Training

DOD’s demonstration program, along with individual efforts, are yielding

lessons learned that could be useful in evaluating the concept of

military-civilian cooperation in trauma care training. Several issues that

may pose difficulties in providing such training have been identified but

can be overcome. These issues include (1) military physician licensure

requirements, (2) the capacity of civilian trauma centers to train large

numbers of military personnel, and (3) concerns that military participation

might detract from training civilian or other military medical graduates in

civilian centers.

If DOD decides to expand its trauma care training, it will need to build on

the Combat Trauma Surgical Committee’s report and develop an overall

strategy for wartime training capabilities. Fundamental preliminary steps

for DOD to take to achieve these goals are completing the ongoing

assessment of wartime medical requirements and determining which

personnel will require trauma care training. Other important DOD actions

include prioritizing the personnel requiring the training, determining the

frequency of refresher training, and devising a means to track trained

personnel. However, the biggest challenge DOD may face is determining

how best to meet the competing demands within its health care system,

which will require balancing the need for providing wartime medical

readiness training with the need to deliver peacetime health care services.

State Licensure Has

Not Been a Significant

Obstacle

In the United States, physicians must generally be licensed in each state

where they practice to protect the health, safety, and welfare of the public.

Each state has its own laws and regulations that govern the practice of

medicine. Therefore, each state can determine the requirements that DOD

must follow to train its medical personnel in civilian trauma centers. In

addition, individual trauma centers can require military trainees to meet

the center’s requirements, which may be more stringent than the state’s, as

part of its contractual agreement with the military.

Licensing is generally not an issue for military physicians practicing in

military health care facilities. Under 10 U.S.C. 1094, military health care

professionals who treat patients in military health care facilities are

required to be licensed in only one state, which does not have to be the

state where they are practicing.

State licensure has not been an issue in most of the programs we

identified. In certain circumstances, state licensing agencies may issue

limited or temporary licenses or certificates for finite periods of time to

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DOD Faces Challenges in Providing Trauma

Care Training

health care professionals licensed in another state. In our review of six

programs located in five states, only one of the states—Georgia—requires

that the military physicians training in a civilian trauma center have a

current state license. According to Georgia’s Professional Examining

Board, the state does not have a trainee license or any law that would

allow military physicians to practice in a civilian facility without a current

license.1

 The other four states only require registration, an institutional

permit, or a trainee license. For example, California generally requires that

military physicians register with the state before starting a training

program in a civilian facility. Registration involves completing a one-page

form at no cost.

Some civilian centers accept registration or a training license, but other

centers required a current state license. Although the Medical Board of

California only requires military physicians to be registered with the state,

surgeons from Naval Medical Center San Diego who trained at Mercy

Hospital and Medical Center were required by the center to have a current

California medical license. Because participation in the program was

voluntary and many of the Naval Medical Center’s surgeons were already

licensed in California, this requirement was not a problem. However, if

training in the civilian centers becomes mandatory, then obtaining a

license could become an issue because of the time and money to obtain a

license. For example, obtaining a license in California takes about 45 to 

90 days and costs about $1,100 to $1,200. Many military physicians we

spoke with stated that DOD will not pay for obtaining this second license.

In fact, DOD’s July 1997 mandated report to Congress stated that, if civilian

facilities require state licenses, DOD might need to make provisions for

reimbursement for that additional license.2

1

Civilian centers may have specific bylaw requirements for physician credentialing beyond just state

licensure that might be a potential obstacle to training in the hospital.

2

Under 10 U.S.C. 1096(d), DOD may reimburse military personnel up to $500 of the cost of a second

license where it is required in order for the member to treat certain military members, retirees,

dependents, and survivors at civilian facilities. Section 737 of the National Defense Authorization Act

for Fiscal Year 1998 (P.L. 105-85, Nov. 18, 1997) authorizes licensed military health care professionals

performing authorized duties for DOD to practice in any state whether the practice occurs in a DOD

facility, DOD-affiliated civilian facility, or any other location designated by the Secretary of Defense.

DOD has not evaluated the applicability of this provision to the section 744 trauma care training

program and its impact on the provisions of 10 U.S.C. 1096 (d).

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DOD Faces Challenges in Providing Trauma

Care Training

Trainee Competition

With Other In-house

Programs Could Limit

Hands-on Experience

Competing with other in-house training programs in the civilian centers

can limit the opportunities for military medical personnel to obtain

hands-on trauma experience. Civilian hospitals that can offer the military

the most beneficial training are generally teaching hospitals with level I

trauma centers. However, these hospitals have internship, residency, and

fellowship programs that train civilian physicians in trauma care; thus, the

military trainees may have to compete with these students for hands-on

experience.

DOD can overcome this issue by arranging for training to occur in

high-volume, understaffed level I trauma centers. According to DOD and

private sector officials, about 12 to 15 inner-city trauma centers have a

very high volume of trauma cases that frequently strain or exceed

personnel resources. Each of these centers, which are geographically

dispersed, treat about 2,000 to 3,000 severe trauma cases per year.

Therefore, these centers would provide more opportunities for military

trainees to obtain hands-on experience.

The Third Marine Aircraft Wing’s trauma training program sends its

medical personnel to Martin Luther King, Jr./Drew Medical Center, an

inner-city trauma center in south Los Angeles. The center is frequently

understaffed for the over 2,500 trauma patients it receives each year. In

addition, almost 50 percent of the injuries at this civilian center were

penetrating trauma, including 32 percent from gunshot wounds. According

to the center’s director, the center has more than enough trauma cases for

all of its civilian and military trainees because the military trainees

augment the civilian members of the trauma team and do not replace staff.

However, the additional staff allows the attending and senior residents to

step back and teach decision-making and procedural skills rather than do

the procedures themselves. The military trainees we spoke with stated

that, during their 30-day rotation, there were more than enough training

opportunities for all of the military and civilian trainees.

No Strategy Exists for

Providing Trauma

Care Training

DOD does not have a long-term strategy for providing trauma care training.

If DOD decides to develop such a strategy, several issues warrant

consideration, including the training needs of the reserve component,

capacity of civilian centers to train military personnel, and the need for a

system to identify trained personnel.

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Care Training

Committee Report Did Not

Include Reserve

Component

Although the Combat Trauma Surgical Committee’s February 1997 report

on policy options for DOD is a commendable beginning for identifying DOD’s

trauma care training needs, DOD does not have a long-term strategy with

clear goals, objectives, and milestones to achieve the Committee’s

recommendations. Moreover, the report did not address the needs of the

reserve component. The Assistant Secretary of Defense for Reserve Affairs

was concerned with the report’s lack of references to the reserves. The

report noted that the reserve component is an integral part of the military

health system and a critical asset in U.S. wartime capability.

The Committee made several recommendations regarding sustainment

training of wartime surgical capabilities, resulting in the establishment of

minimum readiness training standards for general surgeons. The report

defined three categories of surgeons, which are distinguished by different

levels of training and experience, and the required trauma care training for

each category. The services are to propose the required and available

number of general surgeons in each of the three categories and identify

potential training programs at civilian trauma care centers. As of

January 1998, the services’ plans were incomplete. Further, no strategy is

in place to coordinate the development of combat surgical readiness

standards for other surgical specialties, nonsurgeons, nurses, and medical

support personnel.

Questions Exist About

Capacity of Civilian

Centers

The capacity of civilian centers to train large numbers of military

personnel is another DOD concern. However, this concern cannot be

assessed because DOD has not (1) completed its ongoing reassessment of

its medical force structure and (2) determined which personnel will be

required to receive such training. DOD has about 480 general surgeons and

about 74,000 enlisted active duty medical personnel in the force. Table 4.1

provides a breakdown of active duty medical personnel by type of

provider and service for fiscal year 1997.

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DOD Faces Challenges in Providing Trauma

Care Training

Table 4.1: Active Duty Medical

Personnel by Type of Health Care

Provider and Service for Fiscal Year

1997

Army Navy Air Force Total

Physicians

General surgeons 149 152 175 476

Other surgeons 178 163 204 545

Nonsurgical physicians 4,253 3,724 3,752 11,729

Subtotal 4,580 4,039 4,131 12,750

Other medical personnel

Physician assistants 600 209 425 1,234

Nurses 3,169 3,154 4,478 10,801

Enlisted medical personnel 28,497 22,570 22,751 73,818

Subtotal 32,266 25,933 27,654 85,853

Total 36,846 29,972 31,785 98,603

Source: DOD’s Health Manpower Personnel Data System.

The total number of deployable personnel who will need trauma care

training is expected to change from previous wartime planning scenarios.

DOD is updating its April 1994 study of the military medical care system

mandated by Section 733 of the National Defense Authorization Act for

Fiscal Years 1992 and 1993 to determine the appropriate wartime medical

force level requirements. The study concluded that only 50 percent of the

active duty medical force was needed for medical readiness, but that

finding was very controversial among the services. In March 1995, we

testified that the services disagreed with this conclusion and other aspects

of the study and that the commanders in chief did not participate in the

study.3

 Because of the controversy surrounding the study, the Deputy

Secretary of Defense directed that the study be updated to reflect changes

in planning scenarios, operational requirements, and number of forces

deployed. As of January 1998, DOD had not issued the updated study.

DOD has not determined which medical personnel would need to be trained

in trauma care. Not all medical personnel would deploy to a contingency

or, if deployed, would provide initial treatment to injured soldiers. For

example, not all of the 28,497 Army medics would be deployed to the front

lines of a battlefield to provide first responder or enroute care, since Army

tactical units require only about 8,900 combat medics. Likewise, not all of

DOD’s 480 general surgeons would be assigned to combat units or even to

the theater. Although DOD would not likely require all medical personnel to

be trained in trauma care, DOD may face challenges until it determines

3

Wartime Medical Care: Aligning Sound Requirements With New Combat Care Approaches Is Key to

Restructuring Force (GAO/T-NSIAD-95-129, Mar. 30, 1995).

Page 40 GAO/NSIAD-98-75 Medical Readiness
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DOD Faces Challenges in Providing Trauma

Care Training

what portion of the force structure needs trauma care training and the

frequency of such training.

No System Is in Place to

Identify Trained Personnel

In the event of a crisis, DOD would need to quickly identify which medical

personnel have been trained in trauma care. The Combat Trauma Surgical

Committee recognized that a system should be in place to identify and

track individuals trained in trauma care. Currently, no such system is

being used for this purpose since few individuals have received such

training. Two systems currently in development—the Centralized

Credentials and Quality Assurance System and the Defense Medical

Human Resource System—could be used to track trauma care training,

but each has limitations.

The Centralized Credentials and Quality Assurance System is limited to

credentialed medical providers, such as physicians, physician assistants,

and nurse practitioners, and does not include other trauma care providers,

such as nurses, combat medics, and corpsmen. In addition, the medical

readiness training information displayed in the system is very limited: a

medical commander verifies the date of the provider’s sustainment

medical readiness training certificate. Since a list of criteria or standards

outlining what type of training constitutes medical readiness does not

exist, this verification is based on the commander’s judgment and is

therefore subjective.

The Defense Medical Human Resource System is a triservice information

system being developed for use in military hospitals and clinics to

facilitate patient care and staffing. The system includes all military health

care personnel, whether officer or enlisted and credentialed or

noncredentialed. The system has the capability to establish and track

readiness training requirements by individual, military treatment facility or

unit, and service. However, according to service officials, no requirements

have been set to develop a template to facilitate tracking of trauma care

training. In addition, the system is not designed to identify the training

status of medical personnel assigned to nonmedical treatment facilities,

such as physicians, medics, and corpsmen assigned to combat units.

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DOD Faces Challenges in Providing Trauma

Care Training

Competing Demands

Placed on Health Care

System Can Limit

Medical Readiness

Training

DOD must balance the need for training its medical personnel for their

wartime mission and the need for delivering peacetime health care

services to 8.2 million eligible beneficiaries. Large patient workloads can

limit the time military medical personnel can take away from peacetime

duties to participate in wartime medical readiness training, including

trauma care training. In addition, operating budgets at military treatment

facilities can be reduced to the extent that medical personnel participation

in training displaces patient workload. Finally, military commanders may

lack incentives for providing medical personnel with trauma care training

because such training is not linked to wartime readiness.

Although DOD does not provide hands-on trauma care training, it does

provide a number of courses for medical officers that provide the basic

military skills necessary to operate in the military environment, such as

medical service operations and preparation for taking command. Before

deployment, military physicians are required to take a course on combat

casualty care, which focuses on the military casualty management system

and providing casualty care in a battlefield environment. This course

consists of classroom instruction and field training and includes the

principles of Advanced Trauma Life Support, which were developed by the

American College of Surgeons and have become the national and

international standard for basic trauma resuscitation skills. However, in

1993, we reported that only 47 percent of active duty physicians attended

the combat casualty care course. In 1996, DOD’s Office of Inspector General

also found that less than 50 percent of a sample of active duty physicians

assigned to combat support units had completed the combat casualty care

course. According to service officials, medical personnel have limited time

to participate in readiness training and often do not attend this training

due to patient workloads and budgetary constraints.

DOD’s medical mission is to maintain the health of 1.6 million active duty

and 6.6 million other military-related eligible beneficiaries, such as active

duty dependents and retirees and their dependents, through a system of

115 hospitals and medical centers and 471 clinics worldwide. Active duty

personnel are given priority in receiving health care at military treatment

facilities. Military-related beneficiaries are entitled to health care at these

facilities as space is available.

Military treatment facility commanders are required to manage personnel

training within the practical constraints of providing peacetime health

care. According to service officials, the operating budgets at military

treatment facilities are based on the number of patients seen and

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DOD Faces Challenges in Providing Trauma

Care Training

diagnosed for treatment. Therefore, operating budgets may be reduced to

the extent that physician participation in readiness training displaces

patient workload. Service officials told us that military treatment facility

commanders will meet the immediate priority of providing peacetime

health care instead of sending staff to medical readiness training courses

for a potential wartime mission.

Service officials informed us that the impact of medical readiness training,

such as trauma care, on DOD-administered programs that supplement

health care provided in the military treatment facilities is unknown but a

concern. When a military facility cannot provide health care services

because its personnel are at readiness training, patients must obtain

services through the civilian sector. DOD pays these cost through

TRICARE, DOD’s new managed care program that stresses military

treatment facility cost-effectiveness.

Commanders may have insufficient incentives for providing medical

personnel with trauma care training unless this training is linked to

readiness assessments. According to DOD officials, medical readiness

training, including trauma care training, is not currently tied to a unit’s

readiness status for deployment. This status is based on whether essential

mission-related equipment and personnel are on hand and required

individual and team training has been performed. If a unit is missing some

essential items, this information is reflected in the unit’s readiness status

reporting system, and the unit’s status for deployment may be affected.

According to DOD officials, the lack of trauma care training would not be

reflected in the unit readiness status reporting system. There is no trauma

care training or experience requirement for personnel assigned to units

that are to provide care to wartime casualties. For example, a unit’s

readiness status report would not be degraded if the medical officer

assigned to an aid station did not have trauma care training because this

training is not part of the unit’s required individual or team training.

According to DOD officials, a unit commander will use the unit’s limited

resources and time to train required tasks and not do the other training,

such as trauma care, until all mission-essential items have been completed.

Although the infancy of the trauma care training program makes it difficult

to establish the linkage between trauma training and readiness, many

service officials believe that such linkage will be important if trauma

training is to receive this needed priority.

Page 43 GAO/NSIAD-98-75 Medical Readiness
Chapter 5 

Conclusions and Recommendations

Trauma care training is essential for DOD to successfully fulfill its wartime

medical mission. Because of the void left by a lack of priority for combat

trauma care training, individual surgeons, military treatment facilities, and

combat units have been attempting to meet trauma care training needs on

their own. However, command support for these individual efforts has

been difficult to sustain because DOD currently has no clear goals or

strategy for trauma care training as it relates to medical readiness.

Wartime medical readiness should not be the responsibility of individual

surgeons, military facilities, or combat units; it warrants the support of and

coordination by high-level DOD management.

The Combat Trauma Surgical Committee’s report is a good start for

developing clear goals for trauma care training. The report’s

recommendations address the minimum training standards for military

general surgeons, but a DOD strategy for meeting those standards has not

been developed. Information from DOD’s mandated demonstration program

at Sentara Norfolk General Hospital could help with the development of

such a strategy. The demonstration program could be a good training

ground for general surgeons. However, due to the infancy of the program,

it has not generated sufficient data useful to determine the effectiveness of

training surgeons in civilian trauma centers.

It would be difficult for one training model to provide all the data needed

to determine the feasibility and effectiveness of training medical personnel

in civilian training centers. Since other programs outside the

demonstration program train other military medical personnel, such as

orthopedic surgeons, general medical officers, nurses, combat medics, and

corpsmen, coordinating data from these programs with the demonstration

program could be used to determine the feasibility and effectiveness of

training military medical personnel in civilian trauma centers.

Information from the demonstration program and the other trauma

training programs already shows that DOD and the services may face some

challenges if they are to provide hands-on trauma care training. Some

issues, such as licensure, present challenges depending on the location of

the civilian training center. Other issues could arise if trauma care training

is shown to be effective and feasible. The key questions to be answered

then would be who should receive trauma care training and how will those

personnel be identified. Currently, DOD does not have a mechanism to

identify those trained in trauma care, but those who would deploy first to

a contingency would need to receive priority for such training.

Page 44 GAO/NSIAD-98-75 Medical Readiness
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Conclusions and Recommendations

Recommendations Additional data is needed to evaluate the feasibility and effectiveness of

providing trauma care training to military personnel in civilian centers.

Because the authority for the demonstration program at Sentara Norfolk

General Hospital expires on March 31, 1998, we recommend that the

Secretary of Defense consider negotiating a new agreement for a similar

program. We also recommend that the Secretary (1) expedite DOD’s efforts

to establish an evaluation tool to assist in this assessment and (2) broaden

the scope of the evaluation to include other individual programs that have

provided trauma care training to general surgeons as well as other medical

personnel.

In addition, if DOD determines that the trauma care training concept is

feasible and decides to expand such training in civilian trauma care

centers, we recommend that the Secretary of Defense develop a long-term

strategic plan that establishes goals and identifies actions and appropriate

milestones for achieving these goals. This plan should (1) establish criteria

for selecting locations for trauma care training that would maximize the

experiences of military trainees, (2) identify which medical personnel

should receive trauma care training and the frequency of such training,

and (3) develop a mechanism to identify those military medical personnel

who are likely to deploy early in a conflict so that they can receive priority

for medical wartime trauma care training. This plan should also address

the training needs of the active and reserve components.

Agency Comments

and Our Evaluation

In official oral comments on a draft of this report, DOD generally concurred

with our recommendations. DOD noted that it has determined that the

trauma care training concept is feasible for general surgeons, although

there is not yet sufficient data to determine the effectiveness of the

training. DOD is also currently evaluating the concept for other military

medical personnel. We agree with DOD that the demonstration program and

the other individual trauma training programs have shown that it is

feasible to train general surgeons in civilian trauma centers and that

additional data is needed for other military medical personnel. The general

surgeons who have trained in the civilian centers have been given

opportunities to perform hands-on procedures on severely injured patients

and participate in decision-making skills. Many of the trainees stated that

the training in the civilian centers renewed their confidence for treating

severely wounded patients. Even though the demonstration program and

the other initiatives have shown that it is possible to train surgeons in

civilian trauma centers, the impact on the delivery of DOD peacetime health

care when the program is expanded DOD-wide is still unknown.

Page 45 GAO/NSIAD-98-75 Medical Readiness
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Conclusions and Recommendations

DOD stated that it plans to negotiate a new agreement with Sentara Norfolk

General Hospital to provide trauma care training. DOD also agreed with our

recommendation to facilitate development of an evaluation tool to help in

the assessment of the effectiveness of trauma care training. DOD plans to

expand this evaluation to include other individual trauma care training

programs beyond the demonstration program. DOD also plans to establish

panels to determine trauma care sustainment training needs for military

medical personnel in addition to those created for general surgeons.

Regarding our recommendation that DOD develop a long-term strategic

plan that establishes goals and identifies actions and appropriate

milestones, DOD stated that, in February 1998, the Combat Trauma Surgical

Committee reconvened to coordinate with the services to develop and

implement trauma care training plans for both the active and reserve

components that are directed toward building a long-term strategy.

DOD stated that potential military training sites for reserve personnel could

include the three military treatment facilities in Texas that treat trauma

patients—Brooke Army, Wilford Hall, and William Beaumont Army

Medical Centers. However, we believe that these facilities may not be

viable training sites because their low volume of trauma admissions and

their current staffing levels preclude the centers from providing

sustainment training for military medical personnel not already assigned

there.

DOD also stated it has specific concerns regarding (1) the additional costs

for licensure and credentialing of providers, (2) costs for additional

civilian trauma training opportunities, and (3) the sustainment costs of

what will have to become a new readiness mission. We did not identify any

significant financial impact regarding the demonstration program. For

example, only nominal costs were incurred for trainee licenses. In

addition, due to the close proximity of the Naval Medical Center

Portsmouth to Sentara Norfolk General Hospital, no travel or temporary

duty costs were incurred for the trainees. Finally, no additional staffing

was required at Naval Medical Center Portsmouth to cover patient

workload. We recognize that cost is a factor that DOD must consider in

selecting civilian training locations. We note that the extent to which DOD

might incur additional costs depends on the agreement reached between

the military organization and the specific civilian site selected.

Page 46 GAO/NSIAD-98-75 Medical Readiness
Page 47 GAO/NSIAD-98-75 Medical Readiness
Appendix I 

Battlefield Diagnoses and Peacetime Health

Care

The Department of Defense’s (DOD) wartime medical mission is to

preserve the fighting force. One primary goal to achieve this mission is to

treat combat injuries on the battlefield and return personnel to duty as

soon as possible and safeguard those who cannot return to duty.

Historically, 90 percent of trauma sustained in combat on the battlefield

has resulted from penetrating missiles, mostly bullets from small arms and

fragments from explosive munitions.

The care furnished in military medical centers bears little resemblance to

most of the penetrating wounded-in-action injuries that medical personnel

will treat in wartime. The most frequent diagnoses in military treatment

facilities are pregnancies and live births. In fact, none of the 50 most

frequent peacetime diagnoses at military medical centers match a

wounded-in-action condition.

According to DOD, peacetime medical care is an important element of

training for the wartime mission because many of the medical services

provided in war are for diseases and nonbattlefield-related injuries that are

also seen and treated during peacetime. Historically, diseases and

nonbattlefield-related injuries have accounted for between 69 and

96 percent of all care provided in wartime. However, a 1995 Congressional

Budget Office report concluded that peacetime care in military medical

facilities bears little correlation to many of the diseases and

nonbattlefield-related injuries.1

 Table I.1 shows the lack of a correlation

between the top five diagnoses expected during wartime

(wounded-in-action injuries, nonbattlefield-related injuries, and diseases)

and the top five diagnoses seen in military treatment facilities in fiscal 

year 1997.

1

Restructuring Military Medical Care, Congressional Budget Office, July 1995.

Page 48 GAO/NSIAD-98-75 Medical Readiness
Appendix I 

Battlefield Diagnoses and Peacetime Health

Care

Table I.1: Top Five Wounded-in-Action Injuries, Nonbattlefield-Related Injuries, and Diseases Expected in Wartime and Top

Five Peacetime Diagnoses in Fiscal Year 1997

Wartime care Peacetime care

Rank Wounded-in-action injury Nonbattlefield-related injury Disease

1 Lower leg open penetrating

wound with fracture

Heat exhaustion Diarrhea Single infant born without

caesarean delivery

2 Thigh open penetrating wound

with fracture

Sprained ankle Upper respiratory

infection

Single infant born by caesarean

section

3 Multiple, nonperforating fragment

wounds of skin and soft tissue

Heat cramps Fever Uterus and ovary procedures for

nonmalignancy

4 Upper arm open wound with

fracture and nerve injury

Blisters of hands, fingers, feet,

and toes due to friction

Respiratory

disease

Knee procedure

5 Lower leg open penetrating

wound without fracture

Sprained wrist Athlete’s foot Esophagus, gastrointestinal, and

other digestive disorders

Additional training may be needed to bridge the gap between the

knowledge acquired in civilian trauma centers and the actual delivery of

combat casualty care on the battlefield. This military-specific training

would highlight the difference between the civilian experience and what is

expected in a battlefield environment. For example, in civilian trauma

systems, the principles of advanced trauma life support discourage the use

of tourniquets and recommends direct pressure to the wound to stop

major bleeding. However, in a battlefield environment, a tourniquet is

considered the most reasonable choice to stop bleeding and prevent death.

Page 49 GAO/NSIAD-98-75 Medical Readiness
Appendix II 

Organizations Visited or Contacted

Department of

Defense

Office of the Assistant Secretary of Defense for Health Affairs

Office of the Assistant Secretary of Defense for Reserve Affairs

Joint Staff Logistics Directorate, Medical Readiness Division

Defense Medical Readiness Training Institute

Special Operations Command, Office of the Command Surgeon

Uniformed Services University of the Health Sciences

Army Office of the Army Surgeon General

Army Medical Department

Army Special Operations Command, Office of the Command Surgeon

Army Forces Command, Office of the Command Surgeon

Southeast Regional Medical Command, Readiness

Walter Reed Army Medical Center, Borden Institute

Navy Office of the Navy Surgeon General

Navy Bureau of Medicine and Surgery

Naval Special Warfare Command

Naval Health Research Center

I Marine Expeditionary Force, Surgeon’s Office

First Marine Division, Surgeon’s Office

Third Marine Aircraft Wing, Office of the Wing Medical Officer

Air Force Office of the Air Force Surgeon General

Air National Guard Readiness Center, Surgeon General

Military Treatment

Facilities

Naval Medical Center Portsmouth

Naval Medical Center San Diego

Naval Hospital Camp Pendleton

Wilford Hall Medical Center

Brooke Army Medical Center

William Beaumont Army Medical Center

Dwight David Eisenhower Army Medical Center

U.S. Health Care

Organizations

American College of Surgeons, Committee on Trauma

American Trauma Society

National Registry of Emergency Medical Technicians

Federation of State Medical Boards

Page 50 GAO/NSIAD-98-75 Medical Readiness
Appendix II 

Organizations Visited or Contacted

Private U.S. Hospitals Sentara Norfolk General Hospital, Norfolk, Virginia

Martin Luther King, Jr./Drew Medical Center, Los Angeles, California

Mercy Hospital and Medical Center, San Diego, California

R. Adams Cowley Shock Trauma Center, Baltimore, Maryland

Ben Taub General Hospital, Baylor College of Medicine, Houston, Texas

Grady Memorial Hospital, Atlanta, Georgia

D.C. General Hospital, Washington, D.C.

State and City

Governments

California State Medical Board

Georgia State Professional Examining Board

Texas State Board of Medical Examiners

Texas State Board of Nurse Examiners

Texas State Board of Vocational Nurse Examiners

State of Maryland, Department of Health and Mental Hygiene,

 Board of Physician Quality Assurance

Commonwealth of Virginia, Department of Health Professions,

 Board of Medicine

City of Santa Ana, California, Fire Department

Page 51 GAO/NSIAD-98-75 Medical Readiness
Appendix III 

Major Contributors to This Report

National Security and

International Affairs

Division, Washington,

D.C.

Carol R. Schuster

Brenda S. Farrell

Martin E. Scire

Karen S. Blum

Atlanta Field Office Cherie’ M. Starck

Karen B. Thompson

Office of the General

Counsel

Ernie E. Jackson

(703199) Page 52 GAO/NSIAD-98-75 Medical Readiness
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