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. 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. These reports highlighted that some 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.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. 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. 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. 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. 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 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. 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 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. 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.