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3 • Systems of Care in the Management of Vascular Injury 35
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The primary function of the system is to identify each
trauma patient as soon as possible in the clinical course, to
render appropriate treatment, and to ensure swift transfer
to the most appropriate facility. In the case of major trauma,
this will involve directing the patient from the point of
injury to the nearest trauma center that can care for the
patient, while beginning resuscitation at the point of injury.
In the event that a patient arrives at a facility that is not
equipped to provide denitive care within the trauma system because triage protocols are inadequate or misapplied,
or because the patient arrives unannounced, the local facility must maintain sufcient trauma capabilities in early
resuscitation to optimize patients for secondary transfer
to a higher level of care. The regional trauma center must
maintain the ownership of these patients and help coordinate their timely disposition and early resuscitation. In
these scenarios, patients may be transferred in unstable
conditions, and there must be expertise within the system
to provide ongoing resuscitation during transport, as well
as continued coordination with the receiving institution
in order to expedite care. This is particularly important for
patients with demonstrated vascular injuries. The rapid
resuscitation and control of hemorrhage, particularly from
an extremity, can stabilize patients for transport to denitive
care that otherwise would not survive transport.
Once injured patients arrive at regional trauma centers,
the infrastructure of the institution must ensure timely
availability of the trauma team, ancillary staff, blood products, operating room capabilities, and required specialist
and consulting services. The primary trauma team should
maintain the ownership of these patients throughout their
hospitalization and coordinate between consulting and
ancillary services as needed.
The system also includes acute and chronic rehabilitation services both in the hospital and beyond. Patients
managed at a trauma center should eventually be repatriated to the local community as soon as possible following
denitive care. This maintains the capacity of the trauma
center, while ensuring that patients can access appropriate
community services and rehabilitation teams.
Additionally, the primary trauma team must continuously engage in quality improvement across the entire
spectrum of care in order to continue to deliver the best
care possible, from the point of injury to rehabilitation and
return to preinjury status. Quality improvement (QI) can be
conceptualized as follows:
A method of evaluating and improving processes of patient
care which emphasizes a multidisciplinary approach to problem
solving, and which focuses not on individuals but on systems of
patient care that may be the cause of variations. QI consists of
periodic scheduled evaluation of organizational activities, policies, procedures and performance to identify best practices and
target areas in need of improvement and includes implementation of corrective actions or policy changes where needed.
5
This involves feedback as appropriate to the prehospital
team, transferring facilities, and consulting services, as
well as internal review of quality and performance of the
trauma team and the trauma center. This also includes
periodic review and accreditation by independent reviewers
to ensure compliance with best practices and benchmarks
developed by the broader community of trauma specialists,
both regionally and nationally.
Travuma QI is not only the province of mature trauma
systems in well-resourced settings, the principles of QI are
equally applied to trauma care across the entire range of
trauma systems, including those with minimal resources
and austere environments. Importantly, a regional system
delivers trauma care that achieves these benchmarks with
local solutions that reect its own particular geography,
resources, and capabilities.
6–10
Within the trauma system, the provision of quality care
is linked to both designation status and nancial reimbursement. It is possible for trauma centers to lose their status
and for previously undesignated institutions to gain status
as trauma centers depending on their ability to demonstrate
quality care and a commitment to performance improvement. An independent team that periodically reviews the
quality, quantity, and capacity of the institution determines
designation status. These periodic reviews also allow for the
identication of areas for improvement and function as part
of the broader quality improvement and standardization of
therapy across institutions.
There is a growing body of evidence that the institution
of dedicated trauma centers can improve outcomes for
trauma patients across a variety of metrics.11 In addition to
demonstrably more lives saved, trauma centers by virtue of
increased knowledge, experience, resources, and personnel
are able to provide higher quality and more efcient care,
even to those patients without fatal injuries. The upfront
cost is signicant and varies by region, but the provision of
expert and efcient care represents overall a cost savings to
the community served. Around the world, the implementation of trauma systems has resulted in consistent mortality
reductions, and ongoing quality improvement within these
systems should yield increasing cost effectiveness as these
systems mature.12 Patients with vascular injury are the
most likely to benet from robust and well-integrated
trauma systems, as this patient population is at high risk
for rapid decline due to hemorrhage and the necessity of
urgent surgical intervention.
Trauma Center Function
When a hospital is designated as a regional trauma center,
it accepts responsibility for the delivery of injury care to all
people living and working within its catchment area. The
trauma center has a duty to ensure that injured patients will
receive high-quality trauma care at the most appropriate
hospital and in a timely manner. Furthermore, it is responsible for the continuum of care, from the rst prehospital
response through completion of rehabilitation, including
the quality of care received at other trauma-receiving hospitals within its region. The center also has a public health
duty to reduce the injury burden through injury prevention
activities for its population.
Trauma centers have all surgical specialties required
for the care of multisystem trauma patients, as well as onsite and in-house trauma team coverage 24 hours a day.
There is capacity and expert support from diagnostic and
interventional radiology, transfusion services, critical care,
rehabilitation, and other allied services. However, the mere
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presence of these services will not be sufcient for the designation of a regional trauma center, because improvements
in outcomes and the process of care are only seen when the
overall responsibility of the care of trauma patients is managed by a specialist trauma service.
The function of the trauma service is to provide expert
care for trauma patients, integrating the care of multiple
teams and advocating for patients, both within the hospital
system and during ongoing community care. The service
is responsible for trauma education to all staff involved in
trauma care, ensuring appropriate certication and ensuring that best practice guidelines are understood and implemented. Typically, the service will receive all new trauma
patients and direct their early resuscitation and assessment.
Additionally, the trauma team will determine their observation or admission status and will perform a tertiary survey
and radiology review on all evaluated patients to ensure no
injuries are missed.
Patients with a single system injury (e.g., isolated brain
injury or isolated tibia fracture) may be signed over to the
appropriate specialist team, but patients with combined
injuries (e.g., brain injury and a tibia fracture) remain
under the care of the trauma service with appropriate specialty input. The nal responsibility to ensure delivery of
quality trauma care remains with the trauma service for all
admitted trauma patients.
The trauma service is a multidisciplinary team made
up of surgeons, specialist nurses, occupational therapists,
physical therapists, respiratory therapists, pharmacists,
data collection staff, and administrative staff. Traumatrained general surgeons with experience or additional certication in critical care lead most trauma teams. Trauma
program managers, trauma nurse coordinators, and nurse
case managers are also essential to the daily activities of
the service, whereas the data collection staff monitors the
health of the system and compliance with quality improvement initiatives.
Turning a multispecialty hospital into a specialist trauma
center is not a trivial task, and it involves a signicant
investment in staff and resources, as well as changes in the
delivery of health care and clinical governance. Managing
the interface between other hospitals in the region and prehospital care providers requires commitment, communication, education, and intense coordination. Despite this, the
cost to implement trauma centers and regional systems is
relatively cheap and the potential savings from minimized
disability and loss of life represent a large net gain for the
community and region served.
13
Trauma Systems in Combat
Casualty Care
At the time of this publication, US, UK, and other NATO
military medical forces deployed in support of operations
in Iraq and Afghanistan have provided continuous combat
casualty care for nearly two decades. This medical response
initially lacked a cohesive and structured approach. Communication lines between individual medics/corpsmen,
forward operating bases (FOB), combat hospitals, and evacuation facilities did not exist: the prehospital environment
was essentially isolated from the hospitals and tertiary/
quaternary care facilities.14 Hoping to recreate the positive
impact of civilian trauma systems on patient outcomes, a
group of military physicians advocated for a theater trauma
system based on the civilian model.
In late 2004 to early 2005, US Central Command (CENTCOM) implemented an inclusive system of trauma care for
its entire area of operations designated as the Joint Theater
Trauma System (JTTS).15 Simultaneously, the UK Defense
Medical Services began an independent, yet strikingly similar, endeavor to build an ad hoc trauma system for its forces
engaged in Iraq and Afghanistan.16 The stated vision of the
JTTS was to ensure that every soldier, marine, sailor, and
airman injured on the battleeld had the optimal chance
for survival and had maximal potential for functional
recovery—“the right patient to the right care in the right
place at the right time.”17 Although the epidemiology of
military trauma differs from civilian centers, the American
College of Surgeons Committee on Trauma (ACS COT) text
entitled Resources for the Optimal Care of the Injured Patient
served as a useful model for the structure, function, and role
of the JTTS.2 This document, commonly referred to as “the
Orange Book,” identies criteria for civilian trauma care
resources and practices in an effort to optimize standards of
care, policies, procedures, and protocols for care of the traumatically injured patient. The content of the manual provides
guidance for medical care personnel from the prehospital
arena through hospital and subspecialist care. The ACS COT
Verication Review Committee (VRC), initially developed in
the early 1970s, functions as the oversight process and verifying entity for the American trauma care system.
Following the example of the ACS COT, the JTTS identied and integrated processes and procedures to enable
recording of trauma patient–related data at all levels of
care to promote continual process improvement. Establishment of the Department of Defense (DoD) Trauma Registry (DoDTR) provided a comprehensive resource for the
collection of all DoD trauma injury data. These essential
data were used to predict needed resources, evaluate outcomes, educate staff, and identify training needs in order
to improve continuity of care across the combat care continuum. It was essential in facilitating real-time, evidencebased changes in these conicts. Oversight and direction
for the theater trauma system above level I is directed by
the CENTCOM surgeon. The US-based parent organization,
now known as the Joint Trauma System (JTS), was founded
primarily to manage the DoDTR. JTS embraced the system
concept for providing continuity of care from the point
of injury to medical treatment facilities to rehabilitation
centers in the continental United States. A philosophy of
continuous improvement drove and matured the system.
The JTS now exceeds the capabilities of the US trauma care
system on which it was modeled.
Prior to 2016, the JTS was a directorate within Joint Base
Sam Houston; in the fall of 2016, the recommendation was
made by the Under Secretary of Defense to establish the JTS
as an independent authority and lead agency for trauma
in the DoD. With the realignment of US military medicine
and the incorporation of the Defense Health Agency (DHA)
in 2017, the JTS was nally named as the governing body
of trauma care in military medicine. The National Defense
Authorization Act of 2017 (NDAA17) established the
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Combatant Command Trauma System (CTS) as the successor of the JTTS. NDAA17 also granted JTS the power to serve
as the reference body for all military trauma in an effort to
establish standards of care for trauma services provided at
military medical treatment facilities (MTFs). Additionally,
JTS was directed to coordinate the translation of research
from the DoD centers of excellence into standards of clinical
trauma care and to coordinate the incorporation of lessons
learned from the trauma education and training partnerships into clinical practice.
18,19
Experiences from prior US
wars and conicts were largely lost as providers retired and
time passed. Establishment of the JTS ensured that corporate memory is preserved, and that benets of the current
system will be available to future surgeons/conicts.
Organization of the Joint Theater
Trauma System
There are ve levels, or “roles,” (known as echelons in
most NATO nations) of care in the US military traumacare system. Each role has progressively greater resources
and capabilities (Tables 3.1 and 3.2). Role I care provides
aid at or near the point of injury. Role II care consists of
surgical resuscitation provided by forward surgical teams
that directly supports combatant units in the eld. Role III
care provides a much larger and resource-capable facility
and serves as the highest level of care within the theater of
operation. Generally speaking, military role III centers offer
advanced medical, surgical, subspecialist, and trauma care:
they are similar to civilian level I trauma centers or MTCs.
Transfer of casualties between roles I and III is generally via
rotary or xed-wing tactical airframes.
Role IV care is the rst level at which more denitive
surgical management is provided outside the combat zone.
For US forces in the Afghanistan (and Iraq) theater, this is
Landstuhl Regional Medical Center (LRMC) in Germany.
Role V care is the nal stage of evacuation to one of the
major military centers in the continental United States
(CONUS). At a role V facility, there is not only denitive care,
there are also more comprehensive rehabilitation services.
Transfer of casualties between role III and role IV/V facilities is by specialist strategic aeromedical evacuation or by
Air Force Critical Care Air Transport Team (CCATT). The
UK military system has similarly structured in-theater care
from echelon 1 through to echelon 3—generally analogous
to US level I to III, with the Royal Centre for Defence Medicine at Queen Elizabeth Hospital Birmingham (University
Hospitals Birmingham NHS Foundation Trust), United
Kingdom acting as their highest tier.
The elements that comprised JTS were bound by an overarching leadership that was tasked to continually assess
system structure, function, and outcomes, while creating
policy and guidelines based on the analysis of their assessments. An understanding of the epidemiology behind
specic injury mechanisms and casualty injury burden is
essential to placing these functions in proper context.
Each of the following functions is central to adjudicating
trauma system efcacy:
n Assessment: includes the ability to thoroughly describe
the epidemiology of injury within the theater jurisdiction
20–22
Table 3.1 Comparison of US Trauma Center Levels:
Civilian Versus Military
Military Designation Description
V (e.g., BAMC/ISR,
WRNNMC)
IV (e.g., LRMC) Major Trauma Center II
III (e.g., In-theater
hospitals, CSH, TAH)
IIB (e.g., FRSS, FST
EMEDSs, CRTS,
CVN)
IIA (e.g., BAS) Basic aid station, outpatient
I
BAMC, Brooke Army Medical Center; BAS, battalion aid station; CRTS,
casualty receiving and treatment ship; CSH, combat support hospital; CVN,
aircraft carrier battle group; EMEDSs, expeditionary medical services; FRSS,
forward resuscitative surgical system; FST, forward surgical team; ISR, US
Army Institute of Surgical Research; LRMC, Landstuhl Regional Medical
Center; TAH, US Navy hospital ships; WRNNMC, Walter Reed National Naval
Medical Center.
Major trauma center with
teaching and research
Regional trauma
center, limited capability,
30-day ICU holding
capability
Community hospital with
limited emergency
surgery capability
clinic
EMS/corpsman/medic —
US Civilian
Designation
and to scrutinize the efcacy of care via access to
databases depicting performance metrics across the
continuum of care.
n Key policy/guideline development: includes comprehen-
sive authority to maintain trauma system infrastructure
as well as planning, oversight, and command authority
to create and enforce policy and guidelines on behalf of
the welfare of the injured.
n Assurance: includes education and coalition building
with leaders and participants across the system to foster cohesion and collaboration. Also includes the use of
analytical tools to monitor performance, promote injury
prevention, and to evaluate and verify that system components meet agreed-upon criteria.
Successful implementation of these functions with regard
to military trauma care capabilities in Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation Inherent Resolve (OIR) led to the lowest case-fatality
rates recorded for combat casualty populations.
A major challenge arising from the conicts has been
determining how to turn the past successes of the JTTS
approach, developed in Afghanistan and Iraq, into strategies that will assure care to military populations deployed
on future operations. JTTS was built around a very static
and stable network of medical facilities backed up by robust
and largely guaranteed aeromedical evacuation routes. The
system dealt with large volumes of injured combatants over
several years, often being treated by seasoned clinicians
who served on multiple tours. Such enduring conditions
were fertile for systemization and quality improvement.
Future operations, predicted to involve near-peer threats,
are likely to be lighter and shorter, take place in areas where
we will not have established infrastructure, and involve less
assured logistic and evacuation options. The “opportunity
cycle” within which it is possible to characterize problems,
launch improvement initiatives, observe for effect, and
I
III
IV
—
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Table 3.2 US Trauma System Organization
Civilian Trauma System Components Military Trauma System Components
National/Federal
Level
State/Command
Level
Regional Level
Local Level
Local/Regional
Components
AOR, Area of responsibility; Btln, battalion; COCOM, combatant command; CTS, combatant command trauma system; EMS, emergency medical service; JTS,
joint trauma system; PI, performance improvement; RAC, regional advisory council.
American College of Surgeons, Committee on Trauma
n
Registry (National Trauma Data Bank)
n
Academic organizations influencing trauma care
(American Association for Surgery of Trauma/Eastern
Association for Surgery of Trauma/Western Association for
Surgery of Trauma
State trauma system
n
State director (Texas: Governor’s EMS and Trauma
Advisory Committee chair)
n
State registry
n
State trauma system plan
Regional trauma areas
n
Registry
Local trauma center
n
Trauma registry
Regional advisory council
n
RAC chair
n
Rural/urban organizations
n
EMS (ground/air)
n
Hospital representatives, all levels
n
PI/Comm/Rehabilitation/Prev
Department of Defense, Military Health System, Defense Health
Agency, Combat Support Agency
n
Joint Trauma System
n
DoD Trauma Registry
n
Defense Medical Readiness Institute/Committee on Tactical
Combat Casualty Care/Committee on Surgical Combat Casualty
Care/Committee on En Route Combat Casualty Care
COCOM
n
COCOM surgeon
n
CTS-derived COCOM data
n
CTS; COCOM-specific
AOR (Operation Inherent Resolve)
n
CTS-derived AOR data
JTS leadership
Command surgeon
n
JTS director
n
Level II/III facilities
n
Level I/Medevac Btln
n
PI/Comm/Prev
revise accordingly may be much less favorable than during the
JTTS era. Developing swifter, more agile systemization methodologies and improvement mechanisms that not only take
account of new operational realities but thrive within them is
an emerging problem that must be tackled successfully by
DHA and JTS in order to continue delivering the best results.
Challenges of Vascular Injury Care
If it is clear that the outcomes for injury can be improved
by a systemized approach, what are the barriers and challenges faced by surgeons wishing to address the specic
problem of vascular injury within a trauma system?
OWNERSHIP AND RESPONSIBILITY
With increasing concentration of tertiary-level clinical services, vascular centers are now often collocated with trauma
centers. “Ownership” of the vascular trauma patient will
depend on local circumstances but must be clearly dened.
Trauma surgical teams may be the traditional leaders of the
system and may be best placed to ensure that the system
works holistically. However, vascular surgeons embody the
technical subject matter expertise, particularly with regard
to endovascular treatments. The principle province of vascular surgery is age-related degenerative disease. Noniatrogenic vascular trauma represents a small amount of
vascular emergency workload, and interest and enthusiasm
among vascular surgeons to lead system improvements
and novel research may be variable. Nonetheless, vascular
surgeons have led on improvements to systems addressing
aneurysm screening, stroke prevention, and limb revascularization and are familiar with rigorous study and quality
improvement.
23,24
Efforts to improve outcomes from vascu-
lar trauma should leverage this expertise accordingly.
It is essential that both vascular and trauma surgeons
serving a region or population take every opportunity to
jointly champion the benets of a systemized approach.
Even with mature trauma systems, internal and external
pressures may degrade the ability of the system to function,
and these must be anticipated and countered. Challenges
such as cost containment, resourcing of administration, clinician disengagement, and competing health policy agendas must be managed without losing sight of the patients
and their needs.
DATA COLLECTION AND COMPARISON
Generic data should be collected as part of the baseline
performance dataset as part of a broader trauma registry,
but there are a few guidelines on the specic data elds
that should be maintained for vascular patients. In general, data collected for utility as measures of performance
should be readily measurable, should reect or be associated with outcomes, should be set at a threshold that mirrors current standards of practice, should be amenable to
risk stratication, and should signal system-wide quality.6
Clearly, such discrete metrics are required if the vascularspecific processes and outcomes are to be monitored and
included in feedback mechanisms. A suggested list of
potential date fields—in addition to usual data pertaining to trauma epidemiology, indices of physiology, and
resuscitative measures—is included in Box 3.1. Judgments
3 • Systems of Care in the Management of Vascular Injury 39
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Box 3.1 Candidate Vascular–Specific Process
and Outcome Fields for a Vascular-Injury
Database
Quality
Provider
Training level of provider (revascularization; amputation)
Specialty of provider (revascularization; amputation)
Training level of anesthesia provider
Institution
Accredited vascular teaching program
Accredited endovascular program
Vascular quality assurance program
Process
Time Interval: point of injury to vascular imaging
Time Interval: point of injury to surgical vascular control
Time Interval: point of injury to reperfusion of limb
Time Interval: point of injury to definitive vascular repair of limb
Time Interval: from point of consent/assent to amputation or to
surgery
Provision of definitive rehabilitation prescription
Time to definitive limb fitting
Outcome
Postoperative compartment syndrome (rate)
Postoperative vascular repair perfusion failure/end organ
ischemia (rate)
Postoperative wound or graft infection (rate)
Postoperative amputation (within 30 days) (rate)
must be made regarding which process data should be
used as measures of system efcacy. This decision should
be based on evidence. Similarly, outcome data should be
based on agreed denitions. For instance, the terms “early,”
“late,” “primary,” “secondary,” “emergent,” and “elective”
amputation are dened differently among institutions and
contexts. The goal is standardized, evidence-based benchmarks and outcomes of functional recovery that enable
population-stratied comparisons of process and outcomes
with respect to time and institution. The challenge is not
only to develop the data that describe performance, but to
ensure that the data are collected over a large enough population to ensure a sufcient volume of information is available for meaningful analysis of infrequent injury patterns.
CLINICAL PRACTICE GUIDELINES
The JTTR approach to the conicts in Afghanistan and Iraq
led to the dissemination of vascular injury clinical practice guidelines to reduce heterogeneity of practice and to
improve standardization of therapy, which was widely successful. This military experience should serve as a model for
civilian organizations to develop and rene their own version of these, taking into account local and regional specic
factors and the broader capabilities of local trauma systems. Those with the most utility use a systematic review
methodology such as those provided by the Eastern Association for the Surgery of Trauma or the Society for Vascular
Surgery.
25,26
The London trauma system has also published
its own guidelines. Implementation of guidelines should
not occur in isolation but should be followed up by impact
analysis and regular review by the broader trauma and vascular communities. Clinical practice guidelines (CPGs) may
gain effective traction among the clinical community when
championed by senior decision makers and introduced
alongside associated programs of provider education. It is
important that all stakeholders participate in the process,
as unannounced implementation of CPGs frequently fail to
gain traction in clinical practice.
INTRODUCTION AND TRACKING OF NEW
TECHNOLOGY
All trauma systems should have dened and governed
means of reviewing applicant candidate technologies, ltering out those which are a liability, introducing new therapies, and assessing for impact on patient care. Both vascular
and trauma surgeons are familiar with the research paradox encompassed by the increasingly rapid development
of exciting new adjuncts to management of their patients.
The endovascular revolution has allowed multiple types of
devices and of techniques to be introduced to practice—
with a varying degree of governance and data to support
this. A well-worn narrative implies that developments have
occurred at such a pace, that lengthy efforts to properly trial
the novel intervention are not practical, as the results do not
reect emerging or even established practice by the time the
results are disseminated. Countless examples from multiple
domains run counter to this view—including well-run and
informative trials such as CRASH-2 and multiple randomized trials scrutinizing the benets of carotid stenting for
stroke prevention.
27,28
However, in the absence of trial data,
and recognizing that new treatments emerge continuously,
leaders must have local policies regulating the introduction
and surveillance of new treatments that enable follow-up
and tracking. Properly run device or therapy registries (containing prospectively gathered data) are feasible and vital
knowledge-generating tools and should be managed at the
regional or national level.
REBOA
One such new technology has led to renewed interest in
endovascular balloon occlusion of the aorta or REBOA.
First described as a therapy for trauma during the Korean
War, recent vascular surgery experience with endovascular devices has led to renewed interest in this mode of
therapy, with commercial devices now available for expeditious placement by both surgical and nonsurgical trauma
providers. Moore et al. evaluated REBOA versus resuscitative thoracotomy and found improved overall survival
and fewer early deaths due to hemorrhage in patients who
underwent REBOA.29 The American Association for the
Surgery of Trauma’s AORTA registry demonstrated a trend
toward improved survival with REBOA but failed to reach
statistical signicance.30 Despite trends toward improved
survival, these studies continue to demonstrate signicant
morbidity and mortality in this patient population. Additionally, access to the common femoral artery and placement of catheter have been associated with signicant
40 SECTION 1 • Setting the Stage
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complications including aortic dissection, rupture, perforation, embolization, air emboli, and peripheral ischemia.31
Proper patient selection and deployment zone continue to
be an area of ongoing research. Furthermore, although
nonsurgical physicians have been demonstrated to safely
place REBOA, several studies from Japan have demonstrated
the importance of early surgical intervention for denitive
control once the balloon is placed, as aortic occlusion for
a prolonged period (>60 minutes) is associated with poor
outcomes.32 Thus the ultimate utility of this device in the
context of a modern trauma system for control of major
vascular hemorrhage is still being evaluated.
WHOLE BLOOD
Field resuscitation of trauma patients continues to evolve,
and the recent US military experience from the conicts in
the Middle East has spurred renewed interest in both whole
blood resuscitation as well as product resuscitation at the
point of injury and during transport to denitive care.
Patients with vascular injury are some of the primary beneciaries of these advances, as signicant blood loss in the
eld combined with prolonged transport times can result in
signicant physiologic derangement and subsequent morbidity. Civilian trauma systems are increasingly supplying
paramedics and ight personnel with blood products for
use in the eld with the guidance and protocols established
by local Emergency Medical Services medical directors.33
Whole blood represents an exciting new area of research
and appears to be particularly well suited to eld resuscitation, with an available storage time of approximately 30
days. Additionally, a unit of whole blood contains all blood
components within a single unit, allowing paramedics to
carry all components and deliver those products in the
eld.
POINT OF INJURY THERAPY AND COMMUNITY
OUTREACH
Since the early 2000s the United States has seen a rise in
incidence and severity of mass shooting events in which
high-powered semiautomatic weapons inict signicant
injuries to multiple victims over a short period of time. Such
events can rapidly burden even a robust trauma system.
Fortunately, such events are rare. However, when they do
occur, a signicant percentage of the casualties who survive
to be transported to a trauma center are at risk for major
vascular injury, as is typical for patients with penetrating
injuries. Point of injury care by civilians has become one
avenue of recent efforts by the American College of Surgeons to help mitigate the strain these events can have on a
trauma system. Campaigns such as “Stop the Bleed,” which
teach appropriate tourniquet use to civilians as well as strategies for applying direct pressure over wounds, are intended
to increase the role of civilian bystanders in such instances
in an effort to limit blood loss in the eld and deliver patients
to the trauma system with less physiologic derangement.34
Other efforts including local, regional, and national efforts
in support of safe gun practices and safe gun storage are
hoped to also mitigate the overall burden of vascular injury
as a result of ballistic injury in the community. The effectiveness of these programs is hard to judge, but efforts are
underway to evaluate the effectiveness of civilian training
and further rene the process.
35
Conclusion
The development, implementation, and maturation of
trauma systems within the civilian and military communities have resulted in reduced morbidity and mortality from
severe injury. Because of its unique capacity to cause death
and major disability, vascular trauma as a specic injury
pattern warrants unique consideration within this discussion. Furthermore, it is likely that skilled coordination
and application of evidence-based management of vascular trauma within an environment of continuous process
improvement will lead to the greatest gains reducing preventable death following injury.
References
1. Celso B, Tepas J, Langland-Orban B, et al. A systematic review and
meta-analysis comparing outcome of severely injured patients treated
in trauma centers following the establishment of trauma systems.
J Trauma. 2006;60:371–378.
2. American College of Surgeons Resources for Optimal Care of the Injured
Patient. Chicago: Chicago ACS; 1999.
3. Cameron PA, Gabbe BJ, Cooper DJ, Walker T, Judson R, McNeil J. A
statewide system of trauma care in Victoria: ef fect on patient survival.
Med J Aust. 2008;10:546–550.
4. Cornell EE 3rd, Chang DC, Phillips J, Campbell KA. Enhanced trauma
program commitment at a level I trauma center: effect on the process
and outcome of care. Arch Surg. 2003;138:838–843.
5. Mock C, Juillard C, Brundage S, et al. Guidelines for trauma qual-
ity improvement programmes. Geneva: World Health Organization;
2008. Available from: http://whqlibdoc.who.int/publications/2009/
9789241597746_eng.pdf.
6. Willis CD, Gabbe BJ, Cameron PA. Measuring quality in trauma care.
Injury. 2007;38:527–537.
7. Moore L, Stelfox HT, Boutin A, Turgeon AF. Trauma center perfor-
mance indicators for nonfatal outcomes: a scoping review of the
literature. J Trauma. 2013;74:1331–1343.
8. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS
method. J Trauma. 1987;27:370–378.
9. Champion HR, Copes WS, Sacco WJ, et al. The major trauma out-
come study: establishing national norms for trauma care. J Trauma.
1990;30:1156–1165.
10. Eastridge BJ, Wade CE, Spott MA, etal. Utilizing a trauma systems
approach to benchmark and improve combat casualty care. J Trauma.
2010;69(1):S5–S9.
11. Rotondo MF, Bard MR, Sagraves SG, et al. What price commitment?
What price benet? The cost of a life saved in a level I trauma center.
Presented at the American Association of Surgery of Trauma’s 65th
annual meeting. New Orleans, LA, September 2006.
12. Tallon JM, Fell DB, Karim SA, Ackroydstolarz S, Petrie D. Inuence of
a province-wide trauma system on motor vehicle collision process of
trauma care and mortality: a 10-year follow up evaluation. Can J Surg.
2012;55:8–14.
13. Davenport R, Tai N, West A, etal. A major trauma centre is a specialty
hospital not a hospital of specialties. Br J Surg. 2010;97:109–117.
14. Department of Defense Center of Excellence for Trauma. History
of the Joint Trauma System. Available from: https://jts.amedd.army.
mil.
15. Eastridge B, Jenkins D, Flaherty S, Schiller H, Holcomb JB. Trauma
system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma.
2006;61:1366–1372.
16. Hodgetts T, Davies S, Russel R, McLeod J. Benchmarking the UK
military deployed trauma system. JR Army Med Corps. 2007;153(4):
237–238.
17. Eastridge BJ, Costanzo GS, Jenkins DH, etal. Impact of joint theater
trauma system initiatives on battleeld injury outcomes. Am J Surg.
2009;198(6):852–857.
3 • Systems of Care in the Management of Vascular Injury 41
https://t.me/medicina_free
18. Department of Defense Center of Excellence for Trauma. Joint
Trauma System Clinical Practice Guidelines. Available from: https://
jts.amedd.army.mil/index.cfm/PI_CPGs/cpgs.
19. S. 2943—114th Congress. National Defense Authorization Act for
Fiscal Year 2017 (Public Law 114–328). Washington: US Government Publishing Ofce.
20. Holcomb JB, McMullin NR, Pearse L, etal. Causes of death in U.S. Spe-
cial Operations Forces in the global war on terrorism: 2001–2004.
Ann Surg. 2007;245:986–991.
21. Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy
RF. Understanding combat casualty care statistics. J Trauma.
2006;60:397–401.
22. Kelly JF, Ritenour AE, McLaughlin DF. Injury severity and causes of
death from OIF and OEF: 2003–04 versus 2006. J Trauma. 2008;64:
s21–s27.
23. Abdominal aortic aneurysm quality improvement programme.
Interim report. Vascular Society of Great Britain and Northern
Ireland. 2010.
24. Quality improvement framework for major amputation surgery.
Vascular Society of Great Britain and Northern Ireland. 2010.
25. Eastern Association for the Surgery of Trauma. Guidelines for treatment of penetrating lower extremity and arterial trauma. Available
from: http://www.east.org/resources/treatment-guidelines/penetrating-
lower-extremity-arterial-trauma,-evaluation-and-management-of.
26. Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of
traumatic thoracic aortic injury: clinical practice guidelines of the
Society for Vascular Surgery. J Vasc Surg. 2011;53:187–192.
27. The CRASH-2 Collaborators. The importance of early treatment
with tranexamic acid in bleeding trauma patients: an exploratory
analysis of the CRASH-2 randomized controlled trial. The Lancet.
2010;376:23–32.
28. Meier P, Knapp G, Tamhane U, etal. Short term and intermediate term
comparison of endarterectomy versus stenting for carotid artery stenosis: systematic review and meta-analysis of randomized controlled
clinical trials. BMJ. 2010;340:c467.
29. Moore LJ, Brenner M, Kozar RA, et al. Implementation of resuscita-
tive endovascular balloon occlusion of the aorta as an alternative to
resuscitative thoracotomy for noncompressible truncal hemorrhage.
J Trauma Acute Care Surg. 2015;79(4):523–532.
30. Dubose JJ, Scalea TM, Brenner M, etal. The AAST prospective Aor-
tic Occlusion for Resuscitation in Trauma and Acute care Surgery
(AORTA) registry: data on contemporary utilization and outcomes
of aortic occlusion and resuscitative balloon occlusion of the aorta
(REBOA). J Trauma Acute Care Surg. 2016;81(3):409–491.
31. Ribeiro Junior MAF, Feng CYD, Nguyen ATM, etal. The complications
associated with resuscitative endovascular balloon occlusion of the
aorta (REBOA). World J Emerg Surg. 2018;13:20.
32. Reva VA, Matsumura Y, Horer T, et al. Resuscitative endovascular
balloon occlusion of the aorta: what is the optimum occlusion time
in an ovine model of hemorrhagic shock? Eur J Trauma Emerg Surg.
2018;44(4):511–518.
33. Zhu CS, Pokorny DM, Eastridge BJ, etal. Give the trauma patient what
they bleed, when and where they need it: establishing a comprehensive regional system of resuscitation based on patient need utilizing
cold-stored, low titer O+ whole blood. Transfusion. 2019;59:1429–
1438.
34. Zwislewksi A, Nanassay AD, Meyer LK, etal. Practice makes perfect:
the impact of stop the bleed training on hemorrhage control knowledge, wound packing and tourniquet application in the workplace.
Injury. 2019;50(4):864–868.
35. Pasley AM, Parker BM, Levy MJ, etal. Stop the bleed: does the training
work one month out? Am Surg. 2018;84(10):1635–1638.
4
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Training Paradigms for
Vascular Trauma
PAUL W. WHITE and JAMES B. SAMPSON
Introduction
The issue of surgical training—whether vascular or general—faces a number of significant current and future
challenges. Firstly, the advent of vascular surgical residencies in the United States and Great Britain has widened
the gap between vascular surgery and general surgery as
specialties, and it has specically limited the exposure of
vascular surgeons to major trauma and constrained the
general surgeons experience with regard to the fundamentals of diagnosis and management of perfusion abnormalities, techniques of vascular imaging, exposure, and
surgical or endovascular intervention. Secondly, the introduction of work-hour restrictions in the United States, the
United Kingdom, and the European Union has led to dramatically decreased opportunities for professional contact
with patients and clinical material for all trainees.
full impact of these work-hour directives is only now being
assessed. However, a recent study by the Royal College of
Surgeons of England suggests that the quality of patient
care has sharply declined because of the lack of continuity
of care, and it further suggests that operative exposure is
insufcient to ensure competency in an adequate range of
procedures for independent practice.8 Thirdly, the development of ever–increasingly complex procedures, including
endovascular techniques, has strained the ability of surgical residency or fellowship programs to endow competence and prociency in all the required areas of practice.
Fourthly, the extensive adoption of minimally invasive techniques, both endovascular and laparoscopic, has decreased
the opportunities for trainees to develop the open surgical
skills needed to treat traumatic injuries.9 Fifthly, there is
increasing scrutiny of the quality of health care, brought
about by a number of high-prole cases involving medical
errors, such as the Bristol Enquiry in the United Kingdom
and the Institute of Medicine’s “To err is human” report
in the United States.
to closer supervision and less independence during surgical training, which in turn can impede the development of
condent and decisive surgical trainees.
As a result of these challenges, current training paradigms for both general and vascular surgery are inadequate
for expert management of traumatic vascular injury, and
they each provide a different foundation on which to build
with additional training. This has led some individuals who
are particularly interested in vascular injury management
to seek additional training or experience in both trauma
management and vascular disease management. This dual
training has resulted in some true experts, but it is inefcient
10–14
This increasing scrutiny has led
1–7
The
and impractical to meet the demand. Surgical educators
have also responded by developing short courses involving
both didactic and simulation training to meet the demand
for additional training in the management of vascular
injuries.
Graduate Medical Education
Training in surgery has traditionally followed an apprenticeship model, with the trainee undergoing supervised
exposure to decision-making and technical skills under the
tutelage of a “craft” master. Historically, the acquisition of
vascular techniques—whether by master or apprentice—
has followed a model whereby the development of new
skills occurs via adaption and remolding of previously
learned skill sets. However, with the increased adoption of
multimodal imaging in the diagnosis and minimally invasive techniques in the management of general surgical and
vascular disease, the opportunity to transfer previously
learned skills to these new realms of practice is concordantly lower. Image acquisition and interpretation at the
point of care and new endovascular therapies pose substantial technical challenges, similar to those experienced
by practitioners of laparoscopic and minimally invasive
surgery (MIS). These include reduced tactile sensation, a
two-dimensional (2-D) (rather than a three-dimensional
[3-D]) perspective, and the need to overcome proprioceptive and visual issues.
decision-making algorithms and treatment opportunities
often require new training models and educational curricula—applicable to both established specialists and surgical trainees—while paying heed to new restrictions in
duty hours. The relentless and inevitable drive to subspecialize has concurrently required practitioners to master
new techniques at the cost of narrowing clinical focus and
constraining the surgical armamentarium required for
trauma injury management. With these issues in mind, it
is timely to consider new and emerging ways of delivering training to surgeons expected to manage patients with
vascular trauma.
The current trend in surgical training within the United
States is toward a structured, competency-based curriculum with objective and ongoing documentation of
prociency within residency training and then going into
independent practice. Toward this end, national organizations including the American College of Surgeons (ACS),
the American Board of Surgery (ABS), the Residency
Review Committee–Surgery (RRC-S) of the Accreditation
15,16
Additional data sources and new
42
4 • Training Paradigms for Vascular Trauma 43
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Council for Graduate Medical Education (ACGME), the
American Surgical Association, the Association for Program Directors in Surgery, and the Association for Surgical
Education have established a national consortium called
the Surgical Council on Resident Education (SCORE) to
reform general surgical residency education.17 The SCORE
has developed a national curriculum. The SCORE portal
provides a modular curriculum that combines learning
objectives, discussion questions, text resources and videos,
and self-assessment quizzes in a single online format. Program directors can track a trainee’s progress by self-study
through the curriculum over the course of a residency.18
The Association for Program Directors in Vascular Surgery
has nearly completed a similar curriculum specic to vascular surgery (VSCORE). The aim is to ensure alignment of
the core content of the training program, the core competencies expected as learning outcomes, and the assessment
practices. This will conrm that—no matter what program
or tract a resident completes—measurable and acceptable
levels of competence are achieved in all required areas.19
Unfortunately, experiential learning through case volume
has suffered signicantly since the late 1990s, and the
decline in case volume threatens the effectiveness of our
current training paradigms.
GRADUATE MEDICAL EDUCATION/RESIDENCY
TRAINING IN GENERAL SURGERY
The increasing specialization of vascular surgeons and
their training, especially with the advent of stand-alone
GME programs in vascular surgery, has diluted the available
training opportunities for general surgery residents with
the majority of open vascular cases being done by vascular
surgeons and vascular residents/fellows.
22 general surgery residencies, the opening of a vascular
surgery fellowships was associated with a 17% decline in
vascular surgery cases for general surgery residents.24 Similarly, the opening of a 0-5 integrated vascular surgery residency was associated with a 20% decline in vascular case
numbers for general surgery residents at the University of
South Florida.
25
Overall, and in spite of the fact that many still consider
vascular surgery to be an integral part of general surgery training, trainees are getting less experience in this
area. Surgical residents in the United States are required
to self-report the number and nature of the cases they
perform during their training to the ACGME. Although
the quality of these case logs is limited by the nature of
self-reporting, they remain the best quantitative data
20–23
In a study of
available on the operative experience of residents. Examining ACGME case logs from 1999 to 2017, Cortez et al.
found a 10% decrease in vascular case volume reported
by general surgery residents.26 A more detailed analysis
of ACGME case data by Drake et al. found that case volume declined by 50% in the chief resident year, arguably
the most important year to consolidate and rmly establish the knowledge, skills, and abilities (KSAs) of surgical
practice.27 Open arterial cases are clearly those most necessary to develop competence in treating vascular trauma,
and those have also declined at an alarming 38% over
the rst two decades of the 21st century.28 The average
number of vascular cases for trauma that were reported
by graduating residents to the ACGME as being performed
over the entire residency program in general surgery
decreased from 5.2 in 1999–2000 to 1.5 in 2008–09 to
1.1 in 2017–18 (Table 4.1).
29,30
It is important to bear in
mind that these data reect average experience, and as
such there are signicant numbers of trainees who have
no experience caring for patients with major vascular
trauma. Furthermore, the reported experience of all upper
extremity vascular cases by graduating general surgery
residents averaged 2.0 cases per trainee in 2017–18.
29,31,32
These reports reveal extremely limited experience in the
management of vascular injury and very limited experience in open vascular surgery in specic anatomic regions.
This is particularly concerning to the military community because of experience from operations in Iraq and
Afghanistan where the brachial artery was a frequently
injured structure. The decline in case volume is multifactorial, and many of the relevant changes in training
have occurred nearly simultaneously. In addition to the
transition to laparoscopic, endoscopic, and endovascular
techniques, an increasing trend toward conservative management of solid organ injury has contributed to signicantly fewer opportunities for trainees to undertake open
surgical procedures.
33–35
The advent of duty hour restrictions has also had a
deleterious effect. Although overall case numbers have
remained stable for general surgery residents, the breadth
and variety of operative experience has declined. Increases
in laparoscopic and alimentary tract procedures have offset signicant declines in trauma and vascular cases.36
The 80-hour workweek has also increased the variability
of residents’ experience. Whereas average case numbers
remain the same, the difference in case volume between
residents has increased suggesting that the quality of
graduating residents may be more variable.37 The hope
that many of the KSAs needed to treat vascular injuries
Table 4.1 The Average Number of Selected Cases over the Duration of Training
Major vascular cases for trauma—
General Surgery Residents
Major vascular cases for trauma—
Vascular Surgery 5+2 Fellows
Major vascular cases for trauma—
Vascular Surgery 0+5 Residents
Note: This data was reported by graduating chief residents and was supplied as part of the case log submitted to the American Board of Surgery from 1999 to
2018.
Numbers represent the mean for each procedure; and, if missing (NA), that procedure was not reported during that particular year.
Data collated from https://www.acgme.org/Data-Collection-Systems/Case-Logs-Statistical-Reports.
1999–2000 2002–03 2005–06 2008–09 2011–12 2014–15 2017–18
5.2 4.9 4.6 4.7 1.5 1.2 1.1
7.2 8.1 10.7 12.5 10.7 12.2 12.0
NA NA NA NA NA 11.0 10.1
44 SECTION 1 • Setting the Stage
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in trauma patients can be gained by elective operative
experience is unfounded. The concurrent decrease in total
vascular cases, open arterial cases, and trauma cases after
duty-hour restrictions calls in to questions the preparedness of general surgery trainees to treat trauma.
38
Based on the data presented, it is clear that general
surgery residents in the United States have a suboptimal
experience with the surgical management of vascular
trauma. In Canada, vascular surgery has been removed
from the Canadian general surgery training objectives. In
a survey of 29 Canadian surgical residents, 90% reported
an intention to perform vascular procedures after training despite the same cohort self-reporting of inadequate
training in 10 of the 13 procedures surveyed.39 Unsurprisingly, the authors of this study concluded that current trainees may lack the skills and abilities to deal with
vascular emergencies.
In spite of the growing prevalence of specialist-trained
vascular surgeons, there are still many areas in the world
(developed and underdeveloped) where the primary surgeon may not be a vascular surgical specialist and where
opportunities to practice a vascular skill set are infrequent. Ensuring that a fully trained vascular surgical specialist is available for each and every trauma case is not
practical in many hospitals, and is certainly unfeasible in
the austere domains of military and humanitarian surgical practice. Thus, the need to train competent practitioners who can handle vascular trauma is universal.
40–43
The development of vascular damage control techniques
such as vascular shunting, which require a less refined
set of KSAs, offers a potential solution wherein vascular
injuries can be temporarily managed by general surgeons
with shunting followed by evacuation or transport to a
vascular specialist.
44
GRADUATE MEDICAL EDUCATION/RESIDENCY
TRAINING IN VASCULAR SURGERY
Within the United Kingdom, the vascular curriculum is
set by the Intercollegiate Surgical Curriculum Programme
(ISCP).45 The ISCP benets from the input of specialty advisory committees (SACs) representing each of the 10 surgical specialties. It is also informed by and collaborates with
the Surgical Royal Colleges of Great Britain and Ireland and
other professional bodies, including the Local Education
and Training Boards (established in 2013) and the General
Medical Council (GMC). In 2012, vascular surgery became
established as a fully-edged surgical specialty and left the
aegis of the General Surgery SAC, with a dedicated training
pathway leading to specialist certication, separate from
that of general surgery.
In the United States, vascular surgery has been (and is
still considered by many to be) an integral part of general
surgery training and practice.46 Before 1960, no specic
training programs existed in vascular surgery, and vascular surgery was practiced by general and cardiothoracic
surgeons. The rst vascular surgery–specic training programs, including the vascular surgery fellowship at Walter
Reed Army Medical Center, were, in essence, apprenticeships directed by some of the pioneers of vascular surge ry.47 Training opportunities were advanced considerably
when the membership of the Society for Vascular Surgery
(SVS) voted in 1979 to develop accredited vascular training programs. Initially, 17 programs were approved, rising to 52 programs by 1982.48 In 1982, the rst 14 ABS
Certicates of Special Qualications in General Vascular
Surgery were issued, each earned after successful completion of a written examination. In the 1990s, leading vascular surgeons pushed for recognition of vascular surgery
as a specialty distinct from general surgery, based on the
underlying premise that patient outcomes were improved
when care was provided by a specialist in vascular surgery
rather than a general surgeon who occasionally performed
vascular operations.
49–51
Subsequently, vascular surgery
became a distinct specialty of surgery on March 17, 2005,
when (with approval of the American Board of Medical
Specialties) the ABS agreed to offer a Primary Certicate
in Vascular Surgery.46 In October 2005, training program
requirements for this certicate were approved, and the
traditional requirement for 5 years of training and certication in general surgery was eliminated. Effective July 1,
2006, the ABS converted its certicate in vascular surgery
from a subspecialty certicate to a specialty (primary) certicate. These landmark changes heralded the development
of new training paradigms. Two pathways have evolved:
the traditional Independent (5+2) 2-year vascular surgery
fellowships following a 5-year general surgery program and
Integrated (0+5) vascular surgery residency immediately
following medical school. 5+2 graduates are eligible for
dual board certication by the ABS in general and vascular
surgery while 0+5 graduates are only eligible for vascular
surgery certication.
Vascular trauma is increasingly funneled toward specialist trauma or vascular surgeons, but opportunities to
gain experience in vascular trauma are still limited.42 The
numbers of major vascular repairs for trauma that were
reported to the ABS by vascular surgery fellows—though
signicantly greater than that reported by graduates of
general surgery residencies—are small, with the average
number of cases reported as 7.2 in 1999–2000 and 12.0
in 2017–18 (see Table 4.1).29 Furthermore, more than 60%
of these procedures were peripheral in nature with surgical
experience of vascular trauma in the thorax and neck being
particularly low, averaging less than one case in each area
per resident.
Integrated and Independent GME programs seem to
provide a similar volume of vascular trauma cases to
trainees although long-term data is not available yet (see
Table 4.1). In addition, overall case numbers in most
categories of vascular surgery are similar between graduates of integrated and independent programs.52 Nonetheless, there may be important differences in the experiences
of graduates from these different types of programs.
Graduates of independent programs have a more concentrated operative experience performing more open and
major cases during their nal years of training.53 The
advantages of completing general surgery residency may
also be signicant. Between 2012 and 2014, graduating
general surgery residents performed more than twice as
many open abdominal procedures on average than integrated vascular surgery residents.54 Integrated vascular
surgery residents do pursue open surgical procedures
during their general surgery rotations, but these cases are
most often minor, nonabdominal procedures.
55
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