A Perfect Storm: 2019 Scudder Oration on Trauma

TY - JOUR

T1 - A Perfect Storm

T2 - 2019 Scudder Oration on Trauma

AU - Knudson, M. Margaret

N1 - Funding Information: The fourth element of the clinical readiness project involves the conduct of research in the civilian setting that informs the continuously learning military and civilian trauma systems. Conducting research in the deployed environment is extremely challenging, and it most frequently includes collecting observational data, with limited transference to the civilian setting. 35 On the other hand, innovative advances used during war time can be prospectively studied in those US trauma centers with research infrastructure. For the past decade, the National Trauma Institute (NTI) has led the charge in conducting military-relevant research outside of the Department of Defense. Founded in 2003 by Ronald Stewart, MD, FACS, the current medical director of the ACS-COT, the Trauma Institute of San Antonio (TRISAT) supported research grants for 3 level 1 trauma centers including the University of Texas Health Science Centers in San Antonio, the Willford Hall Medical Center, and Brooke Army Medical Center (see also: https://www.NatonalTraumaInstitute.org ). In 2006, the TRISAT Board voted to take the organization national, establishing a national board of directors representing all of the major trauma organizations, and chartered as the NTI. In 2008, NTI managed its first federal research grant for $1.6 million secured via a direct congressional appropriation with the support of Texas Senator Kay Bailey Hutchinson. In 2009, a second federal research grant for $2.1 million was secured, and the first round of Request for Proposals (RFP) was issued for the resulting $3.9 million. Through this process, 16 trauma research studies were funded, including some single center studies, multicenter studies, observational studies, and randomized controlled studies. These grants were primarily awarded to young trauma surgeon investigators. Throughout the studies, NTI managed the contracts and subcontracts, the Department of Defense's Human Research Protection (HRPO) applications, regularly scheduled research conferences and teleconferences, and quarterly reports. All but 1 of these studies was successfully completed and published, a record comparing very favorably to other federally funded studies. 36 By 2011, however, Congress had dissolved the earmark process and NTI was forced to seek new avenues to secure research funding. Through a series of lobbying efforts and meetings with congressional representatives, NTI was successful in securing $5 million to develop The National Trauma Research Repository (NTTR). ). Each of these grants has its foundation in current military experience and is aligned with the concept of wartime lessons shaping the National Trauma Action Plan. 37 Under the direction of the principal investigator, COL (ret) Donald Jenkins MD, FACS, USAF, a set of Human Subjects Protection guidelines were developed for this repository, as was a data dictionary for common elements. The NTTR is a key piece of national research infrastructure and is set to become a vast repository offering thousands of data points from hundreds of studies. It also meets federal requirements for data sharing. The NTI is currently supporting 5 major federal grants including the NTTR, all funded through the Department of Defense via the US Army Research and Material Command structure (USAMRMC) ( Table 5 38 In 2011, COL (ret) Brian Eastridge MD, FACS, USA conducted a study of prehospital deaths that occurred in Iraq and Afghanistan over a 10-year period using the Armed Forces Medical Examiner Service Mortality Surveillance Division. 39 Of the 4,596 deaths examined, 24% were believed to be potentially survivable, with the greatest number of these deaths related to hemorrhage. The investigators concluded that improvements in prehospital hemorrhage control, airway management, and a shorter time to definitive care would be needed to reduce the rate of preventable combat casualty deaths. Armed with this experience, Dr Eastridge successfully competed for Department of Defense grant support to conduct a similar study to be performed in the US, termed the Multi-Institutional Injury Mortality Investigation in the Civilian Pre-hospital Environment (MIMIC). 40 A selected group of subject matter experts and medical examiners from several states are examining autopsy data in order to define the cause of death in trauma patients who never make it to the trauma center. This study is also using Geographic Information System technology to examine proximity of the death to a level 1 or 2 trauma center. The protocols for a damage control resuscitation using a balanced ratio of red blood cells (RBC), plasma, and platelets are largely based on the recent success of this method in saving lives on the battlefield. 41 However, in the austere environment, blood components may be in short supply and whole blood, often supplied by the “walking blood bank” of prescreened fellow soldiers, airmen, sailors or marines, is used. 42 Military investigators have described an improved survival for patients with combat-related injuries who received warm fresh whole blood as part of a damage control resuscitation when compared with those who received packed RBC. 43 , 44 In the civilian setting, a direct transfusion from a donor to a recipient is impractical, but the use of whole blood rather than its component parts is being reconsidered in the setting of trauma. Therefore, Dr Gill Cryer's National Trauma Institute-supported research grant is timely, as he investigates the use of stored fresh whole blood in a civilian trauma center with a particular focus on coagulation parameters in leuko-reduced compared with unfiltered whole blood under standard refrigeration conditions. The severity of the injuries sustained by wounded troops, especially with the high rate of amputations associated with dismount injuries, and coupled with prolonged immobilization during air transport, sets the stage for post-traumatic venous thromboembolic (VTE) events. In a study performed at the evacuation hospital in Landstuhl, Germany, combat casualties admitted to the ICU had an overall deep venous thrombosis rate of 6.4%, and 1.4% had suffered a pulmonary embolism. However, when universal screening was used in order to detect these potential complications before transfer to the continental US, the incidence of deep venous thrombosis detected by duplex ultrasound was 14% and the pulmonary embolism rate detected on surveillance chest CT scans rose to 4.4%. (COL [ret] Raymond Fang MD, FACS, USAF personal communication). We and others had hypothesized that some of these “pulmonary emboli” represented primary thrombi rather than emboli and are often associated with chest trauma. 45 If indeed these are thrombi already in the pulmonary system and are asymptomatic, the question arises as to the need to treat them with potentially dangerous pharmacologic agents that may aggravate bleeding in the setting of trauma. This question is currently being address by the CLOTT study group (Consortium of Leaders in the study of Traumatic Thromboembolism) in 17 level 1 trauma centers from across the country via an NTI-supported Department of Defense grant. An additional related question being investigated on the CLOTT grant is the association between the presence of fibrinolytic shutdown after injury and the development of venous thromboembolism. 46-48 In 2018, the NTI together with The Consortium for National Trauma Research were successful in securing funding for the development and implementation of a National Trauma Research Action Plan (NTRAP). The Consortium for National Trauma Research is supported by the AAST, Eastern Association for the Surgery of Trauma, the Western Trauma Association, and the ACS-COT in addition to NTI, and the principal investigator for this grant is Eileen Bulger, MD, FACS, current chair of the ACS-COT committee on trauma. The research agenda for the National Trauma Research Action Plan aligns with both the Department of Defense research priorities and the goals outlined in the NASEM report. In addition to establishing a comprehensive trauma research agenda, the goals of this grant include coordination of multicenter clinical trials using the strength of the ACS-COT's TQIP and advocating as 1 voice for funding for trauma research at a level commensurate with the burden of the disease. 49 To date, NTI has generated and/or managed more than $80 million directed toward trauma research for 22 studies in 35 cities and 25 states involving more than 70 investigators. To the staff at NTI, Sharon, Michelle, Monica, Pam, Lizette, Amy, Nick, and Ana, the trauma community is indebted to you for all that you have done to help improve the care of injured patients here in our country and on battlefields worldwide.

PY - 2020/3

Y1 - 2020/3

UR - https://www.scopus.com/pages/publications/85077386582

U2 - 10.1016/j.jamcollsurg.2019.11.009

DO - 10.1016/j.jamcollsurg.2019.11.009

M3 - Article

C2 - 31794833

AN - SCOPUS:85077386582

SN - 1072-7515

VL - 230

SP - 269

EP - 282

JO - Journal of the American College of Surgeons

JF - Journal of the American College of Surgeons

IS - 3

ER -