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  1. Christopherson, Nathan A. M. MBA, MSN, RN, TCRN, CEN, EMT-P

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October 1, 2017, Stephen Paddock opened fire on a crowd of concertgoers on the Las Vegas Strip, killing 58 people and injuring over 500 more. As seen in previous mass shootings, such as the Pulse Night Club, Paddock used assault-style weapons, which created devastating injuries not typically cared for in civilian trauma centers (CBS News, 2017). As part of the response, the U.S. Air Force's 59th Medical Wing deployed five medical providers to assist in local hospitals. After the incident, Air Force physicians were quoted as stating injuries were similar to those that you would see in a combat zone and that their military training prepared them to provide the best care possible when faced by overwhelming numbers of patients and dwindling resources (Keller, 2017).


In 2016, the National Academies of Science, Engineering, and Medicine released "A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury." In this report, the authors highlighted how a national trauma system built on the collaborative sharing of best practices from military and civilian trauma centers will reduce mortality from survivable traumatic injury (National Academies of Sciences, Engineering, and Medicine, 2016). The National Defense Authorization Act for Fiscal Year 2017 (2016) (S. 2934) became law on December 23, 2016, and called on the Secretary of Defense to create a military-civilian-integrated health system to improve access to care and patient outcomes for military covered beneficiaries. In addition, the Secretary of Defense will devise a plan for the development of a joint trauma system that would develop standards of trauma care across the military. Finally, the Secretary of Defense is to establish a joint trauma education and training directorate to maintain readiness of traumatologists in the U.S. military. The Secretary of Defense was given permission to enter into partnerships with Academic Level I trauma centers to maintain military provider readiness (National Defense Authorization Act for Fiscal Year 2017 of 2016). Building on the National Defense Authorization Act for Fiscal Year 2017 (2016), the Mission Zero Act of 2017 (H.R. 880/S. 1022) was reintroduced to the Energy and Commerce Committee in the House of Representatives and the Health, Education, Labor, and Pensions Committee in the Senate (2017). On February 26, 2018, the U.S. House of Representatives passed H.R. 880 and the bill has moved to the Senate (Mission Zero Act, 2017). Adoption of the Mission Zero Act would improve the readiness of civilian trauma centers for responding to mass casualty situations, especially when assault-style weapons and improvised explosive devices are used.


Through lessons learned on the battlefield, military medical providers have greatly advanced the care of injured patients, decreasing preventable battlefield deaths from uncontrolled hemorrhage. Research has demonstrated that the use of combat medical care tactics that incorporate the use of tourniquets and wound packing can decrease preventable deaths from mass shootings, bombings, motor vehicle collisions, and other criminal acts (Butler, 2017). Further surgical advances from the military include the resurgence of resuscitative endovascular balloon occlusion of the aorta for noncompressible truncal injury and the use of whole blood and freeze-dried plasma during trauma resuscitation (Northern et al., 2018).


High-velocity firearm and blast injuries present special considerations for care that are not routinely seen in civilian trauma centers (Keller, 2017), including, but not limited to, wound cavitation injury from projectile path and blast lung injury. Failure to recognize the need for specialized care can lead to preventable loss of life and limb. Military medical providers, including physicians, advanced practice providers, nurses, combat medics/corpsmen/medics, respiratory therapists, and other members of the health care team specialize in the care of blast and high-velocity injuries, while incorporating the latest advances in combat medicine into their day-to-day medical practices (Blackbourne et al., 2012; Butler, 2017).


Military providers are routinely faced with overwhelming odds and limited resources on the battlefield. Hence, they have developed skills to quickly assess patient conditions without the use of specialized imaging and testing equipment, which are not practical during mass casualty incidents. Working side by side with their civilian cohorts, military providers can bring the combat readiness to the civilian bedside by streamlining the flow of patient care and utilizing resources to benefit the greatest number of patients (Blackbourne et al., 2012).


Between periods of active combat, it is difficult for military providers to maintain skills by solely working in stateside military medical facilities due to low surgical volume and poor adherence to quality practices (LaFraniere & Lehren, 2014). Incorporating members of the military care team into civilian trauma centers will present opportunities for military providers to routinely use crucial medical skills, thus maintaining combat readiness of military medical forces.


The only drawback to adoption of the Mission Zero Act is the need for funding, through tax dollars, to offset expense incurred by civilian trauma centers that host military providers. Grant funding is incorporated into H.R. 880/S. 1022 to cover costs that would be incurred related to the addition of new providers. Covered costs include medical malpractice, state medical license, fees for training on electronic medical record and other documentation platforms, and office space. Without this grant funding, civilian centers that are willing to take on military medical providers would be required to expend financial resources that could make the system nonsustainable.


The incorporation of military trauma team members into civilian trauma centers will increase the proficiency of our trauma centers to respond to the rising number of mass casualty incidents in the United States while maintaining the combat readiness of our armed forces. In addition, through collaboration, we can expand the adoption of best practices from military and civilian into the trauma system, improving outcomes for all patients.




Blackbourne L. H., Baer D. G., Eastridge B. J., Renz E. M., Chung K. K., DuBose J., Holcomb J. B. (2012). Military medical revolution: Deployed hospital and en route care. Journal Trauma and Acute Care Surgery, 73(6, Suppl. 5), S378-S387. [Context Link]


Butler F. K. (2017). Two decades of saving lives on the battlefield: Tactical combat casualty care turns 20. Military Medicine, 182(3), e1563-e1568. doi:10.7205/MILMED-D-16-00214 [Context Link]


CBS News. (2017). Two of the deadliest mass shootings in U.S. history come just 35 days apart. Retrieved from https://www.cbsnews.com/news/deadliest-mass-shootings-us-las-vegas-texas-church[Context Link]


Keller J. (2017). "This kind of thing happens in Iraq or Syria": Air Force surgeon describes aftermath of Las Vegas shooting. Retrieved from http://taskandpurpose.com/airforce-surgeon-las-vegas-shooting/[Context Link]


LaFraniere S., Lehren A. (2014, September 1). Smaller military hospitals said to put patients at risk. The New York Times. [Context Link]


Mission Zero Act, H.R. 880, 115th Con. (2017). Retrieved from https://www.govtrack.us/congress/bills/115/hr880[Context Link]


National Academies of Sciences, Engineering, and Medicine. (2016). A national trauma care system: Integrating military and civilian trauma systems to achieve zero preventable deaths after injury. Washington, DC: The National Academies Press. doi:10.17226/23511 [Context Link]


National Defense Authorization Act for Fiscal Year 2017, H.R. 114-328, 114th Cong. (2016). Retrieved from https://www.congress.gov/bill/114th-congress/senate-bill/2943/text[Context Link]


Northern D. M., Manley J. D., Lyon R., Farber D., Mitchell B. J., Filak K. J., Holcomb J. B. (2018). Recent advances in austere combat surgery: Use of aortic balloon occlusion as well as blood challenges by special operations medical forces in recent combat operations. Journal of Trauma and Acute Care Surgery, 85(1S Suppl 2), S98-S103. doi:10.1097/TA.0000000000001966 [Context Link]