Committee on Surgical Combat Casualty Care position statement: Neurosurgical capability for the optimal management of traumatic brain injury during deployed operations

Describes the need for neurosurgical capabilities in combat zone to best provide care for combat casualties with trauma brain injury.

BACKGROUND

Experiences over the last three decades of war have demonstrated a high incidence of traumatic brain injury (TBI) resulting in a persistent need for a neurosurgical capability within the deployed theater of operations. Despite this, no doctrinal requirement for a deployed neurosurgical capability exists. Through an iterative process, the Joint Trauma System Committee on Surgical Combat Casualty Care (CoSCCC) developed a position statement to inform medical and nonmedical military leaders about the risks of the lack of a specialized neurosurgical capability.

METHODS

The need for deployed neurosurgical capability position statement was identified during the spring 2021 CoSCCC meeting. A triservice working group of experienced forward-deployed caregivers developed a preliminary statement. An extensive iterative review process was then conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. To provide additional context and a civilian perspective, statement commentaries were solicited from civilian clinical experts including a recently retired military trauma surgeon boarded in neurocritical care, a trauma surgeon instrumental in developing the Brain Injury Guidelines, a practicing neurosurgeon with world-renowned expertise in TBI, and the chair of the Committee on Trauma.

RESULTS

After multiple revisions, the position statement was finalized, and approved by the CoSCCC membership in February 2023. Challenges identified include (1) military neurosurgeon attrition, (2) the lack of a doctrinal neurosurgical capabilities requirement during deployed combat operations, and (3) the need for neurosurgical telemedicine capability and in-theater computed tomography scans to triage TBI casualties requiring neurosurgical care.

CONCLUSION

Challenges identified regarding neurosurgical capabilities within the deployed trauma system include military neurosurgeon attrition and the lack of a doctrinal requirement for neurosurgical capability during deployed combat operations. To mitigate risk to the force in a future peer-peer conflict, several evidence-based recommendations are made. The solicited civilian commentaries strengthen these recommendations by putting them into the context of civilian TBI management. This neurosurgical capabilities position statement is intended to be a forcing function and a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level V.

Over the last 23 years, surgeons and surgical teams have deployed in support of combat operations in Iraq, Afghanistan, and Syria as well as contingency operations in Africa. The deployed combat casualty care system is a continuum of care providing progressively advanced medical and surgical care at each level of care. This continuum progresses from the point of injury (Role 1) to damage-control resuscitation and surgery (Role 2), to specialty and even definitive care and further stabilization (Role 3), followed by long-range evacuation out of the deployed theaters of operations. This chain of survival (Fig. 1) optimizes the care of the battlefield wounded by placing immediately lifesaving interventions close to the point of injury and rapidly moving the patient through the continuum of care with increasing capabilities, as well as holding capacity, at each level of care.

Figure 1.

Military joint trauma system continuum of care. Care increases in capability from the point of injury through the continuum of care. The highest level of care on the battlefield is the Role 3 hospital, referred to as combat support hospitals or field hospitals. After a casualty leaves the Role 3, they move by fixed wing aircraft to a Role 4 hospital, which is the first level of care outside the combat zone. AE, aeromedical evacuation; CFI, Center for the Intrepid; CONUS, continental United States; CSH, combat support hospital; MEDEVAC, medical evacuation; OCONUS, Outside of CONUS; POI, point of injury; VA, Veterans Administration Hospital. Source: The Joint Trauma System, the Department of Defense Center of Excellence for Trauma.

The Role 3 military treatment facility (MTF) is the highest level of care on the battlefield; those who cannot return to duty are evacuated along the continuum of care for additional clinical management outside of the combat zone. During the recent conflicts, the trauma system has adapted to meet the needs of the kinetic, dynamic, and occasionally uncertain environments—transport times adapt to the capabilities on the ground, and there has been a trend to move surgical capabilities closer to the point of injury to optimize survival. Unlike a civilian trauma system that has permanent facilities, the military trauma system is mobile with capabilities moving and adjusting in scope and scale to the clinical and operational demands of the combat environment.

The overall number of combat casualties in Iraq and Afghanistan began to decrease in 2015; however, the deployment tempo for surgeons did not. In fact, the same (or even more) number of surgeons were being deployed on smaller surgical teams. The Committee on Surgical Combat Casualty Care (CoSCCC) previously identified clinical and operational risks concerns with the progressive increase in small and single surgeon teams use and communicated this risk in a previously published position statement.¹

A similar risk was identified by the CoSCCC as the personnel deployed in the theater of operations decreased regarding neurosurgical care for traumatic brain injury (TBI) and other potentially life-threatening neurosurgical conditions. Given the overall small number of neurosurgeons in the military and their deployment tempo, recently medical commanders assumed that neurosurgical care could be performed by trauma surgeons and that a deployed neurosurgical capability was unnecessary. However, this situation was a short-lived because the plan was not acceptable to the higher-level nonmedical commander and neurosurgical coverage was rapidly reestablished in the deployed theater of operations. Secondary to this event, as well as the likelihood that a lack of neurosurgical coverage could occur in the future and subject injured service members to a substandard level of neurosurgical care, the CoSCCC established a working group to develop a position statement. The intent of this position statement is to inform medical and nonmedical military leaders about the risks of the lack of specialized neurosurgical care. In addition, the CoSCCC is advocating for the generation of a military requirement for neurosurgical capabilities during deployed combat operations to mitigate the risk of death or disability from TBI and other neurosurgical trauma.

PATIENTS AND METHODS

The CoSCCC is one of the three Defense Committees on Trauma (DCoTs). The DCoT is composed of three component committees: Committee on Tactical Combat Casualty Care, Committee on En Route Combat Casualty Care, and the CoSCCC. Position statements and guidelines developed by the DCoT are exempt for requiring institutional review board approval and are not human subjects research. These DCoTs provide guidelines, set standards, and work with the services, the Defense Health Agency, and the Combatant Commanders to advise on optimal battlefield care encompassing the entire continuum from point of injury through care definitive care in the United States. The CoSCCC's voting membership is composed of triservice active duty and reserve component subject matter experts with nonvoting civilian experts who participate in and advise the committee. The CoSCCC produces evidence-based clinical practice guidelines governing facility-based combat casualty care.

The need to inform the military clinical community, deployed hospital commanders, medical planners, and nonmedical commanders about the risk of not having an organic neurosurgical capability in a deployed theater of operations was identified in 2021 at the spring CoSCCC meeting. A triservice working group composed of neurosurgeons, trauma surgeons, general surgeons, emergency medicine physicians, and other providers with deployment experience (across all phases of care) developed a preliminary statement on the risk of not having a neurosurgical capability in a combat theater of operations. The statement went through an extensive iterative process consisting of monthly meetings to review the revisions, revision adjudication, afternoon workgroups during the CoSCCC meetings, and then a final committee review and vote, to ensure that the intent of messaging to services (Army, Navy, and Air Force), medical leadership, and operational commanders was met. Ensuring that this position statement had input from not just clinical subject matter experts, but also from other members of the combat casualty care team, helped ensure that it can be used as a communication tool to inform commanders on the risk of not having a neurosurgical capability at Role 3 MTFs that are within 5 hours from potential points of injury for US service members. Once the final statement was agreed upon, it was distributed to selected civilian trauma leaders for comment; these commentaries are included as a supplement to this brief report.

RESULTS

The “Neurosurgical Capability for Deployed Operations” position statement (Fig. 2) was finalized in January 2023 and distributed to the CoSCCC membership for a vote to ensure concurrence among the CoSCCC membership.

Figure 2.

(A) Committee on Surgical Combat Casualty Care position statement (front side). (B) Committee on Surgical Combat Casualty Care position statement (back side).

Commentaries from (1) a recently retired military trauma surgeon boarded in Neurocritical Care, (2) a trauma surgeon who was instrumental in developing the Brain Injury Guidelines (BIG), (3) a practicing neurosurgeon with world renowned expertise in TBI, and (4) the chair of the Committee on Trauma (COT) provided additional context for this statement and offer a civilian perspective on some of the challenges and requirements faced by military surgeons.

CONCLUSION

The military's deployed trauma system has unique challenges when compared with the civilian system—the dynamic nature of conflict requires potential movement of critical capabilities such as neurosurgical care, to meet the needs of combat casualties. Given the high incidence of TBI in combat trauma, neurosurgeons will always have a role on the battlefield. The military is faced with increasing challenges with retention of neurosurgeons, which potentially increases risk of battlefield morbidity and mortality from TBI. There is a clear need to have neurosurgical capability at Role 3 MTFs that can receive combat casualties with head injury within 5 hours of injury to mitigate death and disability from TBI.² This level of care is required at American College of Surgeons (ACS)–verified Levels 1 and 2 trauma centers in the United States and that same level of care should be provided to military members who deploy in support of military combat operations. The position statement on deployed neurosurgical capabilities from the CoSCCC, DCoT, and the Joint Trauma System is intended to be a forcing function and a communication tool to ensure that the right capability is in the right place at the right time for those with battlefield injuries.

by Matthew J. Martin, MD, FACS, DABA

“If you act like you know what you're doing, you can do anything you want — except neurosurgery.” — Sharon Stone

During the last two decades of armed conflict and global US military operations, the deployed military health system has gone through numerous organizational, doctrinal, and tactical changes in how trauma care is fielded and delivered on the battlefield. As with any system that has had to rapidly evolve and adapt under extremely stressful conditions, there have been numerous highs, lows, victories, and defeats. While some critical aspects of trauma care, such as the Department of Defense Trauma Registry, have been established and matured, other aspects remain concerningly deficient or absent. Among these is a clear set of minimum standards for surgical staffing and subspecialty expertise that must be present to deliver high-quality trauma care to our wounded or injured service members, allies, and host national personnel.

In this position statement, Colonel Gurney and coauthors have laid out a focused and cogent assessment of the current state of battlefield neurosurgical care and recommendations for optimization. To any military or civilian with an understanding and investment in deployed trauma care, one does not have to read further than the second sentence of this paper before hearing alarm bells going off. The statement that “there is no doctrine” currently that requires the deployment of advanced neurosurgical capabilities is chilling and frankly shocking given the clearly established and evidence-based absolute requirement for immediate neurosurgeon presence at all major civilian trauma centers. This is not to say that neurosurgeons and neurosurgical capabilities have not been routinely deployed and providing exceptional care in the deployed setting, which they have. Rather, it is that, like many other aspects of our forward deployed fielding of capabilities and surgical specialists, it has been done on an entirely ad hoc and nonstandardized basis. Also, most concerning, there have been periods where there were no forward deployed neurosurgeons in the area of operations. The absence of this critical capability in the civilian trauma sector would result in the immediate loss of verification as a Level 1 or 2 trauma center, and no lower standard should be acceptable for the deployed trauma care system during any war or high-intensity combat operations.

A simple perusal of the available literature supports the critical need for deployed neurosurgeons and the outstanding outcomes that have been achieved with an aggressive posture toward emergent neurosurgical intervention.^3–5 Additional confirmation is provided by an analysis comparing TBI outcomes between casualties treated at US facilities compared with those from United Kingdom MTFs that lacked a deployed neurosurgeon.⁶ The finding of a threefold increased odds of survival associated with treatment by a neurosurgeon highlights the medical and moral imperative that this must be formalized in US military medical doctrine and capabilities requirements. Additional studies have shown the time-critical nature of these injuries and need for expert neurosurgical intervention; these are not cases that can be safely “stabilized and evacuated” to Role 4 or 5 (Fig. 1) facilities with neurosurgical capabilities.^7,8 A commonly proffered solution or stopgap measure has been to have general or trauma surgeons perform emergent decompressive cranial surgery. This approach ignores the available literature and experience and represents a form of magical thinking that must be removed from modern military medical planning. Currently, the military is struggling to field general and trauma surgeons with the requisite minimal clinical experience and caseload to deliver adequate surgical care within their specialty area. The assertion that they could also be reliably trained to effectively perform highly complex neurosurgical procedures with exceedingly thin margins for error, or to maintain those skills if they were somehow achieved, is simply a fantasy.

One relatively minor quibble with this position statement is that, in the opening section of “Facts,” there is a statement that deploying neurosurgical capabilities “will decrease battlefield attrition for neurologic conditions not requiring evacuation.” I think this is highly unlikely, as any condition not requiring neurosurgical intervention can be adequately evaluated and managed by deployed trauma surgeons or internists (or via telemedical consultation), and any condition that actually requires a neurosurgeon would not be something that would result in treatment in the theater of operations followed by a rapid return to duty status. However, the remainder of this thoughtful and expertly crafted statement should be accepted and adopted immediately by military medical leadership and, in lieu of that, should be insisted upon by the combatant commands and other nonmedical military leadership. The stakes for our service members and other patients receiving care at forward deployed medical treatment facilities are simply too high and the hour too late to delay any further. The time for magical thinking and Pollyannaish medical planning is over!

by Bellal A. Joseph, MD FACS

“Brain bleeds are like snowflakes, no two are the same.”

Traumatic brain injuries are a complex and challenging medical emergency, in both military and civilian settings, which must be managed with a tailored approach. Although a vast majority of TBIs are managed nonoperatively, neurosurgical interventions are an absolute lifesaving necessity when required.

Brain Injury Guidelines indicated that not all intracranial hemorrhages require a uniform management approach, necessitating a divergence from a “bleed/no bleed” approach to considering the type and size of the hemorrhage, and determining whether surgical or nonsurgical intervention is appropriate. Brain Injury Guidelines guides the triage, management, and appropriate disposition of TBI patients based on neurological examinations and radiologic findings, the two most important predictors of the need for neurosurgical requirements. Brain Injury Guidelines has been successfully implemented at the Department of Defense Level I trauma center and other trauma centers.⁹ Given the scarcity of neurosurgeons, integrating BIG into the military sphere could be a positive turning point, particularly since most military personnel are not taking anticoagulants. Through BIG, injured personnel who require neurosurgical attention can be quickly identified, allowing for improved outcomes, more efficient use of resources, and decreased battlefield attrition.¹⁰

Neurosurgical intervention within 5 hours of injury has been shown to reduce disability and mortality in severe combat related TBI. Despite this, it is difficult to recognize when surgical intervention is necessary in a battlefield setting without the assistance of computed tomography (CT) scans. The presence of imaging facilities, such as portable CT scanners, at Role 2 MTF helps in the early identification and triage of patients to Role 3 MTF for higher neurosurgical care. This allows neurosurgeons to promptly evaluate the injury and plan for the most appropriate treatment, thus improving the chances of survival.

Considering the evidence presented in the position statement, I agree with the authors' recommendations and support the CoSCCC position statement to ensure better access to neurosurgical care for combat casualties. Specifically, I support the measures to promote the retention and recruitment of neurosurgeons and improve the availability of portable CT scanners at Role 2 MTFs, as well as the inclusion of neurosurgeons at Role 3 MTFs. Such measures are essential to provide the highest quality of life-supporting care for combat casualties who may require neurosurgical attention.

by Alex Valadka MD, FAANS, FACS

“If you can remove it or transplant it, it can't be that important.” This is how neurosurgeons good-naturedly tease their surgical colleagues in other specialties. However, beneath the humor, the bitter fact remains that brain injury continues to be at or near the top of the list of the most common causes of trauma-related death in both military and civilian populations.

In this context, there is much to like about the CoSCCC Position Statement: Neurosurgical Capability for Deployed Operations. One of the first facts listed in the statement is that neurosurgeons are not substitutable. I have had trauma and acute care surgeons who were O6 (Colonel)–level officers in different branches of the service scrub with me on craniotomies in civilian settings. Earlier in their careers, they had been in situations in which they had to attempt emergency craniotomies in the absence of a neurosurgeon. They wanted to scrub with me to get a “refresher” course in case they ever had to do so again, but they made it abundantly clear that they had no desire to repeat those experiences unless absolutely necessary.

Their reluctance is completely appropriate. Performing surgical procedures is a perishable skill that atrophies if not used regularly, especially if a procedure was not learned through constant repetition in a structured curriculum. The same is true of nonprocedural management, including neurocritical care. Many or even most general surgery residency programs no longer require their residents to spend time on a neurosurgery service during their training. Although those who complete a fellowship in trauma and acute care surgery often learn basic neurocritical care, this cannot replace the training and experience of someone who works with the nervous system full-time, especially because many of the concepts and skills in elective care are transferable to emergency settings. As an analogy, a neurosurgeon who knows basic trauma management might be able to run a trauma resuscitation, but it would not flow nearly as smoothly and be as error-free as a resuscitation run by someone who lives in that world every day.

The position statement notes that TBI accounted for 45% of hospital deaths in Afghanistan and Iraq from 2001 to 2009 versus 30% from 2014 to 2021. Across comparable time periods, prehospital TBI deaths decreased from 30% to 23%. These decreases are impressive. However, it will become progressively more difficult to push those numbers lower as care systems improve and inefficiencies are eliminated. Experienced neurosurgical input will be necessary to recognize and capitalize on subtleties that could directly impact patient management. What happens during the initial minutes after TBI can have lifelong consequences—both good and bad.

It is hard to believe that neurosurgical availability is required of civilian Level 1 and Level 2 trauma centers but not of Role 3 MTFs. Another comment in the statement asserts that the availability of neurosurgical capabilities will decrease battlefield attrition for neurologic conditions that do not require evacuation. In truth, many types of mild and moderate TBI are not life-threatening but still cause cognitive and behavioral disturbances of such severity that battlefield attrition will result. Telemedicine can be a game changer in this setting, enabling in-theater military care to easily outstrip the value and efficiency of civilian interhospital consultations regarding TBI patients.

The position statement ends with a recommendation for contingency planning to leverage allied or host nation health systems that provide a comparable level of care. Unfortunately, depending on the location of a future conflict, finding comparable levels of care in host nations may be impossible. Global outreach and efforts to raise the level of care in low- and middle-income countries are areas of growing activity in the neurosurgical community. However, we have a long way to go, and the challenges are many. This is yet another justification for establishing as doctrine the presence of a neurosurgeon at Role 3 MTFs.

by Jeffery D. Kerby MD, PhD, FACS

Since the ACS COT published their first trauma center standards document in 1976,¹¹ the ready availability of specialty surgeons to assist with the management of seriously injured patients has remained a key component. The first standards document, entitled Optimal Hospital Resources for Care of the Seriously Injured, has undergone several revisions and is now named Resources for Optimal Care of the Injured Patient. This change from “optimal hospital resources” to “optimal care” was intentional and reflects an abiding principle that the needs of the patient must be addressed wherever they receive care. The latest version of the standards (released in 2022) clearly states that, to be verified by the ACS COT as an adult or pediatric Level 1 or 2 trauma center, the hospital must have continuous 24/7/365 availability of specialty surgical expertise, to include neurosurgery, without any identified gaps.¹² There is no provision in these standards that allows for neurosurgical expertise to be provided by surgeons other than those specifically trained and boarded in neurosurgery.

This statement authored by Colonel Gurney and colleagues from the CoSCCC is in line with the principles of optimal care as outlined in the ACS COT standards document. The statement from CoSCCC clearly details the benefits and improved outcomes obtained by providing timely access to neurosurgical expertise. One of the primary goals of the initial ACS COT standards, as well as the subsequent ACS COT Trauma Center Verification Program that began in earnest in 1987, was to obtain and verify the institutional commitment to provide the necessary resources and expertise to provide the best possible care and outcomes for seriously injured patients. Likewise, this statement seeks to ensure the institutional commitment of appropriate neurosurgical coverage for military operations through the development of doctrine that will require availability of this expertise as a critical planning factor. This is a particularly vital element given the predicted frequency of neurosurgical injuries in combat operations moving forward.

While having neurosurgical coverage at all Role 3 MTFs would be considered optimal, the statement acknowledges that the current lack of sufficient numbers of active-duty neurosurgeons may require a system of regionalized neurosurgical care in operational theaters that require multiple Role 3 MTFs. The goal of such a system of care would be to provide definitive neurosurgical intervention within 5 hours of injury as supported by military trauma data showing improved survival and outcomes within this specified timeframe. The current approach of developing in-theater trauma systems of care that coordinate movement of wounded personnel across the continuum of care would support this approach. These systems have worked well in recent conflicts where we have enjoyed unchallenged air superiority allowing patient transport with minimal delay. This will likely not be the case in peer or near-peer conflicts where our control of the airspace may be significantly challenged and may limit the ability to provide neurosurgical expertise within the desire timeframe using a regionalized approach. Therefore, the statement's call to prioritize service recruitment and retention of neurosurgeons is of particular importance to optimize placement of neurosurgeons to decrease the time to definitive intervention.

This statement is based on established standards that have been developed to provide optimal care to the seriously injured patient to limit preventable death and disability. These standards need be applied wherever injury occurs to provide the best outcomes. There is ample evidence to support this need and the clear institutional commitment through doctrine to provide this level of care during military operations is of vital importance.