Experts explore acute trauma research and a national plan for disaster preparedness
Homeland defense has increasingly been a national concern, with incidents of domestic and international terrorist activity garnering headlines. As a result, physicians and researchers gathered in Washington, D.C., earlier this year to focus on disaster preparedness and response, for both natural disasters and intentional violence.

EWI XII: Homeland Defense as a Translation of War Lessons Learned was convened by the AAOS, in conjunction with the Orthopaedic Trauma Association (OTA), the Society of Military Orthopaedic Surgeons (SOMOS), and the Orthopaedic Research Society (ORS). The two-day program included presentations and collaborative discussions on disaster education, domestic readiness, communication among providers, and developing response teams, brought together thought leaders in acute trauma care, disaster management, and homeland defense. The event highlighted the importance of collaboration among the AAOS, OTA, SOMOS, and ORS— as well as the American College of Surgeons (ACS) and the American College of Emergency Physicians (ACEP)—to maintain trauma readiness for the next domestic disaster or war. 

Symposium participants were addressed by four Congressional speakers throughout the program, including Reps. Dutch Ruppersberger (D-Md.), Andy Harris, MD (R-Md.), Brad Wenstrup (R-Ohio), and Brian Mast (R-Fla.), each of whom spoke to the group about their own unique background, experiences, and interest in extremity war trauma research. These four speakers also talked about the ways in which advocates can engage with Congress to communicate the importance of funding research for these injuries.

The burden of war
The past 16 years have been the longest sustained period of combat operations in U.S. history. The impact has been considerable: 7,000 people have died and 53,000 have sustained injuries. Of those injured, 90 percent are unable to return to the workforce. In 2006, under the visionary leadership of AAOS, including 2005–2006 AAOS President Stuart L. Weinstein, MD, the first Extremity War Injuries Symposium was held to educate members of Congress and military surgeons on best practices and the potential burden to our society.

National preparedness must involve translation of useful military lessons to civilian medicine. Throughout the past 12 years, EWI has been sustained through a unique partnership of industry, the Department of Defense (DOD), and orthopaedic surgery. In response, Congress has enthusiastically supported these efforts, as evidenced by orthopaedic surgery receiving the largest single source of research funding in the profession's history through the DOD's Peer Reviewed Orthopaedic Research Program (PRORP). Through this program, research funding has flourished; since FY2009, Congress has appropriated $278.5 million to support military-relevant, peer-reviewed orthopaedic research through PRORP. Expanding beyond military populations and direct trauma, PRORP funds are open to all U.S. academic institutions (Fig. 1).

The long-term goal of the AAOS and its partner organizations is to increase PRORP funds and establish a Program Objective Memorandum (POM), which would lock in this funding as a line item in the annual DOD budget. EWI symposia are a key piece of this puzzle, as they increase visibility of the need for musculoskeletal trauma research.

Establishing a national plan for disaster preparedness
In 2015, the ACS published the Hartford Consensus, containing guidelines for improving survival during intentional mass casualty incidents. President Barack Obama directed stakeholders to establish an "all-of-nation, capabilities-based approach" to preparedness.

In 2016, the National Academies of Science Engineering and Medicine (NASEM) released a report aiming for "zero preventable deaths" and minimizing disability after injury in the United States. The NASEM's lofty goals are on par with national public health efforts to address cancer and HIV/AIDS. The report's recommendations provide a blueprint for a national trauma action plan that will build on progress made by military and civilian trauma systems and centers during the past decade. From prehospital care to acute care, surgical management, and rehabilitation, this plan is a "call to action" for the government and healthcare sectors to prevent death and to rehabilitate and restore patients to normal function and productive lives. The opportunity is prime for partnership and collaboration.

Civilian and military clinicians and researchers discussed the NASEM report and recommendations during EWI XII, and identified opportunities for partnership and collaboration. They noted that pairing military and civilian best practices offers early opportunity to gain momentum. Military prehospital successes—for example, with early tourniquet application—afford a platform from which combined clinical management guidelines may be offered, studied, and refined. Military-civilian partnerships, such as domestic military treatment centers that already participate meaningfully in regional civilian trauma care systems, must be studied and replicated where possible.

Symposium participants noted the significant obstacles to effective disaster response highlighted in the NASEM. These include credentialing of clinicians, dealing with medical liability concerns, and providing education and resources for personal risk management (eg, contraction of communicable disease during duty). In addition, other issues—such as the absence of a national strategy for rational distribution of trauma centers and trauma providers—continue to affect the stability of many regional systems.

A national trauma care system that partners military and civilian operations is fundamental to national security and domestic preparedness. Prevention of death and disability in the young, at-risk population restores meaningful years to the military and civilian workforces in ways attention to other diseases cannot. A coordinated national system of trauma care will also decrease overall economic burdens of injury and offset any investments required to develop and maintain the plan.

Looking ahead to EWI XIII
If orthopaedic surgeons are not leading cooperative efforts to transition to disaster preparedness, there is risk of exclusion from vital decisions that may ultimately affect patient care. We must partner with general trauma surgeons, emergency medical providers, and prehospital care teams to drive the agenda moving forward. Through military and civilian collaboration, as well as success in achieving funding through the PRORP, the EWI symposia represent an unparalleled return on investment.

The complete NASEM Report is available online at http://www.nationalacademies.org/hmd/Reports/2016/A-National-Trauma-Care-System-Integrating-Military-and-Civilian-Trauma-Systems.aspx.

The 2017 EWI XII symposium was co-chaired by Andrew Schmidt, MD, and MAJ Daniel Stinner, MD. LTC Justin Orr, MD, was scientific director, and COL (Ret.) James Ficke, MD, FACS, served as EWI project team chair. For additional information on the Extremity War Injuries symposium series and publications, visit www.aaos.org/ewi.

Dr. Ficke is the chair of the Extremity War Injuries Project Team. David Teague, MD, was a moderator and presenter at the EWI XII symposium. Erin Ransford is manager, research advocacy, in the AAOS Office of Government Relations.

Impact of EWI Symposia: 2006-2017

• > $1.5M industry funding
• > $300K DOD funding
• AAOS, SOMOS, OTA, ORS support
• > $350M research funding
• > 80 publications
• EWI research published in the Journal of the AAOS
• Congressional support
• Serves ALL citizens