Medical Readiness: Efforts Are Underway for DOD Training in Civilian
Trauma Centers (Chapter Report, 04/01/98, GAO/NSIAD-98-75).

Pursuant to a legislative requirement, GAO evaluated the effectiveness
of the Department of Defense's (DOD) demonstration program that would
provide trauma care training for military medical personnel through one
or more public or nonprofit hospitals, focusing on: (1) the status of
the demonstration program and DOD's actions to meet the legislative
provisions; (2) other initiatives aimed at training military personnel
in trauma care; and (3) key issues that DOD should address if it decides
to expand its trauma care training program.

GAO noted that: (1) it is too early to assess the effectiveness of DOD's
demonstration program because it has only been in place since November
1997; (2) as of March 1, 1998, only four surgeons had completed their
training rotations; (3) DOD has not finished the evaluation tool it is
developing to assess the program's effectiveness; (4) due in part to the
program's late start, DOD's actions to implement the program have not
been fully consistent with the legislative provisions; (5) DOD missed
the April 1996 implementation milestone and issued a report on its
proposed demonstration program to Congress 5 months late; (6) DOD did
not seek an agreement with the civilian center to provide health care to
DOD beneficiaries that is at least equal in value to the services
provided by the military trainees; (7) DOD officials believed that such
an arrangement might have jeopardized the willingness of hospital
officials to enter into the program; (8) GAO identified several other
initiatives that might be used in assessing the feasibility of training
military personnel in civilian trauma centers; (9) unlike the current
demonstration program, these other initiatives have not limited their
training to general surgeons; (10) the collective experiences of these
programs, together with those of the demonstration program, could
provide DOD valuable information in determining the feasibility and
effectiveness of training military personnel in civilian trauma centers;
(11) DOD will need to address several issues, none of which appear to be
insurmountable, if it decides to expand its trauma care training
program; (12) questions have arisen over physician licensure
requirements; (13) two issues concern whether: (a) civilian trauma
centers have the capacity to train large numbers of military personnel;
and (b) military trainees can obtain sufficient experience, since they
will compete for training opportunities with the centers' own personnel;
(14) the first issue cannot be addressed because DOD has not yet
estimated the number and type of medical personnel that might require
trauma training; (15) DOD could deal with the second issue by selecting
civilian centers that are understaffed because of their large caseloads;
(16) in the longer term, better information will be needed on wartime
medical requirements, the personnel requiring trauma care training and
their priority for such training, and the desired frequency of refresher
training; and (17) the biggest challenge DOD may face is determining how
best to balance need for wartime medical training with the substantial
needs of its peacetime health care system.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  NSIAD-98-75
     TITLE:  Medical Readiness: Efforts Are Underway for DOD Training in 
             Civilian Trauma Centers
      DATE:  04/01/98
   SUBJECT:  Military personnel
             Health care personnel
             Hospitals
             Noncompliance
             Health resources utilization
             Physicians
             Military training
             Emergency medical services
             Defense contingency planning
             Combat readiness
IDENTIFIER:  Civilian Health and Medical Program of the Uniformed 
             Services
             CHAMPUS
             DOD Centralized Credentials and Quality Assurance System
             DOD Medical Human Resource System
             Persian Gulf War
             
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Cover
================================================================ COVER


Report to Congressional Committees

April 1998

MEDICAL READINESS - EFFORTS ARE
UNDERWAY FOR DOD TRAINING IN
CIVILIAN TRAUMA CENTERS

GAO/NSIAD-98-75

Medical Readiness

(703199)


Abbreviations
=============================================================== ABBREV

  CHAMPUS - Civilian Health and Medical Program
     of the Uniformed Services
  DOD - Department of Defense
  GAO - General Accounting Office

Letter
=============================================================== LETTER


B-279215

April 1, 1998

The Honorable Strom Thurmond
Chairman
The Honorable Carl Levin
Ranking Minority Member
Committee on Armed Services
United States Senate

The Honorable Floyd Spence
Chairman
The Honorable Ike Skelton
Ranking Minority Member
Committee on National Security
House of Representatives

This report responds to Section 744 of the National Defense
Authorization Act for Fiscal Year 1996, requiring us to evaluate the
effectiveness of the Department of Defense's (DOD) demonstration
program that would provide trauma care training for military medical
personnel through one or more public or nonprofit hospitals. 
Specifically, we (1) determined the status of the demonstration
program and DOD's actions to meet the legislative provisions, (2)
identified other initiatives aimed at training military personnel in
trauma care, and (3) identified key issues that DOD should address if
it decides to expand its trauma care training program.  This report
contains recommendations to the Secretary of Defense. 

We are sending copies of this report to the Secretaries of Defense,
the Army, the Navy, and the Air Force and the Commandant of the
Marine Corps.  We will also make copies available to others on
request. 

Please contact me at (202) 512-5140 if you or your staff have any
questions concerning this report.  Major contributors to this report
are listed in appendix III. 

Mark E.  Gebicke
Director, Military Operations
 and Capabilities Issues


EXECUTIVE SUMMARY
============================================================ Chapter 0


   PURPOSE
---------------------------------------------------------- Chapter 0:1

Military medical personnel have almost no chance during peacetime to
practice their battlefield trauma care skills.  As a result,
physicians both within and outside the Department of Defense (DOD)
believe that military medical personnel are not prepared to provide
trauma care to severely injured soldiers in wartime, which could
result in the loss of lives and limbs.  Because DOD must be better
prepared to deliver trauma care during wartime, Congress enacted
legislation in 1996 requiring DOD to implement a demonstration
program that would provide trauma care training for military medical
personnel through one or more public or nonprofit hospitals.  This
report responds to a requirement in that legislation that GAO
evaluate the effectiveness of the demonstration program. 
Specifically, GAO (1) determined the status of the demonstration
program and DOD's actions to meet the legislative provisions, (2)
identified other initiatives aimed at training military personnel in
trauma care, and (3) identified key issues that DOD should address if
it decides to expand its trauma care training program. 


   BACKGROUND
---------------------------------------------------------- Chapter 0:2

DOD and GAO reports on medical operations during the Gulf War
questioned the military's ability to meet its wartime medical
mission, particularly in providing trauma care to the predicted
number of casualties.  These reports highlighted that many military
medical personnel, including physicians, nurses, and corpsmen, had
either never treated trauma patients or had no recent experience. 
For example, only 2 of 16 surgeons on a Navy hospital ship had recent
trauma surgical experience.  Military medical personnel receive
readiness training in both military and medical combat casualty
skills.  However, these courses are taught through classroom
instruction and field exercises and do not include actual hands-on
training with injured patients. 

Since most military treatment facilities provide health care to
active duty personnel and their beneficiaries and do not receive
trauma patients, military medical personnel cannot maintain combat
trauma skills during peacetime by working in these facilities.  In
contrast, civilian trauma centers are specialized hospital facilities
with immediately available health care providers and equipment to
care for severely injured trauma patients, such as those with
penetrating stab or gunshot wounds.  Most combat injuries are
penetrating wounds resulting from bullets from small arms and
fragments from explosive munitions.  A 1995 Congressional Budget
Office report stated that 98 percent of the cases treated at one
civilian trauma center matched those casualty-related diagnoses on
the military's list of battlefield injuries, whereas only 5 percent
of the primary diagnoses that military personnel treat match
battlefield injuries. 

Section 744 of the National Defense Authorization Act for Fiscal Year
1996 required the Secretary of Defense to implement a demonstration
program to evaluate the feasibility of providing shock trauma
training for military medical personnel through public or nonprofit
hospitals.  Specifically, the act required DOD to implement a
demonstration program at a civilian center not later than April 1,
1996, and submit reports describing the scope and activities of the
program to Congress not later than March 1, 1997, and March 1, 1998. 
In addition, the act required that the agreement between DOD and the
civilian center include a provision that the center will provide
health care services to DOD beneficiaries that are at least equal to
the value of the services provided by the military personnel training
in the center. 

In August 1996, the Office of the Assistant Secretary of Defense for
Health Affairs, which is responsible for DOD's health care system,
formed the Combat Trauma Surgical Committee to help develop guidance
on improving trauma medical readiness training.  In February 1997,
the Committee issued a report recommending trauma care training
standards for military surgeons, which included both hands-on
experience and continuing education.  The service Surgeons General
approved the recommendations as a first step toward developing a
trauma care training program for military personnel. 

In April 1997, DOD chose Naval Medical Center Portsmouth, Virginia,
to lead the demonstration program.  Naval Medical Center Portsmouth
signed an agreement with Eastern Virginia Medical School to provide
training for Navy surgeons at Sentara Norfolk General Hospital in
Norfolk, Virginia.  The program, which is currently limited to
general surgeons, was initiated in November 1997 and expected to run
through March 1998. 


   RESULTS IN BRIEF
---------------------------------------------------------- Chapter 0:3

It is too early to assess the effectiveness of DOD's demonstration
program because it has only been in place since November 1997.  As of
March 1, 1998, only four surgeons had completed their training
rotations.  Also, DOD has not finished the evaluation tool it is
developing to assess the program's effectiveness.  Due in part to the
program's late start, DOD's actions to implement the program have not
been fully consistent with the legislative provisions.  DOD missed
the April 1996 implementation milestone and issued a report on its
proposed demonstration program to Congress
5 months late.  Further, DOD did not seek an agreement with the
civilian center to provide health care to DOD beneficiaries that is
at least equal in value to the services provided by the military
trainees, as specified in the legislation.  DOD officials believed
that such an arrangement might have jeopardized the willingness of
hospital officials to enter into the program. 

GAO identified several other initiatives that might be used in
assessing the feasibility of training military personnel in civilian
trauma centers.  Unlike the current demonstration program, these
other initiatives have not limited their training to general
surgeons.  Rather, these programs have extended training to
orthopedic surgeons, medics, corpsmen, general medical officers,
nurses, and physicians.  Individual surgeons, military medical
treatment facilities, and combat units appear to have initiated these
programs to fill the void left by the lack of any DOD or servicewide
program for trauma care training.  The collective experiences of
these programs, together with those of the demonstration program,
could provide DOD valuable information in determining the feasibility
and effectiveness of training military medical personnel in civilian
trauma centers. 

DOD will need to address several issues, none of which appear to be
insurmountable, if it decides to expand its trauma care training
program.  Questions have arisen over physician licensure
requirements, but state licensure was an issue in only one of six
programs that GAO examined.  Two additional issues concern whether
(1) civilian trauma centers have the capacity to train large numbers
of military personnel and (2) military trainees can obtain sufficient
experience, since they will compete for training opportunities with
the centers' own personnel.  The first issue cannot be addressed
because DOD has not yet estimated the number and type of medical
personnel that might require trauma training.  DOD could deal with
the second issue by selecting civilian centers that are understaffed
because of their large caseloads.  In the longer term, better
information will be needed on wartime medical requirements, the
personnel requiring trauma care training and their priority for such
training, and the desired frequency of refresher training.  The
biggest challenge DOD may face is determining how best to balance the
need for wartime medical training with the substantial needs of its
peacetime health care system. 


   PRINCIPAL FINDINGS
---------------------------------------------------------- Chapter 0:4


      DOD'S DEMONSTRATION PROGRAM
      IS NOT FULLY CONSISTENT WITH
      LEGISLATIVE PROVISIONS
-------------------------------------------------------- Chapter 0:4.1

Because implementation of the demonstration program was delayed, it
is too early to determine its effectiveness.  Data from the program
is limited because, as of March 1, 1998, only four surgeons had
rotated through the program.  In addition, no evaluation tool has
been completed to capture the data needed to assess the program's
effectiveness.  The implementation and evaluation of the
demonstration program are the responsibilities of the head of the
Department of Surgery at Naval Medical Center Portsmouth.  This
official has many other competing demands and has not been provided
any administrative support personnel to assist with the program. 

Although the legislation stated that the demonstration program was to
be implemented not later than April 1, 1996, Health Affairs did not
select the demonstration site until April 1997, and the first
rotation did not begin until November 1997.  In addition, the law
required reports on the program to Congress on March 1, 1997, and
March 1, 1998.  DOD's first report was not issued until July 24,
1997, and the second report had not been issued as of March 13, 1998. 
According to Health Affairs and service officials, the delay in
implementing the program was due to Health Affairs (1) shifting
responsibility for the program between offices, (2) taking time to
assess whether two existing military trauma centers could be used to
fulfill the legislative mandate for a demonstration program, (3)
establishing the Combat Trauma Surgical Committee to develop the
minimum training requirements for trauma surgery, and (4) waiting
until another ongoing training program at the civilian center was
completed. 

The agreement between Naval Medical Center Portsmouth and Eastern
Virginia Medical School does not contain a provision that the school
or hospital would provide in-kind services to military personnel and
other DOD beneficiaries, as required by the law.  Navy officials
believed that, if they had asked for an in-kind service agreement,
the medical school would not have agreed to provide the training. 
Eastern Virginia Medical School officials confirmed that an in-kind
service arrangement would not have been acceptable because neither
the school nor the hospital receives any financial benefit from this
training arrangement and they have adequate resources without the
Navy trainees to provide needed trauma care. 

DOD's demonstration program only provides trauma care training for
general surgeons.  The program does not include trauma training for
the other medical personnel who would also be expected to take care
of the wounded servicemembers, including those who would be the first
ones to treat combat casualties on the battlefield.  Under the
program, general surgeons from the Naval Medical Center Portsmouth
are on call every other 24-hour period for 3 weeks at Sentara Norfolk
General Hospital's trauma center.  The surgery staff at Eastern
Virginia Medical School provides and directs the trauma service at
the center and supervises the military trainees when they are on
call.  Participating surgeons said that the trauma training they
received in the program was worthwhile, but they reserved judgment on
the effectiveness of the program. 

Health Affairs had no minimum criteria for selecting the site for a
demonstration program other than identifying military treatment
facilities that already had affiliations with civilian trauma
centers.  The Navy suggested Naval Medical Center Portsmouth for the
demonstration program because of its affiliations with a local trauma
center and medical school.  This affiliation consisted of Navy
general surgery residents training at the hospital and two
trauma-trained Navy surgeons being on call at the local trauma center
3 to 4 nights a month.  Although other urban centers might have a
greater penetrating trauma training caseload, Sentara Norfolk General
Hospital's caseload provided an adequate amount of hands-on trauma
care cases. 


      OTHER PROGRAMS ATTEMPT TO
      PROVIDE WARTIME TRAUMA
      SKILLS TRAINING
-------------------------------------------------------- Chapter 0:4.2

DOD does not capture data on existing local cooperative programs
between the military and civilian trauma centers.  Individual
physicians, military medical treatment facilities, and combat units
initiated programs or established affiliations with civilian trauma
centers even though not required to do so by DOD.  For example, the
Third Marine Aircraft Wing trains its corpsmen and general medical
officers at Martin Luther King, Jr./Drew Medical Center, an
inner-city trauma center in south Los Angeles that treats over 2,500
trauma patients a year, including about 1,200 penetrating trauma
cases.  The benefit of this program is that it trains those medical
personnel that would be the first ones to treat and stabilize combat
casualties.  The local programs that GAO identified have generally
tended to be short-lived because they have been based on personal
initiative rather than on a DOD requirement.  Nevertheless, these
programs appear to have yielded valuable experiences that could be
useful in assessing the feasibility and effectiveness of training
military medical personnel in civilian trauma centers. 

DOD also provides limited trauma care training in its two trauma
centers at Brooke Army and Wilford Hall Medical Centers in San
Antonio, Texas.  Each center receives about 800 trauma patients per
year, about 20 to 25 percent of which are penetrating trauma cases. 
The benefit of providing trauma care in these military facilities is
that they can train all members of the team expected to take care of
combat casualties and not just general surgeons.  However, hands-on
training opportunities at these facilities are limited because of the
small number of trauma patients. 


      ISSUES RELATED TO WARTIME
      TRAUMA CARE TRAINING HAVE
      SURFACED
-------------------------------------------------------- Chapter 0:4.3

GAO identified several issues that DOD will need to address if it
decides to expand trauma care training for military personnel, but
these issues do not appear to be insurmountable.  For example, many
military medical officials are concerned that they may need a second
medical license to train in civilian centers and that they would have
to incur the cost of the license.  However, some states are allowing
military personnel to obtain a training license or register with the
state, at no or nominal cost, to train in civilian centers. 

Another issue concerns the ability of the civilian centers to train
large numbers of military medical personnel.  DOD is in the process
of updating its wartime medical force structure requirements. 
Currently, the total number of active duty military medical personnel
is about 100,000.  DOD's assessment will determine the number and
types of personnel that will be needed to meet DOD's wartime
requirements.  However, until this assessment is completed, the
number of personnel who need to be trained in trauma care cannot be
determined. 

According to some military and civilian officials, civilian hospitals
that offer military trainees the most beneficial training are
generally teaching hospitals with trauma centers that provide total
care for the most severely injured patients.  However, since these
hospitals have programs that also train civilian physicians in trauma
care, the military trainees may have to compete with the civilian
trainees for hands-on trauma procedures and decision-making
opportunities.  The directors from three large trauma centers in Los
Angeles, Houston, and Baltimore stated that the large number of
trauma patients at many inner-city trauma centers would enable both
the civilian staff and the military trainees to get more than enough
hands-on experience. 

A longer term issue is the need for an overall strategy and plan to
address the need for trauma care training.  The recommendations in
the February 1997 report of Health Affairs' Combat Trauma Surgical
Committee provide a starting point for DOD to begin developing such a
plan.  However, clear objectives and milestones to build a
comprehensive plan must be in place.  For example, it is important
for DOD to complete its ongoing assessment of wartime medical
requirements, determine which personnel require trauma care training,
prioritize the personnel to be trained, and determine the frequency
with which training will be required. 

DOD currently has no system to identify those personnel that will
receive trauma care training.  The Combat Trauma Surgical Committee
recommended that individual trauma care training should be tracked so
that trained personnel could be quickly identified if a crisis should
arise.  Two systems--the Centralized Credentials and Quality
Assurance System and the Defense Medical Human Resource System--could
be used for this purpose.  However, the first system has limitations,
and the second system is still being developed. 

Another wartime medical training issue is how such training might be
handled in the reserves, but this issue was not addressed by the
Combat Trauma Surgical Committee.  Also, DOD has focused its
attention to date only on providing trauma care training to active
duty general surgeons.  In the longer term, it will also be important
to examine the training needs of other medical personnel. 

DOD's biggest challenge may be in providing wartime trauma care
training while meeting the substantial demands of its peacetime
health care system.  DOD's primary medical mission is to provide
health care to 1.6 million active duty beneficiaries to fulfill its
wartime operational objectives.  In addition, DOD provides health
care to 6.6 million other military-related eligible beneficiaries,
such as active duty dependents and retirees and their dependents. 
Trauma care training will unavoidably compete for resources with the
health care services DOD must provide to these beneficiaries. 


   RECOMMENDATIONS
---------------------------------------------------------- Chapter 0:5

Additional data is needed to evaluate the feasibility and
effectiveness of providing trauma care training to military personnel
in civilian centers.  Because the authority for the demonstration
program at Sentara Norfolk General Hospital expires on March 31,
1998, GAO recommends that the Secretary of Defense consider
negotiating a new agreement for a similar program.  GAO also
recommends that the Secretary (1) expedite DOD's efforts to establish
an evaluation tool to assist in an assessment of the feasibility and
effectiveness of training military personnel in civilian trauma
centers and (2) broaden the scope of the evaluation to include other
individual programs that have provided trauma care training to
general surgeons as well as other medical personnel. 

If DOD determines that the trauma care training concept is feasible
and decides to expand such training in civilian trauma care centers,
GAO recommends that the Secretary of Defense develop a long-term
strategic plan that establishes goals and identifies actions and
appropriate milestones for achieving these goals.  This plan should
(1) establish criteria for selecting locations for trauma care
training that would maximize the experiences of military trainees,
(2) identify which medical personnel should receive trauma care
training and the frequency of such training, and (3) develop a
mechanism to identify those military medical personnel who are likely
to deploy early in a conflict so that they can receive priority for
medical wartime trauma care training.  In addition, this plan should
address the training needs of both the active and reserve components. 


   AGENCY COMMENTS
---------------------------------------------------------- Chapter 0:6

In official oral comments on a draft of this report, DOD generally
concurred with GAO's recommendations.  DOD noted that it has
determined that the trauma care training concept is feasible for
general surgeons and is currently evaluating the concept for other
military medical personnel.  DOD further stated that it is addressing
GAO's concerns.  Specifically, it plans to (1) negotiate a new
agreement with Sentara Norfolk General Hospital to provide trauma
care training, (2) facilitate development of an evaluation tool to
help assess the effectiveness of trauma care training and include
other individual trauma care training programs beyond the
demonstration program in its evaluation, and (3) establish panels to
determine trauma care sustainment training needs for all military
medical personnel and not only general surgeons.  Finally, DOD stated
that, in February 1998, the Combat Trauma Surgical Committee
reconvened to coordinate with the services in developing,
coordinating, and implementing trauma care training strategy for both
the active and reserve components. 

DOD also stated that it has specific concerns regarding (1)
additional costs for licensure and credentialing of providers, (2)
costs for additional civilian trauma training opportunities, and (3)
sustainment costs of what will have to become a new readiness
mission.  GAO recognizes that cost is a factor that DOD must consider
in selecting civilian training locations.  GAO notes that the extent
to which DOD might incur additional costs depends on the specific
site selected. 


INTRODUCTION
============================================================ Chapter 1

Warfighters need to be confident that military medical personnel can
take care of them if they are wounded on the battlefield.  However,
Gulf War reports pointed out that medical personnel were unprepared
to provide combat casualty care.  These reports questioned the
Department of Defense's (DOD) ability to meet its wartime medical
mission, particularly in providing care to the predicted number of
casualties.  A major area of concern was that many military medical
personnel lacked sufficient training or experience in wartime skills,
such as trauma care. 

Few military medical personnel receive hands-on training for trauma
care, which includes treating actual patients who have incurred
severe injuries.  Instead, most medical readiness training is
provided through formal classroom instruction and field exercises. 
In peacetime, medical personnel have little chance to practice their
battlefield trauma care skills because most patient care provided in
military treatment facilities bears little resemblance to injuries
treated in wartime.  For example, the most common wounded-in-action
injury is an open penetrating wound, whereas the most common
peacetime diagnosis is a single live birth.  In fact, none of the 50
most frequent peacetime diagnoses at military medical centers match a
wounded-in-action condition.  Appendix I describes the top five
wounded-in-action injuries, nonbattlefield injuries, and diseases and
the top five diagnoses seen in military treatment facilities in
fiscal year 1997. 


   GULF WAR STUDIES HIGHLIGHTED
   THE NEED TO IMPROVE TRAUMA CARE
   TRAINING
---------------------------------------------------------- Chapter 1:1

DOD lessons learned after the Gulf War highlighted that many medical
personnel had little to no experience in taking care of severely
injured patients.  For example, of the 16 surgeons on the Navy
hospital ship
USNS Mercy, only 2 had recent trauma surgical experience.  Also, none
of the over 100 corpsmen at a surgical support company had ever seen
actual advanced trauma life support given to a trauma patient.  In
addition, an Army report highlighted that surgical teams identified
to complement the rapid movement of troops during the war and provide
emergency surgical services consisted of physicians who were not
surgeons, such as obstetrician/gynecologists.  An Army trauma surgeon
deployed to the area believed that an obstetrician could not have
provided lifesaving definitive surgery. 

In 1992 and 1993, we issued reports on medical readiness weaknesses
identified during the Gulf War.\1 These reports highlighted that some
medical personnel were not trained to take care of combat casualties. 
For example, although Navy nurses and physicians who were deployed to
the war were described as experienced and competent, many of them had
never treated trauma patients, and most had not completed training in
combat casualty care.  The prolonged buildup of forces over a 6-month
period allowed Navy personnel to perform medical training, such as
refresher resuscitative skills, mass casualty drills, and triage
procedures.  Also, one report noted that a slot for an Army thoracic
(chest) surgeon was filled by a gynecologist who admitted that he was
not qualified for the position because he had never opened a human
chest cavity. 

A July 1995 Congressional Budget Office report on restructuring
military medical care, prepared at the request of the House Committee
on National Security, indicated that the military services may need
to establish affiliations with level I civilian trauma centers to
improve wartime medical training and broaden exposure to
wounded-in-action injuries.  Level I centers provide total care for
the most severely injured trauma patients.\2 Many injuries seen in
these centers are similar to the injuries seen in war.  Only 2 of
DOD's 115 military hospitals are level I trauma centers.  These
centers are Brooke Army Medical Center and Wilford Hall Medical
Center, both located in San Antonio, Texas. 

In March 1995, Congress held hearings on DOD wartime and peacetime
medical requirements, including medical readiness training
weaknesses.  In February 1996, Congress enacted the National Defense
Authorization Act for Fiscal Year 1996 (P.L.  104-106).  Section 744
of the act required that the Secretary of Defense implement a
demonstration program to evaluate the feasibility of providing shock
trauma training for military medical personnel in civilian hospitals. 


--------------------
\1 Operation Desert Storm:  Problems With Air Force Medical Readiness
(GAO/NSIAD-94-58, Dec.  30, 1993), Operation Desert Storm: 
Improvements Required in the Navy's Wartime Medical Program
(GAO/NSIAD-93-189, July 28, 1993), and Operation Desert Storm:  Full
Army Medical Capability Not Achieved (GAO/NSIAD-92-175, Aug.  18,
1992). 

\2 Level II through IV centers provide less comprehensive trauma care
than a level I center. 


   DIVERSE MEDICAL TEAMS PROVIDE
   WARTIME TRAUMA CARE
---------------------------------------------------------- Chapter 1:2

DOD has about 100,000 active duty medical personnel, including
general and other surgeons, nonsurgical physicians, physician
assistants, nurses, and enlisted medical personnel.  Various teams of
these personnel provide medical care to wounded soldiers on the
battlefield.  The most critical time for treatment of severe
battlefield trauma is within the first hour of injury.  Historical
data from past conflicts shows that medical treatment, including
nonsurgical, makes a significant contribution to the decrease in loss
of lives and limbs during this critical period. 

Initial care of a wounded soldier is provided by self-aid or a fellow
soldier administering first aid.  The first medically trained team
that responds to battlefield injuries--known as first
responders--includes enlisted medical personnel, such as combat
medics, field corpsmen, and independent duty corpsmen, and a
physician assistant or a physician.  These personnel move with the
combat units they support and provide medical care limited to
emergency procedures that prevent death, such as establishing an
airway, controlling hemorrhaging, administering intravenous fluids,
and stabilizing wounds and fractures. 

Forward surgical teams, which consist of physicians (especially
surgeons), nurses, and medical technicians, also provide care for
those severely injured on the battlefield.  These teams provide
emergency surgical procedures that prevent death, loss of limb, or
body function.  The size of the team is determined by the predicted
number and type of casualties. 


   MEDICAL PERSONNEL RECEIVE
   READINESS TRAINING
---------------------------------------------------------- Chapter 1:3

Military physicians must meet basic civilian education and residency
requirements as well as military training requirements to provide
medical care during wartime.  After 4 years of medical school,
physicians receive specialized training in graduate medical education
or residency programs.  Residents in a surgical specialty are
required to perform a rotation in trauma and critical care to become
board-certified general surgeons.  This rotation provides the
resident experience with hands-on management and treatment of
severely injured trauma patients.  Much of this trauma training
occurs in civilian facilities because DOD has only two level I trauma
centers that receive severe trauma patients.  After physicians
complete residency training, no formal DOD or service hands-on
training program exists for sustaining trauma care skills.  Although
there is no requirement in the civilian sector for continuing
hands-on experience, the American College of Surgeons suggests that
surgeons treat about 50 severe trauma cases per year to remain
adequately trained in trauma care.\3

Enlisted medical personnel, such as combat medics and field corpsmen,
receive initial medical readiness training in both basic military and
life support skills.  The military skills courses teach technical,
tactical, and leadership training necessary for personnel to function
as part of a medical team in a war environment, and the basic life
support course teaches necessary medical skills.  For example, the
entry-level course for Army medics includes about 150 hours of
classroom training devoted to basic emergency medical skills and a
field exercise at the conclusion of the class.  However, the medics
do not receive hands-on trauma experience at a hospital or on board
an ambulance. 

Before deployment, both military physicians and enlisted medical
personnel are required to take courses on combat casualty care, which
focuses on the military casualty management system and casualty care
in a battlefield environment.  These courses consist of classroom
instruction, animal laboratories, and field training and include the
principles of trauma life support.  These courses also do not provide
hands-on exposure to actual trauma patients. 


--------------------
\3 The American College of Surgeons is a professional medical
association founded in 1913 to improve the care of surgical patients
and the education of surgeons. 


   DOD ORGANIZATIONS PLAY A ROLE
   IN TRAUMA CARE
---------------------------------------------------------- Chapter 1:4

The Office of the Assistant Secretary of Defense for Health Affairs
is responsible for the overall supervision of health and medical
affairs within DOD.  In addition to issuing policy, Health Affairs
controls and monitors the services' medical readiness programs and
resources, including medical training programs.  Health Affairs has
established a number of organizations to help oversee medical
readiness.  For example, in June 1996, Health Affairs formed the
Defense Medical Readiness Training and Education Council, which is
responsible for developing joint medical readiness training policy
and overseeing the services' medical training programs, including
trauma care. 

In August 1996, Health Affairs organized the Combat Trauma Surgical
Committee to study policy options for sustaining wartime trauma
surgery capabilities.  Current Committee members include trauma
surgery representatives from each service, Reserve Affairs, the
Uniformed Services University of the Health Sciences, the private
sector, two military treatment facilities that have affiliations with
civilian trauma centers, and DOD's two military trauma centers.  In
February 1997, the Committee issued a report recommending three
categories of military trauma-trained surgeons and trauma training
standards, which included both hands-on experience and continuing
education.  The service Surgeons General approved the
recommendations, and in May 1997, the Acting Assistant Secretary of
Defense for Health Affairs directed the services to develop phased
implementation plans for training active duty personnel in trauma
surgical skills. 

The Surgeons General of the military services are responsible for
policy development, direction, organization, and management of the
health services system within their service.  Each service has a
medical department that is responsible for providing medical
readiness training (i.e., the Army Medical Command, the Navy Bureau
of Medicine and Surgery, and the Air Force Medical Services).  Each
individual department trains its medical personnel for their
missions.  However, the unit commander is ultimately responsible for
certifying that unit personnel have medical readiness training. 

The Deputy Director for Medical Readiness Division in the Joint Staff
Directorate for Logistics is responsible for reviewing medical
portions of the commanders in chief's operation and contingency plans
and Joint Strategic Planning System documents to assess the adequacy,
feasibility, and suitability of medical plans, requirements, and
resources.  In 1997, the Division sponsored five seminars to identify
medical capabilities, training issues, and technology needed to
support future war-fighting missions through 2010.  The seminars
focused on the management of wartime casualties in theater, including
the identification of core medical skills and the subsequent training
requirements. 


   OBJECTIVES, SCOPE, AND
   METHODOLOGY
---------------------------------------------------------- Chapter 1:5

Section 744 of the National Defense Authorization Act for Fiscal Year
1996 requires us to assess the effectiveness of DOD's demonstration
program in providing shock trauma care training for military medical
personnel through one or more public or nonprofit hospitals. 
Specifically, we (1) determined the status of the demonstration
program and DOD's actions to meet the legislative provisions, (2)
identified other initiatives aimed at training military personnel in
trauma care, and (3) identified key issues that DOD should address if
it decides to expand its trauma care training program. 

To obtain background information on DOD medical readiness and trauma
care training, we interviewed officials within many DOD and service
components and reviewed DOD directives, policies, and guidelines. 
Our review focused on active component training because DOD focused
the demonstration program and its initial efforts on the active duty
component.  In addition, active duty personnel provide most of the
care in military treatment facilities.  Nevertheless, reserve
personnel play a major role in wartime medical care since they
represent about 57 percent of all military medical personnel.  Also,
we reviewed DOD reports and studies on medical readiness training,
DOD medical lessons learned reports from the Gulf War, and other
related reports and congressional testimonies on military medical
care.  We examined military medical textbooks, medical journals, and
various other information sources for relevant data on trauma care. 

To assess the effectiveness of DOD's demonstration program, we (1)
monitored the implementation of the program by Naval Medical Center
Portsmouth officials, (2) collected data on the program and the
rotations through the civilian trauma center at Sentara Norfolk
General Hospital, (3) interviewed the program's trainees and Navy
trauma-trained surgeon and medical school officials, and (4)
discussed legal issues regarding the program with Navy judge advocate
officials from both the Naval Medical Center Portsmouth and the Navy
Bureau of Medicine and Surgery. 

To identify other initiatives aimed at providing military medical
personnel training in trauma care and determine the key issues that
DOD faces in providing military medical personnel training in wartime
medical skills, we interviewed officials from Health Affairs,
military treatment facilities that provide trauma care training or
have training affiliations with civilian trauma centers, and private
trauma centers.  We also interviewed military medical personnel who
trained in civilian trauma centers.  In addition, we consulted with
officials from a professional medical association affiliated with
trauma care to learn their perspectives on military trauma care
training.  We did not evaluate the feasibility of increasing the
number of military treatment facilities that receive trauma patients. 
However, DOD officials noted that a substantial investment would be
required to upgrade a military treatment facility to a level I trauma
center.  Appendix II lists all the federal, state, and private
organizations we contacted. 

We conducted our review from April 1997 to February 1998 in
accordance with generally accepted government auditing standards. 


DOD'S DEMONSTRATION PROGRAM
PROCEEDS
AT A SLOW PACE
============================================================ Chapter 2

Section 744 of the National Defense Authorization Act for 1996
mandated the establishment of DOD's demonstration program to evaluate
the feasibility of providing shock trauma training to military
medical personnel in one or more public or nonprofit hospitals. 
However, the program does not fully meet all of the requirements of
the mandate.  Further, the program will only have been in effect for
5 months, as of April 1, 1998, and thus will need to be further
developed before its effectiveness can be fully determined. 


   LEGISLATIVE MANDATE PROVIDES
   REPORTING REQUIREMENTS
---------------------------------------------------------- Chapter 2:1

Section 744 of the National Defense Authorization Act for Fiscal Year
1996 (P.L.  104-106, Feb.  10, 1996) requires DOD to implement a
demonstration program by April 1, 1996, to evaluate the feasibility
of providing shock trauma training for military medical personnel
through one or more public or nonprofit hospitals.  The law also
requires DOD to report on the status of the demonstration program by
March 1, 1997, and March 1, 1998, and us to comment on the program's
effectiveness by May 1, 1998.  Finally, the law requires that
agreements with hospitals include a provision that the hospitals
provide health care services to DOD beneficiaries that are at least
equal to the value of the services provided by the military personnel
training at the hospitals. 


   NAVY DESIGNATED TO LEAD DOD'S
   DEMONSTRATION PROGRAM
---------------------------------------------------------- Chapter 2:2

In April 1996, Health Affairs requested input from the services on
existing programs that could be used for the demonstration program to
train military general surgeons in a civilian trauma center.  In
April 1997, Health Affairs designated Naval Medical Center Portsmouth
in Virginia as the site for the demonstration program because of its
affiliation with Sentara Norfolk General Hospital--a local trauma
center--and Eastern Virginia Medical School.  This affiliation had
consisted of Navy general surgery residents training at the local
trauma center and two Navy trauma-trained surgeons on call at the
civilian trauma center about 3 to 4 nights per month.  In addition, a
Navy surgeon at Portsmouth had been involved in the Combat Trauma
Surgical Committee, which established the standards for trauma
surgery sustainment training.  No other sites were proposed by the
Navy. 

According to Health Affairs and service officials, other sites were
informally suggested but were deemed unacceptable because they were
either military treatment facilities, instead of civilian centers, or
graduate medical education programs, instead of sustainment training
programs.  Other suggestions had limitations.  For example, the Army
initially suggested a trauma sustainment program based in Georgia but
then did not support it because the surgeon in charge of the program
was deployed to Bosnia for a year.  The Air Force suggested Ben Taub
General Hospital in Houston; however, its current program for general
surgeons only consists of observation and no hands-on experience. 
Because of the limitations of these and other possibilities, Health
Affairs requested that the Naval Medical Center Portsmouth conduct
the DOD demonstration program.  In October 1997, the medical center
signed an agreement with Eastern Virginia Medical School to obtain
sustainment trauma training for Navy general surgeons at Sentara
Norfolk General Hospital.  The first rotation began in November 1997. 

Sentara Norfolk General Hospital, a nonprofit hospital, is the only
level I trauma center located in Norfolk, Virginia.  It is also the
primary teaching hospital for Eastern Virginia Medical School.  The
hospital is a 664-bed facility located on a large medical complex
that includes Eastern Virginia Medical School and a children's
hospital.  In 1996, Sentara's trauma center saw 2,060 trauma and burn
patients.  The hospital is also part of a larger regional health
management organization, Sentara Health System, which currently holds
the DOD contract for TRICARE through which approximately 40,000
enrollees eligible for the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS) receive health care services. 

Eastern Virginia Medical School is a private school that does not own
a hospital but provides human resources to Sentara Norfolk General
Hospital and other hospitals in the area.  The school has nearly 600
students in its degree programs as well as 300 residents and fellows
and 300 faculty members.  The surgery staff at Eastern Virginia
Medical School currently provides and directs trauma services at
Sentara Norfolk General Hospital.  General surgery residents from
Eastern Virginia Medical School and Naval Medical Center Portsmouth
also rotate at Sentara Norfolk General Hospital for trauma care
experience. 

Naval Medical Center Portsmouth is a 360-bed facility that provides
medical services to active duty Navy, Marine Corps, Army, Air Force,
and Coast Guard personnel; their families; and other DOD
beneficiaries.  The medical center is one of three major teaching
hospitals in the Navy with residency programs, including general
surgery. 

The head of the Department of General Surgery at Naval Medical Center
Portsmouth has specific responsibility for the demonstration program. 
Under the program, a general surgeon from the medical center performs
a 3-week rotation at Sentara Norfolk General Hospital.  The
Portsmouth official in charge of the program said that the program is
operated at no cost to the government because the hospital is within
commuting distance of the medical center.  In addition, the
Portsmouth official said the absence of a surgeon from the medical
center does not affect the center's patient workload because the
general surgery department is well staffed. 

During the rotation, a Navy general surgeon is to be on call every
other night at Sentara Norfolk General Hospital and, when possible,
under the supervision of a Navy trauma-trained surgeon.  Currently,
Naval Medical Center Portsmouth has only one trauma-trained surgeon
who is to be on call at the hospital 3 to 4 nights a month.  On the
remaining nights, the Navy trainee is to be under the direction of a
civilian attending physician.  The trainee is to function as a trauma
team leader and be responsible for assessing patients and developing
therapeutic and diagnostic plans.  The trainee is to receive hands-on
experience in caring for trauma patients, including stabilizing and
resuscitating the patient by (1) inserting intravenous lines for
fluids, chest tubes for air in the chest cavity, or endotracheal
tubes for airway management and (2) performing surgery if necessary. 
The trainee is also responsible for the management of the patients
after they leave the trauma room and enter the intensive care unit. 


   PROGRAM IMPLEMENTATION IS NOT
   FULLY CONSISTENT WITH
   LEGISLATIVE PROVISIONS
---------------------------------------------------------- Chapter 2:3

DOD's implementation of the demonstration program does not fully meet
the legislative provisions authorizing the program for two reasons. 
First, the program did not meet the congressionally mandated
schedule.  Second, the program agreement does not include a provision
that the civilian center provide health care services to DOD
beneficiaries that are at least equal to the value of the services
provided by military personnel training in the center. 


      DEMONSTRATION PROGRAM IS
      BEHIND MANDATED SCHEDULE
-------------------------------------------------------- Chapter 2:3.1

Public Law 104-106 directed DOD to implement its demonstration
program by April 1, 1996.  However, DOD did not implement the program
at Sentara Norfolk General Hospital until November 1997.  The law
also specified that DOD report to Congress on the scope and
activities of the demonstration program by March 1, 1997, and March
1, 1998.  DOD issued its first report to Congress on July 24, 1997. 
The report describes the activities leading up to identifying the
requirements for peacetime training of military surgeons, describes
the demonstration site, and states that DOD would monitor other
trauma training programs in military treatment facilities and with
civilian centers.  DOD's second report, due March 1, 1998, had not
been issued as of March 13, 1998.  Figure 2.1 shows a timeline of
major events from enactment of the law to the actual start of the
demonstration program. 

   Figure 2.1:  Timeline of Major
   Events for Public Law 104-106

   (See figure in printed
   edition.)

DOD officials cited four main reasons for the delay in implementing
the program.  First, Health Affairs officials explained that the
delay was partly due to shifting responsibility for the program
between its offices.  The program started in the Clinical Services
office because Health Affairs thought trauma care training was a
peacetime training issue.  When Health Affairs realized that trauma
care training was actually a wartime medical readiness training
issue, it transferred responsibility for the program to its Health
Services Operations and Readiness office. 

Second, Health Affairs was examining whether it could use in-house
trauma training programs at DOD's two trauma centers--Brooke Army
Medical Center and Wilford Hall Medical Center--to fulfill the
legislative mandate.  The officials stated that these two military
centers could train the whole trauma team and not just general
surgeons.  However, Health Affairs realized that this training would
not meet the requirement of the law because the training would not
take place in civilian trauma centers.  In addition, according to
Brooke and Wilford Hall officials, their military centers do not have
the trauma volume to train military personnel that are not already
permanently assigned there. 

Third, Health Affairs officials wanted to determine minimum training
standards for general surgeons before the start of the program. 
According to DOD officials, consensus on the minimum number of cases
and the amount of time needed in training was difficult to reach. 
Agreeing and publishing DOD's recommendation for the minimum training
standards for trauma surgery took from August 1996, when the Combat
Trauma Surgical Committee was convened, to February 1997.  According
to a Committee official, consensus took a long time because (1) no
civilian standards existed on how many cases per year a surgeon needs
to manage to be adequately trained in trauma and (2) the length of
training that is both reasonable and doable was difficult to
determine, given DOD's conflicting medical missions. 

Finally, DOD did not want the implementation of the demonstration
program to interfere with other Naval Medical Center Portsmouth
trauma training at the civilian center.  Specifically, from May to
October of each year, senior surgical residents from Naval Medical
Center Portsmouth train for 3 months at Sentara Norfolk General
Hospital.  During this rotation, the surgical residents function as
trauma team leaders.  The official responsible for the demonstration
program did not want to send general surgeons for sustainment
training at the hospital at the same time as senior surgical resident
training because the number of cases that could be managed by each
group would be lessened. 

The Deputy Assistant Secretary of Defense for Health Services
Operations and Readiness was not concerned about the late
implementation of the demonstration program because he believed that
6 months would be adequate to determine the feasibility of training
surgeons in a civilian trauma center.  Other service officials stated
that they were not concerned with the implementation deadline.  These
officials believed that it was more important to take the necessary
time to design the program correctly rather than implement a program
quickly just to meet the target date specified in the legislation. 


      DEMONSTRATION PROGRAM DOES
      NOT INCLUDE AN EXCHANGE OF
      EQUAL VALUE OF SERVICES
-------------------------------------------------------- Chapter 2:3.2

The agreement between Naval Medical Center Portsmouth and Eastern
Virginia Medical School does not include an exchange of equal-value
services, as required by the law.  Specifically, the law states that
an agreement shall require that the value of the services provided by
a hospital to members of the armed forces and other DOD beneficiaries
should be at least equal to the value of the services provided by
military medical personnel under the agreement. 

The Navy did not propose equal value of services in its negotiations
with Eastern Virginia Medical School.  The official at Naval Medical
Center Portsmouth that is responsible for the demonstration program
believed that, if he had asked for this arrangement, the program
would not have been initiated.  Health Affairs officials said that
they instructed Navy officials to try to meet the conditions of the
law but not to allow negotiations on in-kind services to prevent the
program from being implemented.  In addition, officials believed that
the value of the services provided by the military trainees was
offset by the value of the training provided by the medical school. 
Eastern Virginia Medical School officials told us that an in-kind
services arrangement would not be acceptable because neither the
school nor the hospital receives any significant financial benefit
from this arrangement.  Officials also stated that the Navy surgeon
trainee is used as additional staff and does not reduce the medical
school's staffing.  Further, medical school officials stated that, if
the Navy had insisted on such an arrangement, the demonstration
program at Sentara would not have been acceptable. 

We discussed the possibility of in-kind service arrangements with
trauma officials from four large level I trauma centers that provide
training to military medical personnel.  Officials from two of the
centers stated that their hospital would be willing to consider an
in-kind service arrangement with DOD, especially if DOD included a
military trauma-trained surgeon as an attending physician.  One of
these centers currently provides room and board to its military
trainees.  The other center is in the process of negotiating an
agreement in which 20 military trainees would receive room and board. 
Officials from the other two centers stated that their facilities
would not consider providing in-kind services. 


   EFFECTIVENESS OF PROGRAM IS NOT
   YET KNOWN
---------------------------------------------------------- Chapter 2:4

It is still too early to determine the effectiveness of the
demonstration program in training medical personnel in trauma care. 
The program at Sentara is limited to general surgeons, and only a few
surgeons have rotated through the program.  Also, not enough data has
been collected:  a training evaluation tool had not been completed as
of January 1998, and an interim data collection instrument captures
very little data.  In addition, although the site chosen for the
demonstration program provides valuable training, it does not offer
the volume of penetrating trauma cases other urban centers may have
afforded. 


      PROGRAM IS LIMITED TO
      GENERAL SURGEONS
-------------------------------------------------------- Chapter 2:4.1

Although DOD's demonstration program is to evaluate the feasibility
of training military medical personnel in public or nonprofit
hospitals, the program has provided training thus far only to general
surgeons.  The program currently does not include training other
military medical personnel who are expected to be the first to treat
combat casualties, such as combat medics, corpsmen, and general
medical officers.  Health Affairs officials acknowledged that
personnel other than general surgeons need trauma care training but
stated that the training started with the surgeons because they are
considered the trauma leaders.  The officials also believed that
civilian hospitals would more readily accept general surgeons because
of their credentials and licenses.  In addition, DOD already had
numerous affiliations with civilian hospitals to provide graduate
medical education to military physicians.  An official at Eastern
Virginia Medical School indicated that the DOD demonstration program
could be expanded to include personnel other than general surgeons. 
The official noted that the school currently has physician assistant
and surgical assistant training programs that could incorporate
training for military corpsmen. 

Although the demonstration program has been limited to training
general surgeons, we found a number of unrelated programs that are
training medics and corpsmen in civilian trauma centers.  For
example, the Third Marine Aircraft Wing in California trains corpsmen
and general medical officers at a level I trauma center in southern
Los Angeles County.  Likewise, Army Special Operations Forces
enlisted medical personnel train at three civilian facilities located
in Maryland, Colorado, and New Mexico.  The Army is also negotiating
with a level I civilian trauma center in Texas to provide training to
a forward surgical team made up of general surgeons, orthopedic
surgeons, anesthesiologists, nurses, and medics. 


      FEW ROTATIONS HAVE TAKEN
      PLACE
-------------------------------------------------------- Chapter 2:4.2

Only four surgeons will have completed their training rotations by
the March 1, 1998, congressional reporting date.  The first trainee
began his 3-week rotation in November 1997 and saw a total of 65
cases, including
50 blunt trauma, 5 gunshot wounds, 3 stabbings, and 7 other
injuries.\4 Of the total number of cases, 20, or 31 percent, were
categorized as severe.  The trainee performed surgery for six cases,
including three penetrating trauma cases.  The five gunshot wounds
and the three stab wounds are penetrating injuries and are therefore
similar to the type of combat casualties that are expected on the
battlefield.  These penetrating trauma cases represented 12 percent
of the total number of cases. 

As of January 1998, the Portsmouth official responsible for the
demonstration program stated that the feasibility of training
military surgeons in a civilian trauma center had been shown. 
However, he believed that it would probably be another 6 months to 1
year, as additional trainees rotate through the program, before the
effectiveness of the program could be determined.  The trauma-trained
surgeon and the first two Navy trainees, who all had prior deployment
experience in the Gulf War, acknowledged that the training at Sentara
Norfolk General Hospital provided them with recent experience in
treating trauma.  Although the surgeon and trainees reserved judgment
on the overall effectiveness of the program, they believed that the
program built their confidence level in treating severely injured
patients. 


--------------------
\4 As of January 27, 1998, data was only available for one trainee. 


      EVALUATION TOOL HAS NOT BEEN
      COMPLETED
-------------------------------------------------------- Chapter 2:4.3

Naval Medical Center Portsmouth and Eastern Virginia Medical School
have been developing a training evaluation tool.  This tool is
expected to capture data on the number and type of injuries managed
and the procedures performed.  The Portsmouth official in charge of
the demonstration program has the responsibility for developing the
evaluation tool, but no administrative support personnel have been
provided to assist with the official's additional duty. 

As of January 1998, the evaluation tool had not been completed, and
the Portsmouth official did not know when it would be completed
because of other competing demands.  In the interim, the official has
been collecting data on the number and types of cases managed by the
trainees and working on a database to compile this information along
with the procedures performed by the trainees.  The official is also
working on a subjective questionnaire for trainees who have completed
the program.  This questionnaire is to capture the trainees' trauma
experience level before they began their rotation and assess the
adequacy of the training they received at Sentara Norfolk General
Hospital. 


      DOD DID NOT CONSIDER THE
      AMOUNT OF WARLIKE INJURIES
      WHEN SELECTING THE
      DEMONSTRATION SITE
-------------------------------------------------------- Chapter 2:4.4

According to an official in Clinical Services, Health Affairs did not
establish criteria for selecting a site for the demonstration program
other than identifying already established military trauma training
programs with civilian trauma centers.  Health Affairs did not
consider the amount of penetrating trauma cases that these centers
typically see.  As a result, it is not clear whether the site
selected for the demonstration program will provide as many
penetrating trauma cases as other potential sites.  About 90 percent
of battlefield trauma is penetrating (e.g., bullets from small arms
and fragments from explosive munitions). 

Although criteria for site selection was not established when Naval
Medical Center Portsmouth was chosen, DOD and civilian trauma
officials told us that trauma centers that receive more than 2,500
trauma cases per year, with at least 30 percent from penetrating
trauma, would provide the most hands-on exposure to warlike injuries. 
In addition, these officials and representatives of the American
College of Surgeons' Committee on Trauma stated that an ideal trauma
center would also be associated with an academic center to show a
commitment to trauma education, training, and research.  Trauma
centers that frequently meet these criteria are large inner-city
level I centers whose personnel are frequently strained by the large
number of trauma cases.  One DOD official believed that the civilian
center's proximity to a military hospital and the presence of reserve
or retired military personnel at the civilian center should also be a
factor in selecting a site. 

Sentara Norfolk General Hospital is a level I trauma center,
associated with a medical school, located within close proximity to a
military hospital, and staffed with active and retired military
personnel.  However, the trauma center does not have the volume of
penetrating trauma cases as some other civilian level I trauma
centers that train military medical personnel.  Sentara had less than
400 penetrating trauma cases in 1996, but other trauma centers that
train military medical personnel had about 900 to 1,200 cases of
penetrating trauma per year.  For example, Martin Luther King,
Jr./Drew Medical Center received 1,188 cases of penetrating trauma in
1996. 


INDIVIDUAL PROGRAMS ATTEMPT TO
SATISFY WARTIME TRAUMA TRAINING
NEEDS
============================================================ Chapter 3

Before the DOD demonstration program in November 1997, no overall DOD
or servicewide program existed to provide hands-on experience in
treating trauma patients.  A number of individual programs have been
established with civilian trauma centers to fill the void left by the
lack of DOD training programs for trauma care.  These individual
programs generally involve affiliations between physicians, military
medical facilities, or combat units and local civilian trauma
centers.  However, since the programs are mostly local and based on
personal initiatives within the individual services, they are
sometimes short-lived.  The collective experiences of these programs,
coupled with those of the demonstration program, could provide DOD
valuable information in determining the feasibility and effectiveness
of training military medical personnel in civilian trauma centers. 
Finally, although DOD operates two level I trauma centers,
sustainment training at these centers is limited. 


   INDIVIDUAL PROGRAMS ESTABLISH
   AFFILIATIONS WITH CIVILIAN
   CENTERS FOR TRAUMA TRAINING
---------------------------------------------------------- Chapter 3:1

Because of the lack of DOD or servicewide programs for sustainment
trauma care training, a number of individual programs have been
established to provide such training.  Table 3.1 lists the individual
trauma care training programs that we identified, followed by program
descriptions.  All of the programs, except one, have been limited to
military medical personnel from a single service.  The program at Ben
Taub General Hospital in Houston, Texas, plans to include military
medical personnel from all three services.  Because individual
programs are based on personal initiatives, neither DOD nor the
services maintain a central clearing point or database of trauma
training programs.  Thus, there may be additional local trauma care
training programs beyond those that we identified. 



                               Table 3.1
                
                  Individual Military Trauma Training
                    Programs in Civilian Facilities

                                        Type of personnel
Program             Location            trained               Status
------------------  ------------------  --------------------  --------
Regional Trauma     Atlanta, Augusta,   General and           Inactive
Network             and Savannah,       orthopedic surgeons
                    Georgia;
                    Baltimore,
                    Maryland; and
                    Nashville,
                    Tennessee

Military surgical   Houston, Texas      Surgeons, other       Planned
teams at Ben Taub                       physicians, nurses,
General Hospital                        and medics

Third Marine        Los Angeles,        Corpsmen and medical  Active
Aircraft Wing at    California          officers
Martin Luther
King, Jr./Drew
Medical Center

Third Marine        Santa Ana,          Corpsmen and medical  Active
Aircraft Wing at    California          officers
Santa Ana Fire
Department

First Marine        San Diego,          Corpsmen              Planned
Division at         California
Scripps Hospital

Naval Medical       San Diego,          General surgeons      Suspende
Center San Diego    California                                d
at Mercy Hospital

Naval Hospital      Oakland,            General surgeons      Canceled
Oakland             California

Army Special        Denver, Colorado;   Medics                Active
Operations at       Gallup, New
civilian centers    Mexico; and
                    Baltimore,
                    Maryland
----------------------------------------------------------------------

      ARMY PROGRAMS
-------------------------------------------------------- Chapter 3:1.1

The first of two Army programs that train military medical personnel
in civilian trauma centers is the Regional Trauma Network.  In 1993,
Dwight David Eisenhower Army Medical Center in Augusta, Georgia,
initiated a trauma training program for Army general and orthopedic
surgeons in the Southeast Regional Medical Command.  The Chief of
Trauma and Surgical Critical Care at the center started this program
because of the unavailability of sustainment trauma training in most
military treatment facilities.  Implementation of the program began
in 1993 and was not completed until 1996 because of the lack of local
command support for the program and funding for temporary duty and
travel costs.  Funding was ultimately obtained from the Army Surgeon
General. 

This program was intended to give surgeons hands-on experience in
managing and treating critically injured trauma patients in one of
five
level I trauma centers.  From January to September 1996, seven
surgeons trained in the five different trauma centers for 30 days,
including two surgeons from deployments in Bosnia and Hungary.  The
cost for the seven surgeons was less than $19,000, or about $2,665
per surgeon.\1 Many participants stated that the training renewed
their confidence for treating seriously wounded patients. 

Between September 1996 and January 1998, only one surgeon rotated
through the program.  This rotation occurred in October 1997 at no
cost to the military because the surgeon was stationed within
commuting distance of the civilian trauma center.  According to the
surgeon in charge of the program, no additional rotations have
occurred mainly due to insufficient funding for the trauma training
and not the lack of available slots at the civilian centers or the
lack of military volunteers.  The surgeon intends to begin rotating a
surgeon through a civilian center in April 1998. 

The second program, which is still in the planning stages, is at Ben
Taub General Hospital in Houston, Texas.  The hospital's level I
trauma center receives approximately 2,800 trauma cases per year,
including about 900 penetrating injuries.  Since November 1997, the
Army has been negotiating with officials from the hospital to rotate
forward surgical teams through the trauma center.  The teams consist
of three general surgeons, one orthopedic surgeon, two nurse
anesthetists, one critical care nurse, one operating room nurse, one
emergency room nurse, three licensed vocational nurses, three
operating room technicians, four emergency medical technicians
(medics), and one administrator.  The team also includes a military
trauma surgeon who would be given attending privileges at the
hospital and would coordinate and monitor the training. 

Currently, two 30-day rotations are planned.  An Army surgical team
will rotate through the center in April 1998 and an Air Force team in
May 1998.  In addition, a Navy surgical team may rotate through the
center in June 1998.  The Army, along with the Defense Medical
Readiness Training Institute, plans to develop an evaluation tool to
capture travel costs, opportunity costs (decreased patient workload
at a military treatment facility), and the benefits of training in a
civilian trauma center. 

According to an Army official, the Great Plains Army Medical Command
will provide funding for travel and any licensing fees for the Army
team.  The physicians are not required to have a Texas license and
can train under the hospital's institutional permit, which costs $50
per physician.  The nurses will need a current Texas nursing license,
which costs between $75 and $90.  The hospital will provide room and
board for the teams. 


--------------------
\1 One surgeon commuted less than 2 miles to a civilian center at no
cost, but the travel and temporary duty costs for the surgeon from
Hungary totaled $4,600. 


      MARINE CORPS PROGRAMS
-------------------------------------------------------- Chapter 3:1.2

In May 1997, the Third Marine Aircraft Wing at El Toro, California,
established a trauma training agreement with Martin Luther King,
Jr./Drew Medical Center in south Los Angeles.  The hospital has a
level I trauma center that receives approximately 2,500 trauma cases
per year.  Under the agreement, a Navy general medical officer and
two hospital corpsmen, all from the same squadron, will train for 30
days on one of the center's trauma teams.\2

The first team completed its training in June 1997, and one team per
month was expected to train at the center through March 1998.  The
program has been operating at no cost to the government.  The
trainees pay their own travel expenses to and from the center, and
the center provides free housing, meals, and parking for the
trainees. 

The trainees complete after-action reports detailing their training
experience.  According to these reports and interviews with the
trainees, their confidence and skill levels in trauma care improved
because of the training.  For example, one rotation of trainees saw
an average of two gunshot wounds per night, and in one night six
gunshot wound victims arrived at the center.  Under the direct
supervision of the attending physician or senior surgical resident,
the corpsmen were allowed to perform procedures, such as initial
assessments of trauma patients for injuries, intubations, chest tube
placements, central line placements, suture lacerations, and removal
of bullets lodged under the skin. 

Before the rotations, the corpsmen stated that their duties in
military treatment facilities did not include treating trauma
patients.  One corpsman said that he never saw trauma patients while
working in the emergency department at the Naval Medial Center San
Diego.  His duties consisted of drawing blood and starting simple
intravenous lines.  All of the corpsmen stated that they had attended
classroom training and field exercises on how to treat combat
casualties but had not performed hands-on procedures with actual
patients. 

Because of the aircraft wing's experience at the civilian trauma
center, officials at the First Marine Division at Camp Pendleton,
California, are negotiating with Scripps Memorial Hospital, a local
level I trauma center in San Diego, to provide trauma training for
their corpsmen.  According to the Deputy Commander of the I Marine
Expeditionary Force, if the trauma training program is a success, the
Force will consider expanding the training to the medical personnel
in the support group, which includes the medical battalions and
surgical teams. 

Third Marine Aircraft Wing officials also negotiated an agreement
with the Santa Ana Fire Department to provide prehospital trauma
training experience.  Corpsmen and general medical officers rotate
with the ambulance service for 30 days and act as emergency medical
technicians.  During one rotation, a corpsman started numerous
intravenous lines, treated one person with severe burns over 60
percent of his body, evaluated and treated gunshot patients from a
multiple shooting, and practiced spine stabilization procedures.  The
corpsman stated that he was able to practice invaluable skills and
refresh old training with hands-on experience in an unusual,
nonclinical, and unpredictable environment, which will allow him to
perform more efficiently in a combat scenario. 


--------------------
\2 Navy medical personnel provide health care services for the Marine
Corps. 


      NAVY PROGRAMS
-------------------------------------------------------- Chapter 3:1.3

According to a Navy trauma-trained surgeon, five or six Navy surgeons
from the Oakland Naval Hospital obtained trauma sustainment training
at Highland General Hospital, Oakland, California, from 1991 to 1995. 
Under this program, a Navy trauma-trained surgeon was assigned for 2
years as the medical center's Director of Trauma.  Navy surgeons
performed 30- to 90-day rotations as attending surgeons, with the
trauma-trained surgeon backing them up. 

According to the trauma-trained surgeon, the lack of experience of
the surgeons deployed to the Gulf War was a major factor that allowed
him to convince the naval hospital of the need for this training.  In
January 1992, the general surgery specialty advisor for the Navy
recommended that a similar program be set up at all four Navy
teaching hospitals.  However, when Oakland Naval Hospital was closed,
the program was discontinued. 

According to Naval Medical Center San Diego officials, seven surgeons
from the Naval Medical Center San Diego received trauma sustainment
training at Mercy Hospital and Medical Center, also in San Diego,
between 1992 and 1995.  Five of these surgeons trained for 1 month,
and two surgeons trained for 2 months.  The current chairman of the
general surgery department at the Navy medical center, appointed in
the spring of 1995, has been hesitant to reestablish the program.  He
believes that, before the program can be restarted a curriculum
should be developed for the training and all general surgeons should
be required to obtain this training. 

The commander of the Navy medical center does not want to implement
the agreement with Mercy Hospital and Medical Center because Mercy
Hospital requires each Navy surgeon to obtain a current California
medical license, even if the surgeon is licensed in another state. 
Military physicians who are training in civilian facilities in
California are not required to have an active state medical license;
they are only required to register with the state.  Registration is
done at no cost to the physician, whereas a California medical
license can cost between $1,100 and $1,200.  The Navy commander
believes that, if this training is going to be required, DOD should
pay for his staff to obtain a California medical license. 


      ARMY SPECIAL OPERATIONS
      COMMAND PROGRAMS
-------------------------------------------------------- Chapter 3:1.4

Enlisted medical personnel in the Army Special Operations Command
have been obtaining trauma sustainment training at the R.  Adams
Cowley Shock Trauma Center in Baltimore since 1989.  The Command also
has sustainment training agreements with Gallup Indian Medical Center
in New Mexico and Denver General Hospital in Colorado.  In addition,
personnel obtain training at Brooke Army Medical Center and Wilford
Hall Medical Center in San Antonio, Texas. 

From October 1995 to April 1997, 61 Army enlisted medical personnel
within the Command trained at the 5 centers at a cost of about
$157,000, which includes airfare, rental car, lodging, and meals. 
After-action reports from some trainees indicated that the training
provided the hands-on experience they needed to be confident that
they could care for injured soldiers.  For example, one trainee
stated that he was able to see and do things that he had only read
and studied about in classroom training and while working in a
military treatment facility. 

In April 1997, the Special Operations Command required all its
enlisted medical personnel from the Army, the Navy, and the Air Force
to become National Registry Emergency Medical Technician Paramedic
trained and certified.\3 As a result, sustainment training for the
Army enlisted medical personnel at the three civilian centers was
temporarily put on hold while resources were focused on getting all
medical personnel certified.  Sustainment training resumed in
September 1997. 


--------------------
\3 The Special Operations Command is the headquarters command for the
three services' special forces. 


   SUSTAINMENT TRAINING IN DOD
   TRAUMA CENTERS IS LIMITED
---------------------------------------------------------- Chapter 3:2

Through a unique relationship with the city of San Antonio, Texas,
the Army and the Air Force operate level I trauma centers at their
medical centers in the city.  This affiliation allows civilian trauma
patients to be brought to these military hospitals for care. 

Brooke Army Medical Center at Fort Sam Houston receives about
one-third of the city's trauma patients.  The center has been
providing trauma care for about 15 years and receives about 800
admissions per year, 25 percent of which are penetrating trauma
wounds.  Wilford Hall Medical Center at Lackland Air Force Base also
receives about 800 cases per year, about 20 percent of which are
penetrating trauma. 

DOD and service officials believe that these centers offer an
advantage over civilian trauma centers because they can train
military surgeons and the rest of the military trauma team, including
other types of physicians, nurses, and enlisted medical personnel. 
However, officials at the centers stated that their low volume of
trauma admissions and their current staffing levels preclude them
from providing sustainment training for military medical personnel
not already assigned to the centers.  The current physicians,
residents, interns, and fellows are already competing for limited
hands-on trauma experiences.  Medical personnel from the Army Special
Operations Command confirmed that they received little hands-on
training at Brooke and Wilford Hall compared with other civilian
centers because the military facilities did not have enough trauma
patients for the military staff already assigned there. 

In addition, the city of El Paso, Texas, and the county-owned public
hospital there have invited William Beaumont Army Medical Center,
also in El Paso, to participate in a formal citywide trauma system. 
This system would require that the medical center become a level I
trauma center.  Currently, the center assists the community with
civilian emergency support and receives about 500 of the 2,000 trauma
injuries per year in the El Paso area. 

The Army Surgeon General views the citywide trauma care system as an
opportunity to train surgical teams in trauma management.  However,
an official at William Beaumont stated that, even with a level I
designation, the center cannot train military medical personnel
beyond those already assigned there because of the limited number of
trauma patients the center can receive.  However, with additional
funding of about $2.7 million for start-up costs and annual funding
of about $1.4 million, the official believes that the center could be
expanded to accept more trauma patients and therefore could train an
additional 330 military medical personnel per year in trauma. 


DOD FACES CHALLENGES IN PROVIDING
TRAUMA CARE TRAINING
============================================================ Chapter 4

DOD's demonstration program, along with individual efforts, are
yielding lessons learned that could be useful in evaluating the
concept of military-civilian cooperation in trauma care training. 
Several issues that may pose difficulties in providing such training
have been identified but can be overcome.  These issues include (1)
military physician licensure requirements, (2) the capacity of
civilian trauma centers to train large numbers of military personnel,
and (3) concerns that military participation might detract from
training civilian or other military medical graduates in civilian
centers. 

If DOD decides to expand its trauma care training, it will need to
build on the Combat Trauma Surgical Committee's report and develop an
overall strategy for wartime training capabilities.  Fundamental
preliminary steps for DOD to take to achieve these goals are
completing the ongoing assessment of wartime medical requirements and
determining which personnel will require trauma care training.  Other
important DOD actions include prioritizing the personnel requiring
the training, determining the frequency of refresher training, and
devising a means to track trained personnel.  However, the biggest
challenge DOD may face is determining how best to meet the competing
demands within its health care system, which will require balancing
the need for providing wartime medical readiness training with the
need to deliver peacetime health care services. 


   STATE LICENSURE HAS NOT BEEN A
   SIGNIFICANT OBSTACLE
---------------------------------------------------------- Chapter 4:1

In the United States, physicians must generally be licensed in each
state where they practice to protect the health, safety, and welfare
of the public.  Each state has its own laws and regulations that
govern the practice of medicine.  Therefore, each state can determine
the requirements that DOD must follow to train its medical personnel
in civilian trauma centers.  In addition, individual trauma centers
can require military trainees to meet the center's requirements,
which may be more stringent than the state's, as part of its
contractual agreement with the military. 

Licensing is generally not an issue for military physicians
practicing in military health care facilities.  Under 10 U.S.C. 
1094, military health care professionals who treat patients in
military health care facilities are required to be licensed in only
one state, which does not have to be the state where they are
practicing. 

State licensure has not been an issue in most of the programs we
identified.  In certain circumstances, state licensing agencies may
issue limited or temporary licenses or certificates for finite
periods of time to health care professionals licensed in another
state.  In our review of six programs located in five states, only
one of the states--Georgia--requires that the military physicians
training in a civilian trauma center have a current state license. 
According to Georgia's Professional Examining Board, the state does
not have a trainee license or any law that would allow military
physicians to practice in a civilian facility without a current
license.\1 The other four states only require registration, an
institutional permit, or a trainee license.  For example, California
generally requires that military physicians register with the state
before starting a training program in a civilian facility. 
Registration involves completing a one-page form at no cost. 

Some civilian centers accept registration or a training license, but
other centers required a current state license.  Although the Medical
Board of California only requires military physicians to be
registered with the state, surgeons from Naval Medical Center San
Diego who trained at Mercy Hospital and Medical Center were required
by the center to have a current California medical license.  Because
participation in the program was voluntary and many of the Naval
Medical Center's surgeons were already licensed in California, this
requirement was not a problem.  However, if training in the civilian
centers becomes mandatory, then obtaining a license could become an
issue because of the time and money to obtain a license.  For
example, obtaining a license in California takes about 45 to
90 days and costs about $1,100 to $1,200.  Many military physicians
we spoke with stated that DOD will not pay for obtaining this second
license.  In fact, DOD's July 1997 mandated report to Congress stated
that, if civilian facilities require state licenses, DOD might need
to make provisions for reimbursement for that additional license.\2


--------------------
\1 Civilian centers may have specific bylaw requirements for
physician credentialing beyond just state licensure that might be a
potential obstacle to training in the hospital. 

\2 Under 10 U.S.C.  1096(d), DOD may reimburse military personnel up
to $500 of the cost of a second license where it is required in order
for the member to treat certain military members, retirees,
dependents, and survivors at civilian facilities.  Section 737 of the
National Defense Authorization Act for Fiscal Year 1998 (P.L. 
105-85, Nov.  18, 1997) authorizes licensed military health care
professionals performing authorized duties for DOD to practice in any
state whether the practice occurs in a DOD facility, DOD-affiliated
civilian facility, or any other location designated by the Secretary
of Defense.  DOD has not evaluated the applicability of this
provision to the section 744 trauma care training program and its
impact on the provisions of 10 U.S.C.  1096 (d). 


   TRAINEE COMPETITION WITH OTHER
   IN-HOUSE PROGRAMS COULD LIMIT
   HANDS-ON EXPERIENCE
---------------------------------------------------------- Chapter 4:2

Competing with other in-house training programs in the civilian
centers can limit the opportunities for military medical personnel to
obtain hands-on trauma experience.  Civilian hospitals that can offer
the military the most beneficial training are generally teaching
hospitals with level I trauma centers.  However, these hospitals have
internship, residency, and fellowship programs that train civilian
physicians in trauma care; thus, the military trainees may have to
compete with these students for hands-on experience. 

DOD can overcome this issue by arranging for training to occur in
high-volume, understaffed level I trauma centers.  According to DOD
and private sector officials, about 12 to 15 inner-city trauma
centers have a very high volume of trauma cases that frequently
strain or exceed personnel resources.  Each of these centers, which
are geographically dispersed, treat about 2,000 to 3,000 severe
trauma cases per year.  Therefore, these centers would provide more
opportunities for military trainees to obtain hands-on experience. 

The Third Marine Aircraft Wing's trauma training program sends its
medical personnel to Martin Luther King, Jr./Drew Medical Center, an
inner-city trauma center in south Los Angeles.  The center is
frequently understaffed for the over 2,500 trauma patients it
receives each year.  In addition, almost 50 percent of the injuries
at this civilian center were penetrating trauma, including 32 percent
from gunshot wounds.  According to the center's director, the center
has more than enough trauma cases for all of its civilian and
military trainees because the military trainees augment the civilian
members of the trauma team and do not replace staff.  However, the
additional staff allows the attending and senior residents to step
back and teach decision-making and procedural skills rather than do
the procedures themselves.  The military trainees we spoke with
stated that, during their 30-day rotation, there were more than
enough training opportunities for all of the military and civilian
trainees. 


   NO STRATEGY EXISTS FOR
   PROVIDING TRAUMA CARE TRAINING
---------------------------------------------------------- Chapter 4:3

DOD does not have a long-term strategy for providing trauma care
training.  If DOD decides to develop such a strategy, several issues
warrant consideration, including the training needs of the reserve
component, capacity of civilian centers to train military personnel,
and the need for a system to identify trained personnel. 


      COMMITTEE REPORT DID NOT
      INCLUDE RESERVE COMPONENT
-------------------------------------------------------- Chapter 4:3.1

Although the Combat Trauma Surgical Committee's February 1997 report
on policy options for DOD is a commendable beginning for identifying
DOD's trauma care training needs, DOD does not have a long-term
strategy with clear goals, objectives, and milestones to achieve the
Committee's recommendations.  Moreover, the report did not address
the needs of the reserve component.  The Assistant Secretary of
Defense for Reserve Affairs was concerned with the report's lack of
references to the reserves.  The report noted that the reserve
component is an integral part of the military health system and a
critical asset in U.S.  wartime capability. 

The Committee made several recommendations regarding sustainment
training of wartime surgical capabilities, resulting in the
establishment of minimum readiness training standards for general
surgeons.  The report defined three categories of surgeons, which are
distinguished by different levels of training and experience, and the
required trauma care training for each category.  The services are to
propose the required and available number of general surgeons in each
of the three categories and identify potential training programs at
civilian trauma care centers.  As of January 1998, the services'
plans were incomplete.  Further, no strategy is in place to
coordinate the development of combat surgical readiness standards for
other surgical specialties, nonsurgeons, nurses, and medical support
personnel. 


      QUESTIONS EXIST ABOUT
      CAPACITY OF CIVILIAN CENTERS
-------------------------------------------------------- Chapter 4:3.2

The capacity of civilian centers to train large numbers of military
personnel is another DOD concern.  However, this concern cannot be
assessed because DOD has not (1) completed its ongoing reassessment
of its medical force structure and (2) determined which personnel
will be required to receive such training.  DOD has about 480 general
surgeons and about 74,000 enlisted active duty medical personnel in
the force.  Table 4.1 provides a breakdown of active duty medical
personnel by type of provider and service for fiscal year 1997. 



                               Table 4.1
                
                Active Duty Medical Personnel by Type of
                  Health Care Provider and Service for
                            Fiscal Year 1997

                          Army    Navy        Air Force          Total
----------------------  ------  ------  ----------------------  ======
Physicians
General surgeons           149     152           175               476
Other surgeons             178     163           204               545
Nonsurgical physicians   4,253   3,724          3,752           11,729
======================================================================
Subtotal                 4,580   4,039          4,131           12,750
Other medical
 personnel
Physician assistants       600     209           425             1,234
Nurses                   3,169   3,154          4,478           10,801
Enlisted medical        28,497  22,570          22,751          73,818
 personnel
======================================================================
Subtotal                32,266  25,933          27,654          85,853
======================================================================
Total                   36,846  29,972          31,785          98,603
----------------------------------------------------------------------
Source:  DOD's Health Manpower Personnel Data System. 

The total number of deployable personnel who will need trauma care
training is expected to change from previous wartime planning
scenarios.  DOD is updating its April 1994 study of the military
medical care system mandated by Section 733 of the National Defense
Authorization Act for Fiscal Years 1992 and 1993 to determine the
appropriate wartime medical force level requirements.  The study
concluded that only 50 percent of the active duty medical force was
needed for medical readiness, but that finding was very controversial
among the services.  In March 1995, we testified that the services
disagreed with this conclusion and other aspects of the study and
that the commanders in chief did not participate in the study.\3
Because of the controversy surrounding the study, the Deputy
Secretary of Defense directed that the study be updated to reflect
changes in planning scenarios, operational requirements, and number
of forces deployed.  As of January 1998, DOD had not issued the
updated study. 

DOD has not determined which medical personnel would need to be
trained in trauma care.  Not all medical personnel would deploy to a
contingency or, if deployed, would provide initial treatment to
injured soldiers.  For example, not all of the 28,497 Army medics
would be deployed to the front lines of a battlefield to provide
first responder or enroute care, since Army tactical units require
only about 8,900 combat medics.  Likewise, not all of DOD's 480
general surgeons would be assigned to combat units or even to the
theater.  Although DOD would not likely require all medical personnel
to be trained in trauma care, DOD may face challenges until it
determines what portion of the force structure needs trauma care
training and the frequency of such training. 


--------------------
\3 Wartime Medical Care:  Aligning Sound Requirements With New Combat
Care Approaches Is Key to Restructuring Force (GAO/T-NSIAD-95-129,
Mar.  30, 1995). 


      NO SYSTEM IS IN PLACE TO
      IDENTIFY TRAINED PERSONNEL
-------------------------------------------------------- Chapter 4:3.3

In the event of a crisis, DOD would need to quickly identify which
medical personnel have been trained in trauma care.  The Combat
Trauma Surgical Committee recognized that a system should be in place
to identify and track individuals trained in trauma care.  Currently,
no such system is being used for this purpose since few individuals
have received such training.  Two systems currently in
development--the Centralized Credentials and Quality Assurance System
and the Defense Medical Human Resource System--could be used to track
trauma care training, but each has limitations. 

The Centralized Credentials and Quality Assurance System is limited
to credentialed medical providers, such as physicians, physician
assistants, and nurse practitioners, and does not include other
trauma care providers, such as nurses, combat medics, and corpsmen. 
In addition, the medical readiness training information displayed in
the system is very limited:  a medical commander verifies the date of
the provider's sustainment medical readiness training certificate. 
Since a list of criteria or standards outlining what type of training
constitutes medical readiness does not exist, this verification is
based on the commander's judgment and is therefore subjective. 

The Defense Medical Human Resource System is a triservice information
system being developed for use in military hospitals and clinics to
facilitate patient care and staffing.  The system includes all
military health care personnel, whether officer or enlisted and
credentialed or noncredentialed.  The system has the capability to
establish and track readiness training requirements by individual,
military treatment facility or unit, and service.  However, according
to service officials, no requirements have been set to develop a
template to facilitate tracking of trauma care training.  In
addition, the system is not designed to identify the training status
of medical personnel assigned to nonmedical treatment facilities,
such as physicians, medics, and corpsmen assigned to combat units. 


   COMPETING DEMANDS PLACED ON
   HEALTH CARE SYSTEM CAN LIMIT
   MEDICAL READINESS TRAINING
---------------------------------------------------------- Chapter 4:4

DOD must balance the need for training its medical personnel for
their wartime mission and the need for delivering peacetime health
care services to 8.2 million eligible beneficiaries.  Large patient
workloads can limit the time military medical personnel can take away
from peacetime duties to participate in wartime medical readiness
training, including trauma care training.  In addition, operating
budgets at military treatment facilities can be reduced to the extent
that medical personnel participation in training displaces patient
workload.  Finally, military commanders may lack incentives for
providing medical personnel with trauma care training because such
training is not linked to wartime readiness. 

Although DOD does not provide hands-on trauma care training, it does
provide a number of courses for medical officers that provide the
basic military skills necessary to operate in the military
environment, such as medical service operations and preparation for
taking command.  Before deployment, military physicians are required
to take a course on combat casualty care, which focuses on the
military casualty management system and providing casualty care in a
battlefield environment.  This course consists of classroom
instruction and field training and includes the principles of
Advanced Trauma Life Support, which were developed by the American
College of Surgeons and have become the national and international
standard for basic trauma resuscitation skills.  However, in 1993, we
reported that only 47 percent of active duty physicians attended the
combat casualty care course.  In 1996, DOD's Office of Inspector
General also found that less than 50 percent of a sample of active
duty physicians assigned to combat support units had completed the
combat casualty care course.  According to service officials, medical
personnel have limited time to participate in readiness training and
often do not attend this training due to patient workloads and
budgetary constraints. 

DOD's medical mission is to maintain the health of 1.6 million active
duty and 6.6 million other military-related eligible beneficiaries,
such as active duty dependents and retirees and their dependents,
through a system of 115 hospitals and medical centers and 471 clinics
worldwide.  Active duty personnel are given priority in receiving
health care at military treatment facilities.  Military-related
beneficiaries are entitled to health care at these facilities as
space is available. 

Military treatment facility commanders are required to manage
personnel training within the practical constraints of providing
peacetime health care.  According to service officials, the operating
budgets at military treatment facilities are based on the number of
patients seen and diagnosed for treatment.  Therefore, operating
budgets may be reduced to the extent that physician participation in
readiness training displaces patient workload.  Service officials
told us that military treatment facility commanders will meet the
immediate priority of providing peacetime health care instead of
sending staff to medical readiness training courses for a potential
wartime mission. 

Service officials informed us that the impact of medical readiness
training, such as trauma care, on DOD-administered programs that
supplement health care provided in the military treatment facilities
is unknown but a concern.  When a military facility cannot provide
health care services because its personnel are at readiness training,
patients must obtain services through the civilian sector.  DOD pays
these cost through TRICARE, DOD's new managed care program that
stresses military treatment facility cost-effectiveness. 

Commanders may have insufficient incentives for providing medical
personnel with trauma care training unless this training is linked to
readiness assessments.  According to DOD officials, medical readiness
training, including trauma care training, is not currently tied to a
unit's readiness status for deployment.  This status is based on
whether essential mission-related equipment and personnel are on hand
and required individual and team training has been performed.  If a
unit is missing some essential items, this information is reflected
in the unit's readiness status reporting system, and the unit's
status for deployment may be affected. 

According to DOD officials, the lack of trauma care training would
not be reflected in the unit readiness status reporting system. 
There is no trauma care training or experience requirement for
personnel assigned to units that are to provide care to wartime
casualties.  For example, a unit's readiness status report would not
be degraded if the medical officer assigned to an aid station did not
have trauma care training because this training is not part of the
unit's required individual or team training.  According to DOD
officials, a unit commander will use the unit's limited resources and
time to train required tasks and not do the other training, such as
trauma care, until all mission-essential items have been completed. 
Although the infancy of the trauma care training program makes it
difficult to establish the linkage between trauma training and
readiness, many service officials believe that such linkage will be
important if trauma training is to receive this needed priority. 


CONCLUSIONS AND RECOMMENDATIONS
============================================================ Chapter 5

Trauma care training is essential for DOD to successfully fulfill its
wartime medical mission.  Because of the void left by a lack of
priority for combat trauma care training, individual surgeons,
military treatment facilities, and combat units have been attempting
to meet trauma care training needs on their own.  However, command
support for these individual efforts has been difficult to sustain
because DOD currently has no clear goals or strategy for trauma care
training as it relates to medical readiness.  Wartime medical
readiness should not be the responsibility of individual surgeons,
military facilities, or combat units; it warrants the support of and
coordination by high-level DOD management. 

The Combat Trauma Surgical Committee's report is a good start for
developing clear goals for trauma care training.  The report's
recommendations address the minimum training standards for military
general surgeons, but a DOD strategy for meeting those standards has
not been developed.  Information from DOD's mandated demonstration
program at Sentara Norfolk General Hospital could help with the
development of such a strategy.  The demonstration program could be a
good training ground for general surgeons.  However, due to the
infancy of the program, it has not generated sufficient data useful
to determine the effectiveness of training surgeons in civilian
trauma centers. 

It would be difficult for one training model to provide all the data
needed to determine the feasibility and effectiveness of training
medical personnel in civilian training centers.  Since other programs
outside the demonstration program train other military medical
personnel, such as orthopedic surgeons, general medical officers,
nurses, combat medics, and corpsmen, coordinating data from these
programs with the demonstration program could be used to determine
the feasibility and effectiveness of training military medical
personnel in civilian trauma centers. 

Information from the demonstration program and the other trauma
training programs already shows that DOD and the services may face
some challenges if they are to provide hands-on trauma care training. 
Some issues, such as licensure, present challenges depending on the
location of the civilian training center.  Other issues could arise
if trauma care training is shown to be effective and feasible.  The
key questions to be answered then would be who should receive trauma
care training and how will those personnel be identified.  Currently,
DOD does not have a mechanism to identify those trained in trauma
care, but those who would deploy first to a contingency would need to
receive priority for such training. 


   RECOMMENDATIONS
---------------------------------------------------------- Chapter 5:1

Additional data is needed to evaluate the feasibility and
effectiveness of providing trauma care training to military personnel
in civilian centers.  Because the authority for the demonstration
program at Sentara Norfolk General Hospital expires on March 31,
1998, we recommend that the Secretary of Defense consider negotiating
a new agreement for a similar program.  We also recommend that the
Secretary (1) expedite DOD's efforts to establish an evaluation tool
to assist in this assessment and (2) broaden the scope of the
evaluation to include other individual programs that have provided
trauma care training to general surgeons as well as other medical
personnel. 

In addition, if DOD determines that the trauma care training concept
is feasible and decides to expand such training in civilian trauma
care centers, we recommend that the Secretary of Defense develop a
long-term strategic plan that establishes goals and identifies
actions and appropriate milestones for achieving these goals.  This
plan should (1) establish criteria for selecting locations for trauma
care training that would maximize the experiences of military
trainees, (2) identify which medical personnel should receive trauma
care training and the frequency of such training, and (3) develop a
mechanism to identify those military medical personnel who are likely
to deploy early in a conflict so that they can receive priority for
medical wartime trauma care training.  This plan should also address
the training needs of the active and reserve components. 


   AGENCY COMMENTS AND OUR
   EVALUATION
---------------------------------------------------------- Chapter 5:2

In official oral comments on a draft of this report, DOD generally
concurred with our recommendations.  DOD noted that it has determined
that the trauma care training concept is feasible for general
surgeons, although there is not yet sufficient data to determine the
effectiveness of the training.  DOD is also currently evaluating the
concept for other military medical personnel.  We agree with DOD that
the demonstration program and the other individual trauma training
programs have shown that it is feasible to train general surgeons in
civilian trauma centers and that additional data is needed for other
military medical personnel.  The general surgeons who have trained in
the civilian centers have been given opportunities to perform
hands-on procedures on severely injured patients and participate in
decision-making skills.  Many of the trainees stated that the
training in the civilian centers renewed their confidence for
treating severely wounded patients.  Even though the demonstration
program and the other initiatives have shown that it is possible to
train surgeons in civilian trauma centers, the impact on the delivery
of DOD peacetime health care when the program is expanded DOD-wide is
still unknown. 

DOD stated that it plans to negotiate a new agreement with Sentara
Norfolk General Hospital to provide trauma care training.  DOD also
agreed with our recommendation to facilitate development of an
evaluation tool to help in the assessment of the effectiveness of
trauma care training.  DOD plans to expand this evaluation to include
other individual trauma care training programs beyond the
demonstration program.  DOD also plans to establish panels to
determine trauma care sustainment training needs for military medical
personnel in addition to those created for general surgeons. 
Regarding our recommendation that DOD develop a long-term strategic
plan that establishes goals and identifies actions and appropriate
milestones, DOD stated that, in February 1998, the Combat Trauma
Surgical Committee reconvened to coordinate with the services to
develop and implement trauma care training plans for both the active
and reserve components that are directed toward building a long-term
strategy. 

DOD stated that potential military training sites for reserve
personnel could include the three military treatment facilities in
Texas that treat trauma patients--Brooke Army, Wilford Hall, and
William Beaumont Army Medical Centers.  However, we believe that
these facilities may not be viable training sites because their low
volume of trauma admissions and their current staffing levels
preclude the centers from providing sustainment training for military
medical personnel not already assigned there. 

DOD also stated it has specific concerns regarding (1) the additional
costs for licensure and credentialing of providers, (2) costs for
additional civilian trauma training opportunities, and (3) the
sustainment costs of what will have to become a new readiness
mission.  We did not identify any significant financial impact
regarding the demonstration program.  For example, only nominal costs
were incurred for trainee licenses.  In addition, due to the close
proximity of the Naval Medical Center Portsmouth to Sentara Norfolk
General Hospital, no travel or temporary duty costs were incurred for
the trainees.  Finally, no additional staffing was required at Naval
Medical Center Portsmouth to cover patient workload.  We recognize
that cost is a factor that DOD must consider in selecting civilian
training locations.  We note that the extent to which DOD might incur
additional costs depends on the agreement reached between the
military organization and the specific civilian site selected. 


BATTLEFIELD DIAGNOSES AND
PEACETIME HEALTH CARE
=========================================================== Appendix I

The Department of Defense's (DOD) wartime medical mission is to
preserve the fighting force.  One primary goal to achieve this
mission is to treat combat injuries on the battlefield and return
personnel to duty as soon as possible and safeguard those who cannot
return to duty.  Historically, 90 percent of trauma sustained in
combat on the battlefield has resulted from penetrating missiles,
mostly bullets from small arms and fragments from explosive
munitions. 

The care furnished in military medical centers bears little
resemblance to most of the penetrating wounded-in-action injuries
that medical personnel will treat in wartime.  The most frequent
diagnoses in military treatment facilities are pregnancies and live
births.  In fact, none of the 50 most frequent peacetime diagnoses at
military medical centers match a wounded-in-action condition. 

According to DOD, peacetime medical care is an important element of
training for the wartime mission because many of the medical services
provided in war are for diseases and nonbattlefield-related injuries
that are also seen and treated during peacetime.  Historically,
diseases and nonbattlefield-related injuries have accounted for
between 69 and 96 percent of all care provided in wartime.  However,
a 1995 Congressional Budget Office report concluded that peacetime
care in military medical facilities bears little correlation to many
of the diseases and nonbattlefield-related injuries.\1 Table I.1
shows the lack of a correlation between the top five diagnoses
expected during wartime (wounded-in-action injuries,
nonbattlefield-related injuries, and diseases) and the top five
diagnoses seen in military treatment facilities in fiscal
year 1997. 



                                    Table I.1
                     
                       Top Five Wounded-in-Action Injuries,
                       Nonbattlefield-Related Injuries, and
                       Diseases Expected in Wartime and Top
                     Five Peacetime Diagnoses in Fiscal Year
                                       1997

                          Wartime care                         Peacetime care
      ----------------------------------------------------  --------------------
      Wounded-in-action   Nonbattlefield-
Rank  injury              related injury      Disease
----  ------------------  ------------------  ------------  --------------------
1     Lower leg open      Heat exhaustion     Diarrhea      Single infant born
      penetrating wound                                     without caesarean
      with fracture                                         delivery

2     Thigh open          Sprained ankle      Upper         Single infant born
      penetrating wound                       respiratory   by caesarean section
      with fracture                           infection

3     Multiple,           Heat cramps         Fever         Uterus and ovary
      nonperforating                                        procedures for
      fragment wounds of                                    nonmalignancy
      skin and soft
      tissue

4     Upper arm open      Blisters of hands,  Respiratory   Knee procedure
      wound with          fingers, feet, and  disease
      fracture and nerve  toes due to
      injury              friction

5     Lower leg open      Sprained wrist      Athlete's     Esophagus,
      penetrating wound                       foot          gastrointestinal,
      without fracture                                      and other digestive
                                                            disorders
--------------------------------------------------------------------------------
Additional training may be needed to bridge the gap between the
knowledge acquired in civilian trauma centers and the actual delivery
of combat casualty care on the battlefield.  This military-specific
training would highlight the difference between the civilian
experience and what is expected in a battlefield environment.  For
example, in civilian trauma systems, the principles of advanced
trauma life support discourage the use of tourniquets and recommends
direct pressure to the wound to stop major bleeding.  However, in a
battlefield environment, a tourniquet is considered the most
reasonable choice to stop bleeding and prevent death. 


--------------------
\1 Restructuring Military Medical Care, Congressional Budget Office,
July 1995. 


ORGANIZATIONS VISITED OR CONTACTED
========================================================== Appendix II


   DEPARTMENT OF DEFENSE
-------------------------------------------------------- Appendix II:1

Office of the Assistant Secretary of Defense for Health Affairs
Office of the Assistant Secretary of Defense for Reserve Affairs
Joint Staff Logistics Directorate, Medical Readiness Division
Defense Medical Readiness Training Institute
Special Operations Command, Office of the Command Surgeon
Uniformed Services University of the Health Sciences


      ARMY
------------------------------------------------------ Appendix II:1.1

Office of the Army Surgeon General
Army Medical Department
Army Special Operations Command, Office of the Command Surgeon
Army Forces Command, Office of the Command Surgeon
Southeast Regional Medical Command, Readiness
Walter Reed Army Medical Center, Borden Institute


      NAVY
------------------------------------------------------ Appendix II:1.2

Office of the Navy Surgeon General
Navy Bureau of Medicine and Surgery
Naval Special Warfare Command
Naval Health Research Center
I Marine Expeditionary Force, Surgeon's Office
First Marine Division, Surgeon's Office
Third Marine Aircraft Wing, Office of the Wing Medical Officer


      AIR FORCE
------------------------------------------------------ Appendix II:1.3

Office of the Air Force Surgeon General
Air National Guard Readiness Center, Surgeon General


      MILITARY TREATMENT
      FACILITIES
------------------------------------------------------ Appendix II:1.4

Naval Medical Center Portsmouth
Naval Medical Center San Diego
Naval Hospital Camp Pendleton
Wilford Hall Medical Center
Brooke Army Medical Center
William Beaumont Army Medical Center
Dwight David Eisenhower Army Medical Center


   U.S.  HEALTH CARE ORGANIZATIONS
-------------------------------------------------------- Appendix II:2

American College of Surgeons, Committee on Trauma
American Trauma Society
National Registry of Emergency Medical Technicians
Federation of State Medical Boards


   PRIVATE U.S.  HOSPITALS
-------------------------------------------------------- Appendix II:3

Sentara Norfolk General Hospital, Norfolk, Virginia
Martin Luther King, Jr./Drew Medical Center, Los Angeles, California
Mercy Hospital and Medical Center, San Diego, California
R.  Adams Cowley Shock Trauma Center, Baltimore, Maryland
Ben Taub General Hospital, Baylor College of Medicine, Houston, Texas
Grady Memorial Hospital, Atlanta, Georgia
D.C.  General Hospital, Washington, D.C. 


   STATE AND CITY GOVERNMENTS
-------------------------------------------------------- Appendix II:4

California State Medical Board
Georgia State Professional Examining Board
Texas State Board of Medical Examiners
Texas State Board of Nurse Examiners
Texas State Board of Vocational Nurse Examiners
State of Maryland, Department of Health and Mental Hygiene,
 Board of Physician Quality Assurance
Commonwealth of Virginia, Department of Health Professions,
 Board of Medicine
City of Santa Ana, California, Fire Department


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================= Appendix III

NATIONAL SECURITY AND
INTERNATIONAL AFFAIRS DIVISION,
WASHINGTON, D.C. 

Carol R.  Schuster
Brenda S.  Farrell
Martin E.  Scire
Karen S.  Blum

ATLANTA FIELD OFFICE

Cherie' M.  Starck
Karen B.  Thompson

OFFICE OF THE GENERAL COUNSEL

Ernie E.  Jackson


*** End of document. ***