When it comes to improving U.S. health care, what 20 years of war can teach us
When the ambulances started rolling in and news trickled out that multiple police officers had been shot, Kathy Barnard braced herself for one of the worst days in her 26 years on the job. One thing gave her confidence though.
“I pray we never, ever experience that again, but there were military doctors on duty. I had military nurses on duty,” said Barnard, a nurse manager at Atrium Health in Charlotte, N.C.
The day was April 29, when four officers died trying to serve an arrest warrant and four others were wounded. The hospital's experienced civilian staff were shored up by active duty Army doctors and nurses from nearby Fort Liberty.
“We had the right team here to carry out the amazing care we gave everybody that hit our door that day,” Barnard said.
Techniques learned in war
A partnership funded by the Mission Zero Act, passed by Congress in 2019, has resulted in dozens of civilian-military public health partnerships across the country, ideally suited to collaborate in just such a crisis.
“Eight shooting victims that involved a rifle with high caliber wounds -- this is what we train for. We train for multiple patients. We train for these high-velocity wounds,” said Dr. Michael Clemens, an Army Special Operations combat surgeon who pulls shifts at Atrium Health in Charlotte.
The partnership offers more than extra staff and expertise for mass casualty events. It's a possible solution to twin health crises. Civilian hospitals are struggling with staff shortages nationwide, made worse by COVID burnout. At the same time, the Pentagon has acknowledged that an effort to outsource health care to the private sector has gone too far and is starving its own practitioners of valuable experience. And the collaboration allows the hard-won medical gains from 20 years of war to be preserved and practiced in peacetime, which is where Mission Zero got its name.
“The idea behind this was how do we get to zero preventable deaths from trauma?” said David Callaway, chief of crisis operations at Atrium Health.
Callaway is himself a veteran. He became a military surgeon just in time for 9/11. He watched the U.S. military’s steep learning curve in Iraq, where medical advances like the use of whole blood and tourniquets cut combat deaths nearly in half. Callaway was dismayed to learn that some of these life-saving techniques were not new; they had been discovered in previous wars only to be forgotten. It’s a phenomenon called the “Walker dip,” used to describe how crucial medical advances, going back more than a century, get repeatedly forgotten during periods of peace.
“We've invested trillions of dollars, thousands of lives. We have to take lessons out of this that help our community members in the U.S. and, and then also help our men and women serving overseas,” said Callaway.
His hope is that these Mission Zero collaborations can keep that knowledge current in an ongoing cycle between military and civilian providers.
Dr. Michael Clemens said it’s worked for him. He finished med school as the Iraq and Afghanistan wars wound down. He worried that his work treating troops and their families at military hospitals wasn’t enough to keep his skills sharp between special operations missions.
“It was a very stark contrast. I see appendicitis, I see hernia repairs, and I’m treating those daily processes. … All of a sudden I'm thrown into a war zone where the majority of my patients are now coming in multiples and they're coming with explosive trauma from IEDs. They're coming with rifle wounds and high caliber wounds,” Clemens said.
Working shifts in Charlotte gives Clemens the chance to do more complicated surgeries and keep his skills up to date, he said, and he can often see ways that civilian medicine and battlefield techniques build on each other. One example is a balloon used to block the aorta.
“That is something we use to decrease bleeding in traumas. That is a skill that has evolved and been used commonly on the battlefield and so I get to have firsthand experience with that device before I go use it in a more austere environment,” said Clemens.
Stateside, that same device is now being used to stop bleeding in high-risk pregnancies, which also happen on deployment. In war zones like Syria, American medics often treat civilians -- and not just for war wounds. Clemens said he and his colleagues regularly perform emergency cesarean sections.
The knowledge flows in both directions. Experienced civilian surgeons often have plenty to teach newer military staff, and it’s also a good way for them to learn about civilian hospital culture for the day when they transition from active duty into non-military work. Military medical staff train on working in low or zero light and other disaster conditions, something they’re able to share with their civilian colleagues. That came in handy as teams from Atrium health traveled last month to help parts of North Carolina hard-hit by Hurricane Helene.
Dr. Callaway was working remotely on April 29, and came in to the hospital to help coordinate care. He said there’s one more thing this exchange and mentoring can provide.
“The other piece is to be able to put a hand on the shoulder of someone afterwards and say ‘There's nothing else that could have been done.’ And to have that trusted. It's not a platitude of, ‘Hey, good job.’ It is a deep solemn knowledge that nothing else could have been done,” he said.
