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1st Quarter 2017, Volume 10 Issue 1

The Unofficial Newsletter Recognizing the Efforts of the DoD Joint Trauma System to Improve Trauma Care.

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JTS: It’s not just a good idea. It’s the law —

specifically section 707 of the “National

Defense Authorization Act (NDAA) for Fis-

cal Year 2017,” known colloquially as

NDAA 17, or the Defense Budget. On

23 Dec 2016, former Pres. Obama signed

NDAA 17 into law, and we are a part of it.

This marks what will become a new era in

the Joint Trauma System (JTS). Over the

last year, many forces have been at work

highlighting the importance of military trau-

ma care and the need to make enduring

the system that we have all helped to

build. This culminated in first the JTS DoD

Instruction (DoDI) of September, and now

the language within the NDAA. That’s

about as permanent as it gets in our sys-

tem of government.

The DoDI and NDAA collectively have us

expanding our role into all geographic com-

DIRECTOR’S NOTES

batant commands worldwide. This

includes performance improvement (PI),

data collection, training Combatant

Command (COCOM) PI personnel,

advising trauma training, and of course

developing COCOM trauma systems.

Obviously, that’s going to require a few

more resources, which are unlikely to

materialize overnight.

So now what? Many clichés spring to

mind: “the devil is in the details,” “Rome

wasn’t built in a day,” the journey of a

thousand miles begins with but a single

step,” and of course “the road to hell is

paved with good intentions.” (CAPT: Re-

member to edit that last one out. Cyn-

thia: Oops!) In other words, whatever

happens, it will take a while to get it all

sorted out. Especially when one bears in

mind that NDAA 17 moves hospitals from

the services to DHA and rearranges all

sorts of things within the Military Health

System, so it’s not all about li’l old us.

Fortunately, the process to figure out the

trauma bits of NDAA 17 are already well

under way, in part through the Capabili-

ties Based Assessment sponsored by the

Army Surgeon General and the Joint Staff

Surgeon. This looks at the entirety of

trauma care within the DoD including

training, education, clinical medicine, PI,

prevention, and resourcing, to create a

“system of systems” that accomplishes

CAPT Zsolt Stockinger, MC, USN,JTS Director

the ultimate goal, which just happens to

be ours, optimal care for the trauma pa-

tient. And while the ongoing series of

meetings to do this at times seems to be

asking how many angels can dance on

the head of a pin, I’ll refer you back to the

first cliché.

So, in the background of what everyone

at JTS does every day, our scope will slow-

ly change. No, let me rephrase that: As

JTS: It’s not just a good idea. It’s THE LAW

the background TO what everyone at JTS

does every day, our scope will slowly change.

Because the foreground at JTS remains data

collection, abstraction, analysis, and the PI

that results from it to improve patient care.

We do not stop what we do to reorganize.

Charles Darwin said that it is not the strong

who survive, but the adaptable. Change is

good. (Bills are better.) But patience is a

virtue.

CAPT Zsolt Stockinger, MC, USN, JTS Director presents JTS Deputy Director Dr. Mary Ann Spott with a collection of congratulatory messages from JTS staff on her receipt of the prestigious DoD Distinguished Civilian Award presented at the Pentagon. Messages on the next page.

Mes sages to Mary Ann

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D R . M A R Y A N N S P O T T : R E C O G N I Z E D B Y P E N T A G O N

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A d v e n t u r e s i n D a ta C l e a n i n g

Laura Scott, Epidemiologist, presented her case for the importance of data cleaning prior to using DoDTR data for statistical analyses at the JTS 1st quarter staff meeting. Data cleaning is the process of detecting and amending/removing data that is incorrect, incomplete, improperly formatted or duplicated for the purpose of improving the quality of the data.

Scott outlined three main steps of the data cleaning process:

Data screening/error identification

Diagnosis of potential errors

Error correction

These steps can all be completed at different stages of data collection and anal-ysis. System feedback is also a critical element of this process. There are a varie-ty of different types of data abnormalities, including duplicate data, missing da-ta, odd data such as misspellings, contradictory data and outliers, and incorrect "normal" data. To make the data as useful as possible, epidemiologists and data analysts use different methods to identify potential errors. These can include calculating descriptive statistics and frequencies, plotting box plots and histo-grams, and selecting records that meet specific criteria. Once data with poten-

tially invalid values are identified, we investigate (i.e., the diagnostic step) by reviewing information from the original data source as well as comparing the data with information obtained from other sources. The last step involves data editing. This can be accomplished by correcting the data, deleting data/records, or leaving the data unchanged. Rarely should data ever be deleted. It's crucial during this step that all changes to the data are verified and documented. Docu-mentation protects researchers from accusations of fraud and is crucial for sys-tem feedback.

The main messages to take away from the presentation were:

Don't ignore data you are concerned about (don't assume it's all incorrect, but don't assume all the values are valid either)

We can't "fix" all data errors - having some missing and abnormal data in your data set isn't the end of the world (epidemiologists have a number of methods they can use to address these issues), but we should do our best to minimize errors

Data issues should be prioritized based on impact (this will be specific to each study)

Exercising caution is crucial when editing data - data should never be delet-ed or changed without justification

Collaboration among those that collect, manage and analyze the data is necessary for this process to be effective.

“Laura's presentation revealed the detailed way in which the JTS epidemiolo-gists work with Data Acquisition Branch to revise and update their analytic datasets to ensure that the most accurate and complete data available are used for each project,” said JTS Senior Epidemiologist Jean A. Orman, ScD, MPH. “This is a labor intensive process, but one that is necessary to ensure that the results that JTS reports are scientifically sound, and that all projects meet the high standards for quality that JTS leadership expects.”

Laura Scott, Epidemiologist.

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ROAD ON U.S. BASE IN IRAQ HONORS JTS

LEADER, NAMED AFTER DR. FRANK BUTLER

Need directions to the Forward Surgical Team facility at the Logistical Support Area just south of Mosul, Iraq? It’s easy to find. It’s on the corner of the base runway flight line and Frank Butler Blvd. The road was named in November 2016 to honor retired Navy CAPT (Dr.) Frank K. Butler Jr. Butler started his career as a Navy SEAL officer, went on to become an Undersea Medical Officer, and then an eye surgeon. He retired as the Command Surgeon of the US Special Operations Command in 2006. “This was a complete surprise,” said Butler, chairman of the Committee on Tactical Combat Casualty Care and chief of prehospital trauma care at the Joint Trau-ma System. “Navy CAPT Tom Craig, a deployed emer-

gency medicine physician, e-mailed me from Iraq and told me about it.” Craig, a physician serving at a medical facility in Mosul, led the effort to name the road at the LSA after Butler as a result of Butler’s 20 years devoted to developing and improving Tactical Combat Casu-alty Care (TCCC). TCCC is a set of evidence-based, best-practice prehospital trauma care guidelines customized for use on the battlefield. TCCC is has become the standard throughout the Department of Defense and in allied militaries for battlefield trauma care and has been credited with saving thousands of lives in combat in Iraq and Afghanistan. Butler’s involvement in developing TCCC began in 1996 when he co-authored a manuscript that was published in a supplement to the peer-reviewed medical journal Military Medicine. The document, titled “Tactical Combat Casualty Care in Special Operations” presented the results of a four-year research effort that reviewed the evidence base for every aspect of battlefield trauma care as it was practiced in the U.S. military in 1992 and proposed sweeping changes in this care. “That 1996 article did as much as any other single piece of medical literature to nudge the military medical community forward in modernizing combat Story reprinted with permission by the USAISR Innovator.

casualty care,” explained Frumentarius (a pseudonym for a former SEAL/CIA case officer) in a story published on the website sofrep.com in December 2016. “Frank Butler’s contributions to TCCC have continued unabat-ed over the course of the 20 years since the publica-tion of the 1996 paper.” Having a road named to honor him means a great deal to Butler, “Because it happened as a spontaneous ‘thank you’ for TCCC from the Navy docs and Corps-men at our Role II in Iraq, and they are the ones out there using TCCC to save lives downrange,” he said. “Also, and very importantly, this is a strong endorse-ment for the work done by the Committee on TCCC and the TCCC Working Group over the last 15 years to improve battlefield trauma care,” added Butler. “Many advances in combat casualty care achieved by the military in wars past have been lost during the en-suing peace interval. After seeing the dramatic reduc-tion in preventable deaths that TCCC has helped to achieve, the U.S. military has to ensure that we sustain this success, so that it will benefit our country's com-bat wounded in the future. Our country’s men and women in uniform count on military medicine to pro-vide them with the best care possible if they are wounded in combat – and we must live up to that trust every day.”

By Dr. Steven Galvan, USAISR Public Affairs

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New JTS Committees Commence, Set Goals, Identify Deliverables 2016 ended with the inaugural meetings of the Joint Trauma System’s newly formed Committees on Surgical (CoSCCC) and En-route (CoERCCC) Com-bat Casualty Care. The two committees will complement the long-standing Com-mittee on Tactical Combat Casualty Care (CoTCCC) to address improvements in trauma care along the entire continuum.

Each committee is comprised of a diver-sified panel of both officer and enlisted subject matter experts from medical fields representing the broad scope of DoD trauma care. Although the three committees are separate entities, they share a mutual vision to lead change and inform, prepare and educate the DoD trauma community.

Acting as the Interim Chair for both com-mittees, Col Stacy Shackelford, has led efforts to focus on differentiating between “what matters, what we can change, and where efforts need to be focused” to make the biggest impact. Heavy emphasis is placed on research gaps and implementing training stan-dards that support a Joint Trauma Com-bat Core Curriculum (JTCCC), and encom-pass techniques and tactics prescribed in Clinical Practice Guidelines (CPGs).

Shackelford conducted the inaugural

meeting of the new JTS committees. Both groups identified five sub-committees to ensure yearly delivera-bles are met. They are as follows.

C o S C C C S ub co m mi t t e es

CPG Committee:

Evaluates CPGs to ensure doctrine, organization, training, materiel, leader-ship and education, personnel and facilities (DOTMLPF) domains are covered.

Research Priorities Committee:

Research gaps and priorities

Facilitate operationally relevant research

Support deployed research

Operational Resources Committee:

Develop capability based standards across the continuum of care.

Standards for Training, Staffing, Procedures and Equipment with focus on verification processes and metrics.

Education and Training Committee:

Recommend Training Standards

JTCCC Course

Austere Surgical Team Committee:

Austere Surgical Team CPG

News 1 of 2

CoSCCC Mission Promotes optimal surgical care of combat casualties and recommends changes to DoD trauma care delivery related to surgical care and resuscitation through the Commander, Medical Research and Material Command; Director of Defense Health Agency; the Service Surgeons General; the Joint Staff; and the Combatant Commands.

CoERCCC Mission Promotes optimal en route care of combat casualties and recom-mends changes to DoD trauma care delivery related to en route care and resuscitation through the Commander, Medical Research and Material Command; the Director of Defense Health Agency, the Service Surgeons General, the Joint Staff and the Combatant Commands.

Develop standards for austere surgi-cal and resuscitative capabilities

Improve data collection and analysis for austere surgical team

C o E R C C C S ub c o m m it t e es

Policy and Doctrine:

Develop Doctrine of Care Statement

Develop Joint Theater Lexicon

Standardization for level of certification

Transfer of Care (Austere):

Develop formal handoff report

Standardize tri-service documentation

CPG/Performance Improvement:

Emphasis on intra-theater transport and blood product.

Education & Training:

Curriculum review

Set training standards

Pursue training opportunities (i.e. mobile training)

Research Steering:

Monitor top 10 and maintain journal watch.

The committees will meet twice yearly, with the next conference scheduled for May 2017 in San Antonio, TX.

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News 2 of 2

Establishing a Joint Theater Trauma System During Phase Zero Operations http://militarymedicine.amsus.org/doi/pdf/10.7205/MILMED-D-16-00167 Two Decades of Saving Lives on the Battlefield: Tactical Combat Casualty Care Turns 20 http://militarymedicine.amsus.org/doi/pdf/10.7205/MILMED-D-16-00214 Joint Trauma System Takes Shape from Lessons Learned https://health.mil/News/Articles/2017/01/09/Joint-Trauma-System-takes-shape-from-lessons-learned The Future of Trauma Care on Capitol Hill: Implementing Military-Civilian Trauma Care and Establishing a National Trauma System http://bulletin.facs.org/2017/04/future-trauma-care-capitol-hill-implementing-military-civilian-trauma-care-establishing-national-trauma-system/ Defense Health Agency Poised for Huge Growth Under Just-Passed Defense Bill http://federalnewsradio.com/defense/2016/12/defense-health-agency-poised-huge-growth-just-passed-defense-bill/ From the Washington Office: ACS Works to Establish Joint Trauma System in NDAA http://www.mdedge.com/acssurgerynews/article/128650/practice-management/washington-office-acs-works-establish-joint-trauma Saving Lives on the Battlefield: A Joint Trauma System Review of Pre-Hospital Trauma Care in Combined Joint Oper-ating Area? Afghanistan (CJOA-A) Executive Summary https://www.researchgate.net/publication/253336029_Saving_Lives_on_the_Battlefield_A_Joint_Trauma_System_Review_of_Pre-Hospital_Trauma_Care_in_Combined_Joint_Operating_Area_Afghanistan_CJOA-A_Executive_Summary Tactical Emergency Medicine https://www.ahcmedia.com/articles/140073-tactical-emergency-medicine Stop the Bleed: Training Bystanders to be Prepared in a Crisis https://www.emcare.com/news-events/emcare-blog/january-2017/stop-the-bleed-training-bystanders-to-be-prepared DoD Issues Guidance on Trauma Care http://www.mdedge.com/fedprac/article/132032/trauma/dod-issues-guidance-trauma-care “Zero Preventable Deaths and Minimizing Disability”—The Challenge Set Forth by the National Academies of Scienc-es, Engineering, and Medicine http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=23&cad=rja&uact=8&ved=0ahUKEwi_y_jasYvTAhVB5iYKHQD3CRo4FBAWCCIwAg&url=http%3A%2F%2Fjournals.lww.com%2Fjorthotrauma%2FFulltext%2F2017%2F04000%2F_Zero_Preventable_Deaths_and_Minimizing.15.aspx&usg=AFQjCNEeHq1tE1QMl-z4Wy9IQGoYw78JKg

JTS in the News...JTS in the News...JTS in the News Survey The Right Way

A new manual to help the JTS staff better understand how to formulate, write and conduct surveys is now available. Many of the examples given in this manual are real examples of surveys conducted by JTS, while others are from previous surveys performed by staff members. Care was taken to ensure this manual was written specifically for the JTS. All examples and in-formation are related to the work performed at JTS. It is my sincere hope that the JTS staff are able to garner useful tips and tricks from the information and exam-ples contained in this manual. This project helps de-mystify the survey process and encourage JTS staff members to conduct more surveys in the future.

A special thanks goes to Jeana Orman, PhD, Laura Scott and Jud Janak, PhD, for their help in organizing, editing and writing this manual. A special thank you is owed to LTC Jennifer Gurney, MD for giving insight into surveys at JTS and for allowing the use of her sur-veys as examples in this manu-al. Thank you also goes to Mary Ann Spott, PhD and CAPT Zsolt Stockinger, MD for allowing me to dedicate time and resources towards the writing of this manual.

JTS Manual for Conducting Successful Surveys is located at: https://amedc2aisr0031.amed.ds.army.mil/jts_jttr_overview_files/Successfully%20Conducting%20Surveys%20April%205%20Final.pdf

By Caryn Turner, MPH, ORISE Fellow

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The past year found JTS looking inward, focusing on its expanding role in the Tri-Service continu-um of combat casualty care. The Office of the Under Secretary of Defense for Personnel and Readiness officially named JTS as the model for the official DoD Combatant Command Trauma System last September in the publication of the JTS DoD Instruction (DoDI) 6040.47. The JTS DoDI outlines the roles and responsibilities of such a broad-reaching tri-service trauma system. Then, in December, the National Defense Author-ization Act for Fiscal Year 2017 allotted funds for JTS, turning the vision into a reality.

The JTS began preparing for this huge task last spring with a SWOT analysis to uncover the Strengths, Weaknesses, Opportunities and Threats. Each division and branch contributed to this effort by identifying specific requirements, personnel and resources necessary to be support operations as a self-sustaining organization (as opposed to a directorate under another).

This exercise was extended this spring with special break-out sessions made up of “mixed” teams, so staff members from the different branches got to brainstorm together. The mixed nature of the break-out sessions allowed people who might never see each other - except in the quarterly staff meetings - to get acquainted and learn about what others o and how they contribute to the JTS. This new perspective provided fresh ideas into how the different teams can work more efficiently and productively. The need for better communication between the teams was uncovered. The meet-

By Cynthia Kurkowski, Senior Technical Writer

Gap Analysis Enables the JTS to Refine Processes,

Prepare for Future Role as DoD Trauma System

ings also revealed previously unknown areas of inefficiency and manpower challenges. Once the issues are categorized, the groups will meet again for solutions.

Below are some examples of how JTS has applied gap analysis concepts to identify areas of improve-ment.

Communication: The efficiency meetings proved to be particularly helpful generating productive conversations between members of different teams which would never have happened other-wise. The exchanges brought to light tools like TransVerse chat which could resolve a coworker’s communications issues with a team member who works in a different part of the building, yet works closely with you on projects or daily tasks. In most cases, the tool was available, but its availability was not known by all. Leadership is evaluating the communications issue.

Capture of trauma care data: JTS is constantly looking for new venues and ways to capture more

trauma care data by working with groups in the prehospital care and en route care, for instance.

Manpower: Determining what supporting personnel JTS will require in its new expanded role.

Resources/Equipment: Determining what resources (e.g., IT tools, web services)

(Continued on page 9)

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that could make life so much easier, enables staff to work more efficiently. One suggestion was the need for a heavy duty scanner and a dedicated person to scan the patient records, so the data abstractors can focus on data.

Research/Performance Improvement: The Research Determination process implemented last fall and managed by Dr. Jean Orman is streamlining research activities by cutting out un-necessary work and frivolous data pulls resulting from the lack of project planning.

Cleaner data: This is being accom-plished in a number of ways: Regis-tries built on cleaner normalized “precise” data reduce user input error. Intelligently mapping data provides the option to eventually integrate spe-cialty modules (i.e. Role 2) with DoDTR modules. The IT team also conducted extensive problematic data cleaning exercises and reorganized and mapped data to DoDTR standard lookup values (i.e. drugs, coded proce-dures). This mapping enhances report-ing by adding a new dimension to the data reporting. The use of a common interface that matches the DoDTR front end to the Role 2 Registry, for instance, will make cross application work and training much easier.

IT process improvement: Establishing formal processes for change requests, functional requirements, testing and implementation will help projects stay on track and on schedule to ensure delivery of better products.

(Continued from page 8)

The JTS is participating in the DoD Zero-based Budget Re-view (ZBR) which is the mother of all gap analyses. This nation-al initiative determines which government programs best serve the DoD missions.

The ZBR has become a daily part of some staff at JTS. Before describing the latest ZBR hoops the JTS is scaling, let’s review what is a ZBR.

Refresher: The Defense Health Information Technology review team established the ZBR review panel to evalu-ate the need for existing and planned MHS IT invest-ment in FY 16, FY17 and years of the Future Year Defense Plan using a zero-based budgeting approach.

The ZBR is a DoD Chief Information Officer (CIO)-driven effort to identify duplicate/redundant programs and to find opportunities to consolidate compatible registries with the ultimate goal of saving federal dollars.

The JTS often finds itself in the position of educating government officials on unique qualities of a data registry as entities try to lump DoDTR into the electronic health record realm. That is one upside of the grueling ZBR process. JTS has the opportunity to discuss the differentiating features of DoDTR and promote the strengths of the JTS and the DoDTR in a high-profile venue.

The ZBR effort for all registries is complete for this year. The groups submitted the functional require-ments, financial recommenda-tions and supporting documents to the Functional Advisory Council (FAC). The FAC will deliver its final recommendation to the DoD CIO Business Technology Officer by June.

In February the teams participated in a MHS Manpower Sur-vey which is looking for overlap and opportunities to consoli-date Help Desk and IT capabilities. The survey is evaluating every program listed in the DoD Information Technology Port-folio Repository (DITPR). Each program office provides staffing numbers and funding spanning five years for military, civilian and contractors supporting the program. JTS was also required to extract and provide separate reporting of those designated as Help Desk and IT support. All of this data was then rolled up to the service level: Army, Air Force, Navy, DHA. The Manpower Survey is on-going; however, one initial analy-sis has identified approximately 1,000 personnel that were not accounted for during the ZBR analysis, resulting from underre-porting.

Based on JTS’s quality track record and noted contributions to the combatant and Readiness support, an initial ZBR recom-mendation is that the DoDTR will consider some of the regis-tries that participated in the ZBR analysis. The effort just start-ed. Expect an update in the next newsletter.

J T S P a s s e s Z B R S c r u t i n y

“There is one upside of the grueling ZBR

process. JTS has the opportunity to discuss

the differentiating features of DoDTR and

promote the strengths of the JTS and the

DoDTR in a high-profile venue.”

By Mary Jo Glunz-Bartz, IT Project Lead

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G u e s t S p e a k e r

From the NFL to the Battlefield:

THE LONG‐TERM EFFECTS OF TRAUMATIC BRAIN INJURY

Daniel P. Perl, MD is Professor of Pa-

thology, Uniformed Services University

of the Health Sciences, and Director,

Neuropathology Core, Center for Neu-

roscience and Regenerative Medicine,

Bethesda, MD

TBI among Military Personnel

50% of military recruits have already experienced at least one TBI prior to starting their military career.

About 80% of TBIs experienced by active duty service members occur off battlefield.

Contact sports

Motor vehicle accidents

Falls

Fights (Note: boxing is a required course at West Point!)

In March, Daniel P. Perl, MD, Director, Neuropathology Core, at the Center for Neuroscience and Regenerative Medicine, presented his case for the need to capture and analyze traumatic brain injury data – particularly brain tissue data - related to blast and impact to de-velop evidence-based guidelines for definitive diagnosis and treat-ment. The absence of guidelines is partly due to the fact that the un-derlying pathology is unknown. According to Perl, few neuropatho-logical studies have addressed whether blast exposure produces unique lesions in the human brain, and if those lesions are comparable with impact-induced traumatic brain injury (TBI). Perl’s work focus-es on uncovering unique patterns of damage produced by blast expo-sure as opposed to the damage associated with impact-induced, non-blast traumatic brain injuries. Perl’s presen-tation to JTS was based on the article, Characterization of Interface Astroglial Scarring in the Human Brain after Blast Exposure: a Post-mortem Case Series, published June 2016 in Lancet Neural.

Perl outlined the parallels and similarities between the

Punch Drunk vs Common Persistent Post-Concussive Symptoms

Early symptoms

Staggering unsteady gait, disequi-librium, mental confusion, slowed muscular movement

Appeared as if suffering from al-

cohol intoxication, “slug nutty”

Late stages (often years after retire-ment)

Parkinsonism – rest tremor, shuffling gait, masked facies

Cognitive dysfunction, including

frank dementia

Hypothesized progressive neuro-

degenerative process

Martland, H. JAMA 1928.

Physical: headache, nausea, vomit-ing, dizziness, fatigue, blurred vision, sleep disturbance, sensitivi-ty to light/noise, balance prob-lems, hearing difficulties/loss, seizure

Cognitive: impaired attention, con-centration, recent memory, speed of processing, judgment, execu-tive function

Behavioral/emotional: depression, anxiety, agitation, irritability, impulsivity, aggression

VA/DoD Clinical Guidelines For Man-agement of Concussion/mTBI, 2009

Wounded Warrior’s blast/impact injuries and the sports “punch drunk” condition common among boxers and foot-ball players. The clinical name for “punch drunk” is Chronic Traumatic Encephalopathy (CTE). CTE is an invisible wound; Magnetic resonance imaging indicates the brain is normal. There are no clear criteria or way to know what type of blow

(severity, frequency) leads to CTE. There is no clear threshold.

The public pervasiveness of CTE in the professional sports community for decades has led to the clinical study of the condition. Consequently, professional athletes have contrib-uted most of the research pathology data. This pathological data is imperative to understanding CTE since the condition is only seen in the brain tissue – sometimes years after the

injury. The visible damage, interface Astroglial Scar-ring, is caused by the brain trying to repair itself. This scarring triggers CTE and can cause Post Traumatic Stress Disorder.

Perl works with the Center for Neuroscience and Re-generative Medicine’s Brain Tissue Repository CNRM, Brain Tissue Repository for the DoD. Brain tissue sample data analysis is fairly new and compli-cated by clinical and societal barriers to obtaining brain tissue samples to study. Perl is looking for op-portunities to link the tissue sample data with trau-ma care data housed in the DoD Trauma Registry data to yield important insights into prevention and diagnosis.

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The Pacesetter Program recognizes and honors JTS staff members who set the pace for the organization’s standard of excellence. Pacesetters lead by example, demonstrate a positive attitude when faced with challenges, and are known for their collaborative spirit. They take pride in their work and it shows in the product. Each quarter, JTS leadership selects professionals whose behaviors and work ethics support or further the mission, goals, values and initiatives of JTS.

This quarter’s Pacesetter, Beatrice “Bea” Stephens joined the JTS Data Acquisition Branch in 2006 after retiring as a Lieutenant Colonel in the Army Nurse Corps. She initially worked 3 months as an abstrac-tor, but was quickly reassigned by COL John B. Holcomb (retired) to work on a project in response to a Congressional inquiry regarding the use of Factor VII for traumatic coagulopathy. The initial dataset became the basis of the transfusion data-base of US Military Members (currently 4,177) who received blood products in the first 24 hours of trauma. Stephens helps lead the Data Analysis Branch with data abstraction and works with the IT Automation Branch to develop and update/add new data elements as the lead. This dataset is often utilized to identify the Massive Transfusion patients, a high risk population.

That particular project morphed into the JTS Blood Transfusion Database which she continues to work on today as a Research Analyst. “I enjoy working for the JTS because I believe in supporting our wounded warriors and I absolutely enjoy working with the JTS staff,” said Stephens.

Stephens has inspired confidence in many of her peers. Nurse Analyst Greg Dokken recalled when he started working at JTS in April of 2012. He said in the beginning he had no idea what his new job en-tailed. Dokken did not serve in the military, nor was he raised around it, so the "military world" was ex-

tremely different concept. He consider himself very fortunate to have had someone such as Bea Stephens to help him adjust to the new environ-ment. “Bea displays an exceptional level of profes-sionalism and leadership daily,” said Dokken. “She is one of the reasons that I enjoy coming to work each day.

Stephens helps Branch Chief Susan West lead the Data Analysis/ Special Projects team. She leads da-ta request projects. She initiated the continuity binder, consolidating all policies, directives and forms for the Secret Internet Protocol Router (SIPR) Network Room.

In the absence of the Data Analysis Branch Chief, Stephens assumes the functions of data request re-view, attending meetings, and other administrative issues as appropriate. Stephens is admired by her team for her stellar traits. She is:

A great team player.

Not afraid to speak up

Always interested in new information to im-prove the data quality

Always willing to assist with projects

“Bea has been with the JTS since its inception and has been a consistent element in the success of the organization,” said JTS Deputy Director Dr. Mary Ann Spott. “She has maintained the massive transfu-sion database and has provided strong leadership to the SIPR room in her supervisor's absence. Bea's long time dedication to the patient has followed her from her active duty days as the chief of the burn unit, to the JTS in her civilian role. JTS is fortunate to have such a dedicated patient advocate.”

On the home front, Stephens enjoys tending to her flower garden and spending time with her husband, Ned, and two children Shelby and Christopher. “My favorite part of gardening is selecting the flowers and then telling my husband where to plant them. I love all flowers, one of my favorites is the Gerani-um,” said Stephens.

CAPT Zsolt Stockinger, JTS Director, presents JTS Research Nurse Beatrice Stephens with the Pacesetter Certificate for her dedication and exemplary performance.

PACESETTER ’S CAREER IS A TESTAMENT

OF HER DEVOTION TO THE JTS M ISSION

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It’s hard not to get excited when you read the JTS De-partment of Defense Instruction (DoDI) 6040.47. The DoDI represents promise of great things to come. It renews the JTS’ sense of purpose and reaffirms the value of the DoD Trauma Registry (DoDTR). The DoDI guarantees the livelihood of the JTS within the Defense Health Program. The official document elevates the JTS position within the military trauma care community by extending JTS’ ability to influence standardized trauma care guidance and see that this guidance is included in training throughout the military departments. The DoDI elaborates on the Defense Health Board’s recom-mendations published 09 Mar 2015 Combat Trauma Lessons Learned from Military Operations of 2001-2013.

The Defense Health Board (DHB) members recom-mended the DoD “establish the JTS, in its role as the DoD Trauma System , as the lead agency for trauma in DoD with authority to establish and assure best-practice trauma care guidelines to the Director of the Defense Health Agency, the Services, and the Combat-ant Commanders.”

The DoDI elaborates on how to set up the DoDTS with directions on who does what with whom and how. The overarching purpose* of DoD Instruction 6040.47

Establishes policy, assigns responsibilities, and provides procedures to develop and maintain an enduring global trauma care capability that sup-ports a full range of military operations, including a comprehensive DoDTR.

Establishes the Secretary of the Army as the Mili-

tary Health System (MHS) Lead Agent for trau-ma care and recognizes the JTS as a DoD Center of Excellence (DCoE).

Establishes an integrated Combatant Command (CCMD) Trauma System (CTS) modeled after the Joint Theater Trauma System (JTTS), and a re-quirement to input data into the DoDTR to sup-port unique CCMD mission requirements.

*In accordance with DoD Directive 5124.02.

JTS is a natural fit for the assignment. The JTS mission aligns with the DoD Policy. In Section 1.2 Policy, the DoDI states the policy encompasses the following:

The DoD supports trauma care research to in-crease readiness and decrease injuries and pre-ventable death, while improving health and quality of life for those Service members who have suffered traumatic injuries.

Trauma initiatives focus on the prevention, diag-nosis, mitigation, treatment of trauma injuries, and rehabilitation of injured Service members.

The DoD uses a central trauma data repository to standardize and facilitate performance im-provement.

Trauma-related data through the full spectrum of military operations is gathered and analyzed in order to exchange information across the DoD, and across national and international trau-

ma communities of interest.

SYSTEM POLICY D IRECT IVE

The DoD identifies, tracks, and recommends per-formance improvement measures to ensure the appropriate evaluation and treatment of injured Service members across the continuum of care.

Besides the fact that the JTS has the DoDTR , it also has the teams in place to facilitate and implement the plans and tasks outlined in DoDI 6040.47. JTS has the research, education/training and performance im-provement teams to leverage trauma care data to standardize and facilitate performance improvement. JTS has close working relationships with the subject matter experts who recommend best practices in clini-cal practice guidelines.

In truth, JTS is already fulfilling most of the functional requirements listed by the DHB. Today, JTS:

Enables accurate and timely entry of casualty and trauma care data into the DoDTR or current DoD system of record.

Develops, assesses and recommends best practic-es in treating traumatic injuries, including clinical practice guidance and TCCC Guidelines adapted to the medical mission requirements.

Assists in identifying trauma-care-related require-ments for education and training, research, infor-matics, and operations.

Supports the timely reporting of casualty care and trauma-related metrics.

The DoDI 6040.47 will just make it easier for the JTS to perform the duties with which it’s been tasked.

JTS M I SSION A L IGNS WITH DOD TRAUMA

By Cynthia Kurkowski, Senior Technical Writer

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TCCC UPDATE

P E LV I C B I N D E R C H A N G E Blast injuries resulting from dismounted improvised explosive device (IED) attacks have been a major cause of combat injury in the Afghanistan conflict. Dismounted IED attacks are frequently associated with pelvic fractures, which in turn may result in massive hemorrhage and death. Pelvic fracture is also frequently caused by penetrating trauma and high-energy blunt trauma such as motor vehicle crashes, falls, and aircraft accidents.

The CoTCCC reviewed the use of pelvic binders in 2008 and decided at the time that there was insufficient evidence of benefit to warrant their addition to the TCCC Guidelines. At the Feb 2016 meeting of the CoTCCC, CAPT Stephen Bree, the UK Liaison Officer to the US military and an experienced combat medical provider, was asked to present the top three things that he thought needed to be changed about TCCC.

One of those three items was a recommendation to add the use of pelvic binders to the TCCC Guidelines. Col Stacy Shackelford presented a review of this topic for the committee. Her extensive review of the literature and consideration by the CoTCCC led the committee to recommend that pelvic binders be reconsidered for addition to the TCCC Guide-lines.

TCCC updates are provided by Frank K. Butler, MD, FAAO, FUHM CAPT MC USN (Ret), Chairman - Committee on Tactical Combat Casualty Care Chief - Prehospital Trauma Care- Joint Trauma System Adjunct Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences

The Committee of Tactical Combat Casualty Care (CoTCCC) anticipates three new TCCC knowledge products: TCCC Hand-book, TCCC Clinical Algorithm and TCCC Mobile.

The TCCC Handbook is a succinct summary of TCCC information designed to serve as both an introduction for new TCCC students and as a quick reference for TCCC users.

The TCCC Clinical Algorithm is a visual depiction of the sequence of actions in battlefield trauma care that the TCCC Guidelines call for.

The TCCC Web/Mobile project is a effort to improve the delivery of TCCC knowledge products, especially to combat med-ical personnel. This effort is being funded through the Defense Health Agency R+D Department and comprises both the CoTCCC.com website and the TCCC Mobile Application that presents TCCC information on personal electronic devices without requiring constant internet access. MSG (R) Montgomery and his working group of TCCC medics, corpsmen, and pararescue jumpers have had the point on these three efforts and they will soon be valuable additions to the TCCC stra-tegic messaging effort.

* N E W T C C C P R O D U C T S * UP DA T E D

CPG S Since last summer, the Education Branch and over 200 subject matter experts have authored about 28 CPGs. The following CPGs are the latest in a multifaceted effort to update every single CPG and add relevant topics.

Acute Respiratory Failure

Catastrophic Non-Survivable

Brain Injury

Damage Control Resuscitation

Frostbite and Immersion Foot

Care

Hyperkalemia and Dialysis in the

Deployed Setting

Management of Pain, Anxiety

and Delirium

Neurosurgery and Severe Head

Injury

Pelvic Fracture Care

Radiology

Unexploded Ordinance

Management

Prolonged Field Care

Crush

Burn

14

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Questions? Contact Christopher Wells at christopher.m.wells4.ctr@mail.mil

15

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Questions? Contact Christopher Wells at christopher.m.wells4.ctr@mail.mil

16

Editorial Note: Projects are new projects or projects not previously published here. Team members listed are JTS members.

Role 3 Survival Proportions by MTF : Objective: Calculate the survival proportions (percent discharged alive) by individual MTF for patients admitted to Role 3. CAPT Zsolt Stockinger, MD; Laura Scott; Geraldo Pacheco.

Pelvic Binders: Objective: determine whether prehospital application of pelvic binders to seriously injured combat casualties at risk for pelvic fracture is associated with increased survival. Col Stacy Shackeford, MD; Deborah del Junco.

Economic Impact of Combat Casualties : This is a collaborative research Project. Objec-tive: quantify the economic costs of combat casualties in OEF/OIF and estimate cost savings from interventions such as tourniquets and damage control resuscitation. PI: Dr. Ted Miller with Pacific Institute for Research and Evaluation; Jean Orman, PhD.

Clinical Implications of Pharmacologic Alterations of Thrombosis following Severe and Penetrating TBI : Collaboration with Walter Reed Military Medical Center and The Uni-formed Services University of the Health Sciences Evaluate the use of venous thrombo-embolism chemoprophylaxis (heparinoids) as well as pro-coagulant medications (i.e. TXA, Factor VII) populate the JTS TBI Module with training support from JTS Data Acqui-sition Branch PI CDR. Randy Bell, MD; Jean Orman, PhD.

South Command: PI project. Objective: Compare causes of death among Special Opera-tions Forces and other casualties. Russ Kotwal, MD; Laura Scott.

Descriptive Analysis of the usage of Whole Blood from 2002-2016 in the Wars in the Middle East. Objective: This project to assess the amount of whole blood that has been transfused over time and compare it to the amount of component therapy transfused over the same time period. LTC Jennifer Gurney, MD; Laura Scott.

Predeployment training survey. Objective: This survey was conducted in 2015 to assess perceptions of training and readiness amongst military in terms of deployment. It also wanted to get opinions regarding the current predeployment training courses and query the deployable surgical population about potential opportunities for improve-ment in training for the trauma care mission performed downrange. LTC Jennifer Gurney, MD; Deborah del Junco.

Preventable Deaths. Objective: To perform a series of qualitative and quantitative per-formance improvement projects in order to recommend guidelines and standard oper-ating procedures for military preventable death reviews. CAPT Zsolt Stockinger, MD; Jud Janak, PhD; Mary Ann Spott, PhD; Col Shackelford, MD; LTC Jennifer Gurney, MD;

COL (ret) Russ S. Kotwal, MD; Frank K Butler, MD; Harold Montgomery.

Integrated Registry. Objective: This project will describe the integrated DoDTR registry and provide a summary of basic data from a) each module and b) for linked data from selected modules. Laura Spott; Dr. Jean Orman.

Clinical Implications of Pharmacologic Alterations of Thrombosis following Severe and Penetrating TBI. Objectives: Evaluate the use of venous thromboembolism chemopro-phylaxis (heparinoids) as well as pro-coagulant medications (TXA, Factor VII; populate the JTS TBI Module with training support from JTS Data Acquisition Branch. PI CDR Randy Bell, MD; Dr. Jean Orman.

CPG Evaluation. Objective: evaluate the impact of CPG’s on mortality and other out-comes. Col Stacy Shackelford, MD; CAPT Zsolt Stockinger, MD; LTC Jennifer Gurney, MD; Dallas Burelison; Osei-Bagyina, Deborah el Junco; Dr. Jean Orman.

Prolonged Field Care. Objective: Identify and describe cases in the DODTR with docu-mented wait times of 4 hours or more for transport. Col Stacy Shackeford, Deborah del Junco.

Craniectomy – Data Analysis. Objective: Search the Role 2 registry and the DoDTR to identify and describe all combat-casualties who underwent craniectomy. Col Stacy Shackeford, MD; Deborah del Junco.

Craniectomy – Survey. Objective: Collect self-report data from surgeons regarding their experience in performing craniectomies or burr hole procedures in Role 2 or 3 without a neurosurgeon present. Col Stacy Shackeford, MD; Deborah del Junco.

I N C O M I N G S T A F F

Meredith Peiffer Clinical Nurse Abstractor (MOTR) 28 Nov 2016

Nirailda Vicente Administrative Assistant 15 Dec 2016

Edgar Miller Clinical Nurse Abstractor (MOTR) 04 Jan 017

Judson Janak General Health Scientist / Epidemiologist 09 Jan 2017

17

ARTICLES SUBMISSION

Cynthia R. Kurkowski

IT Automation Branch

(210) 539-7756

Cynthia.R.Kurkowski.Ctr@mail.mil

3698 Chambers Pass

Building 3611 - BHT1

JBSA Fort Sam Houston

TX 78234-6315

A b o u t T h e J o i n t T r au m a S y s t e m

M i s s i o n : O p t i m i z i n g C o m b a t C a s u a l t y C a r e

The Joint Trauma System (JTS) is the Center of Excellence for Trauma for the Department of Defense (DoD). The JTS mission is to provide evidence-based process improvement of trauma and combat casualty care, to drive morbidity and mortality to the lowest possible levels, and to provide evidence-based recommendations on trauma care and trau-ma systems across the Department of Defense. JTS captures and reports battlefield injury demographics, treatments and outcomes using the DoD Trauma Registry (DoDTR), formerly known as the Joint Theater Trauma Registry. DoDTR captures trauma data from battlefield first responders to definitive care stateside, plus en route care for military and civilian personnel treated in US military facilities in wartime and peace-time. The vision of the JTS is that every Soldier, Sailor, Airman and Marine injured on the battlefield or in any theater of operations will be provided with the optimum chance for survival and maximum potential for functional recovery.

JTS Website: http://www.usaisr.amedd.army.mil/10_jts.html AKO/DKO: https://www.us.army.mil/suite/page/131956

C o m b a t C a s u a l t y C a r e C o n f e r e n c e C u r r i c u l u m The JTS offers clinicians, nurses, and medics the oppor-tunity to acquire Continuing Education credits on a weekly basis. The telemedicine conference was devel-oped to increase the knowledge-base of clinicians, nurses, medics, and other non-healthcare providers while deployed. The dual technical platforms of land line telephones and Defense Collaboration Services are used to connect far forward providers throughout the continuum of care. If you would like to join the confer-ence, please contact the JTS Education Branch Chief Dallas Burelison at dallas.r.burelison.ctr@mail.mil

13 Apr Emergent Resuscitative Thoracotomy

20 Apr Principles of External Fixation

27 Apr MOC2, KSA, NDAA Define Readiness

04 May Pelvic Fracture – REBOA (Giants in Surgery Lecture)

11 May Catastrophic Care

18 May The History of the Medical Soldier, from the Roman Capsari to TC3

25 May Prolonged Field Care Pain Sedation

01 Jun From the NFL to the Battlefield; Long Term Effects of TBI

08 Jun TBA

15 Jun Needle Chest Decompression

22 Jun TBA

29 Jun TBA

S p e c i a l N o t i c e

The updated DoD Trauma Registry (DoDTR Load 43) is up and performing smoothly but experiencing technical difficulties caused by network issues\outages.

The issues are a result of USAISR Information Management Office’s (IMO) efforts to maintain compliancy with vendor and install DISA-issued patches and updates.

Unfortunately, when IMO performs unscheduled updates, they affect the connectivity to DoDTR. DoDTR is not actually down, but network issues or outages

prevent users from accessing it. This also impacts JTS Manager and Direct Connect Report Writer. We've requested IMO give us advance notice when they plan to

perform an update outside of their regularly scheduled maintenance hours (2200 - 0700). I will continue to work with IMO leadership to ensure we receive

sufficient notice if maintenance will occur during the normal business hours. The IT Automation team will notify you when IMO informs us of maintenance tasks

during business hours. Don't hesitate to reach out to me with questions regarding network issues\outages. We also seeking user feedback and suggestions about

DoDTR. Tell us what you want to see in the next DoDTR build. James.b.mason4.civ@mail.mil

By James B. Mason, MBA, MS, Chief, IT Automation Branch

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