Military civilian partnerships: International proposals for bridging the Walker Dip

Abstract

The Walker Dip refers to the cycle of the improvement of care for the battle injured soldier over the course of a conflict, followed by the decline in the skills needed to provide this care during peacetime, and the requisite need to relearn those skills during the next conflict. As the operational tempo of the conflicts in Afghanistan and Iraq has declined, concerns have arisen regarding whether US military surgeons are prepared to meet the demands of future conflicts. This problem is not unique to the US military and allied nations have taken creative steps to address the Walker Dip in their own surgical communities. A panel entitled Military and Civilian Trauma System Integration: Where Have We Come; Where Are We Going and What Can We Learn from Our International Partners at the 2018 American Association for the Surgery of Trauma meeting brought together a cadre of civilian and military surgeons with experience in this area. The efforts described involved the creation of a new trauma training program in Doha,Qatar, the military civilian partnership in the Netherlands, and the steps taken to address the deficit of penetrating trauma in Sweden. This article focuses on the lessons that can be learned from our allied partners to assure readiness for deployment amongst military surgeons.

Integrated military and civilian partnerships are necessary for effective trauma-related training and skills sustainment during the inter-war period

“…Eighteen articles described MCP where forward deployed caregivers were provided skills sustainment opportunities of previously learned skills (e.g., original Graduate Medical Education (GME) residency training or from previous deployments). These skills sustainment MCP involved multiple provider types, including surgeons (general, trauma/critical care, orthopedic, vascular, and neurosurgery), anesthesia providers (nurse anesthetists or anesthesiologist), nursing (emergency/trauma, critical care, operating room), surgical technicians, paramedics, and medics 13–29 . Twenty-three described just-in-time training MCP where predeployment multidisciplinary trauma team training at civilian Level I academic centers occurred.…”

“…These skills sustainment MCP involved multiple provider types, including surgeons (general, trauma/critical care, orthopedic, vascular, and neurosurgery), anesthesia providers (nurse anesthetists or anesthesiologist), nursing (emergency/trauma, critical care, operating room), surgical technicians, paramedics, and medics. [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] Twenty-three described justin-time training MCP where predeployment multidisciplinary trauma team training at civilian Level I academic centers occurred. These types of MCP included a combination of didactics, highfidelity simulation using models and/or cadavers and clinical trauma experiences.…”

Acquisition and retention of military surgical competencies: a survey of surgeons’ experiences in the UK Defence Medical Services

“…Only half of the respondents had deployed in a surgical capacity, and only a quarter felt adequately prepared for management of penetrating trauma, although importantly the less prepared respondents were often those in training, rather than consultant surgeons. The requirement for more specific trauma training to help bridge the ‘Walker Dip’ (the phenomenon where casualty care improves during a war, only to then degrade during peacetime15) has been echoed in recent articles 16 17. Proposed solutions to this include overseas trauma training programmes and civilian military collaborations,18 19 the latter which has had ongoing benefits for both the civilian and military sectors over the last century 20.…”

“…One suggestion to help mitigate this is trauma-focused fellowships to overseas nations where surgical practice is more generalist, at a relatively early stage in training 24. Other authors have noted that standardised cadaver-based surgical skills, as well as virtual reality simulation training, can be effective in improving the procedural skills required for the deployed trauma surgeon 16 17…”

Optimizing combat readiness for military surgeons without trauma fellowship training: Engaging the “voluntary faculty” model

“…Low volume combined with low operative complexity exacerbates this readiness issue. The dynamics underlying low volume and complexity within the military health care system (MHS) have previously been well described 2–6 …”