LAUSR

The management of serious trauma has been significantly advanced by the lessons learnt from combat care throughout history. With subsequent conflicts, battlefield mortality rates have continued to improve, in part due to a strong focus on timely access to care within a wellorganized system and the adherence to damage control principles. The Australian Defence Force (ADF) military trauma experience in Afghanistan 2001–2021, comprised of a multi-national, trauma-dedicated, highly-skilled trauma team, have demonstrated their ability to deliver exceptional care, as evidenced by their mortality rate, which was significantly lower than civilian major trauma centres. In the recently published article, LTCOL Pilgrim et al. undertook a retrospective review of available documentation regarding injured ADF personnel on deployment to Afghanistan during 2001–2021. Pilgrim et al. sought to collate and analyse hardcopy medical records containing details of surgical intervention following injuries sustained by ADF personnel during deployment. Despite the limited data available for the time period, similar conclusions regarding the excellence in trauma care delivery were reached. Likely fundamental to this outcome was the predominantly US-led military trauma system of care, in which Australian trauma specialists were embedded. Given the relative inexperience of many military specialists in the ADF workforce, it is important to consider what can be implemented to advance our ADF trauma capabilities. The multinational collaboration with our esteemed, and somewhat more battle-experienced, colleagues from the USA provides an excellent opportunity for learning highly valuable skills that can be employed not only on the battlefield overseas, but can also be applied to our civilian trauma centres at home. The typical means by which ADF military surgeons gain most of their trauma experience is in the civilian setting. As highlighted by Pilgrim et al., there are significant differences between the military and civilian trauma systems. In the civilian setting, major trauma often bypasses smaller regional hospitals and is instead directed to major trauma centres, where depending on physiology, injuries are addressed either by performing damage control or by definitive management. Conversely, in the military environment, there is more emphasis placed on performing timely damage control surgery as far forward as possible. In military terms, these facilities are mostly role 2 and 3 facilities, which face significant challenges with resource allocation and limited medical imaging capabilities. The ability to successfully operate in such an austere environment requires a specific mindset and highly developed skillset that can only be gained through specific experience and training. It therefore follows that Australian military surgeons and trauma specialists would benefit greatly from specific military trauma team training. Our highly-experienced US counterparts who lead the way with respect to military systems of care would be an invaluable source of experience and education with which to inform future combat operations of the ADF. While the ADF does incorporate several simulated mass casualty events into the framework of their training, additional training alongside our US counterparts would be highly beneficial. Such a collaboration would also present a valuable opportunity to observe and appreciate the different approaches and training methodologies, and skillsets maintained between our nations, thereby enhancing interoperability prior to deployment. Such training would not only be advantageous for military surgeons, but for all members of the trauma team. A closer working and training relationship would optimize the trauma teams and solidify their preparedness, while also potentially improving attraction and retention of an appropriately experienced ADF medical workforce. The Joint Trauma System (JTS) underpins the clinical governance of US military trauma care. Its mission is ‘to improve trauma readiness and outcomes through evidence-driven performance improvement’. Central to this is a well-maintained and comprehensive trauma registry, which is used for research and to inform quality improvement activities. The challenges met by Pilgrim et al. in reviewing the often several hundred and up to 1700 pages of nonstandardized medical chart records, I believe obviates the ADF’s need for a system similar to that utilized by the USA. While electronic records have been in use for some time and are an improvement on paper records, the ADF does not have a system analogous to the JTS to specifically support trauma care. Limited availability of data due to relatively low numbers of injured personnel and a small workforce presents challenges in trauma care innovation. However, future directions should consider the means by which the Australian military can adopt a cost-effective model to facilitate audit procedures, research and improve the quality of trauma care. This, in turn, could enhance the surgical capabilities across the ADF, with the aims of not only informing innovative training methodologies, but also sustaining a well-prepared and enthusiastic workforce. Ultimately, our injured military personnel deserve the best possible trauma care despite the austere environment in which they operate. Pilgrim et al. confirm that highly favourable outcomes were achieved overall in the examined cohort of ADF-injured personnel during their time in Afghanistan. This quality in trauma care highlights the effectiveness of the predominantly US-led system of care, while also acknowledging the important contribution of multinational medical personnel, including those in the ADF. Embracing existing opportunities and exploring further prospects for the ADF and US forces to both train and deploy together would serve to further enhance interoperability and preparedness. This is particularly important for the ADF in current times, given low numbers of traumatic injuries sustained in combat and the comparatively small size of our Defence Force. As