A seriously injured patient arrived at Penn Presbyterian Medical Center (PPMC) in critical condition and was treated by a highly skilled trauma team with expertise in casualty care. While that situation might sound typical for Presby, the clinicians might not be who you’d expect: The team consisted entirely of U.S. Navy personnel.
PPMC trauma surgeon (and former Navy surgeon) C. William Schwab, MD, recalled the calm professionalism of the Navy team in contrast to the swarm of activity outside, due to it being a high-profile case.
“Everything flowed beautifully. We were so impressed watching the Navy team take care of that patient … The best way to describe it is ‘grace under pressure,’” said Schwab.
An Unprecedented Collaboration
The Navy has previously worked with civilian trauma centers for “just in time” training – on-demand preparation for military teams weeks before deployment. Their partnership with the University of Pennsylvania Health System (UPHS), however, is the first embedded model of its kind, a groundbreaking three-year program that integrates Navy medical personnel with the Trauma team at PPMC.
Under this agreement, The Naval Strategic Health Alliance for Readiness and Performance (NSHARP), a military team of three physicians, three nurses, two hospital corpsmen, a physician assistant, and one health care administrator, works as members of their respective departments at PPMC, Hospital of the University of Pennsylvania (HUP), and PennSTAR for the program’s duration. After 15 months of supervised orientation, the nine clinicians also cover the trauma bay as a cohesive team.
Ensuring Military Readiness
Penn Medicine has a strong history of training military trauma surgeons. The Penn Trauma Program, founded by Schwab, has trained more than 20 in its Trauma and Surgical Critical Care fellowship program. Still, Schwab saw an opportunity to do more.
“A number of fellows who deployed and returned told us, ‘We’re not learning the skillset we need on the battlefield.’ So I gathered a [group] and said to the clinical administrative leaders, ‘We have to do this differently,’” he said.
Navy trauma surgeon Commander Jay A. Yelon, DO, FACS, FCCM, explained how vitally important hands-on casualty care is for the military and the country.
“In inter-war periods, history has shown that the level of skills and ability of the medical community to meet the needs of injured war fighters goes down,” he said.
To prevent that decline in skills (known as the “Walker Dip”), the National Defense Authorization Act for fiscal year 2017 provided for expansion of military-civilian trauma training sites and mandated integrated training. This dovetailed nicely with Penn Medicine’s plans to boost its trauma and surgical critical care training.
Schwab and his colleagues created a training blueprint with an emphasis on teams; in discussions, military surgeons noted the challenge of working during deployment with individuals they hadn’t previously met.
The Navy team “meeting” Ben Franklin as a part of the inaugural tour of the University campus in September 2021.
“These are critical, intimate teams, and one of the things that makes these teams functional – whether it’s special operatives in the military, a SWAT team in police forces, or a trauma team – is working together,” Schwab said. “It really has to be orchestrated like a piece of music.”
Schwab raised the concept of a military-civilian partnership with UPHS in 2017 to Chief Executive Officer Kevin Mahoney (at the time, executive vice president) and other clinical leaders who galvanized around the idea.
In September 2021, the Navy and UPHS signed a three-year agreement. Their goal: preparing a team of active-duty Navy providers for combat casualty care and developing a model for sustaining their skills between deployments.
Benefits to the Navy Team
The Navy team has seen more cases in months at PPMC than they’d see in years at a military hospital, which has exponentially advanced their proficiency.
Many of the injuries seen over the last 20 years during wars in Afghanistan and Iraq were blast injuries; however, penetrating trauma, like gunshots, is common in combat. As a Level 1 Trauma Center, PPMC treats hundreds of penetrating traumas annually, making it an optimal place for Navy specialists to hone their skills while saving lives in Philadelphia.
The injuries treated at PPMC have application for combat casualty care. Many patients require immediate efforts to stop the bleeding, reverse shock, and provide stabilization for procedures. Similar to the conditions of war, critically injured patients may arrive with little to no advance notice. (Philadelphia’s drop-off policy allows police to transport victims of penetrating trauma directly to the Trauma Center versus waiting for an ambulance – thus shortening time between injury and care.)
“Since being on the Navy trauma team at Penn, I have notably increased my skills in trauma, resuscitation, and leadership. I have learned to remain vigilant, maintain professional readiness, and other skills paramount to successful resuscitations,” said Lieutenant Hyun Kyoung Na, CEN, BSN, RN.
She added, “I believe these skills will translate well when operating in a small surgical team with limited resources. I have cross-trained to the Trauma Surgical Intensive Care Unit and do monthly rotations with PennSTAR to better understand prolonged field care and en route care, which are imperative to know in an austere setting.”
Yelon said it has been academically valuable for the Navy team to follow trauma patients all the way through to recovery, which they rarely do in combat zones. He also pointed out the value of developing what he termed a “learning organization” within the collaboration – a strong characterization of the trauma program at PPMC.
“The learning organization provides psychological safety for team members to speak openly, regardless of rank, to ensure excellence in patient care. That safety allows for effective dialogue between team members,” he said. “The ultimate output from this, other than innovation and team learning, is a trust between team members that we can work effectively together.”
“We’ve created a culture of trust between the two teams where it’s okay to question, to do things differently, and in the debrief and learning sessions, to tell us how we can improve,” Schwab said.
Benefits to the Civilian Team
Trauma program manager Kristen Chreiman, MSN, RN, TCRN, said her staff has learned much from their military partners. “Their expertise in areas like disaster preparedness and management of multiple casualties has been invaluable, especially in a high-volume penetrating center like ours,” she said.
(from left): U.S. Navy Surgeon General Rear Admiral Bruce L. Gillingham, MC, USN with Kevin Mahoney, chief executive officer, University of Pennsylvania Health System.
The Navy team also taught trainees in PPMC’s fellowship program how to translate civilian protocols to field conditions and deliver care under less-than-ideal conditions.
Trauma/Surgical Critical Care Fellow Phillip M. Dowzicky, MD, MSHP, said, “The Navy team has experienced an entirely different practice environment than ours. This has led them to develop techniques, pathways, and procedures that may differ from how we treat similar patients, but are equally valid. Trauma surgeons need a toolkit of diverse ideas and techniques … Exposure to the Navy team has helped me broaden this toolkit.”
In addition, the Navy team has taught tactical combat casualty care (TCCC) – how to deliver lifesaving care on the street or a hostile environment – to local law enforcement and first responders. Recently, quick action by an officer they trained saved the life of a gunshot victim.
Looking Ahead
To mark the halfway point of the partnership, Navy Surgeon General Rear Admiral Bruce L. Gillingham, MC, USN, and his team conducted a site visit on February 21, 2023 to review performance data, speak with the troops, and discuss the future. Leaders from both the Navy and UPHS enthusiastically support expanding the program.
Gene Gofman, MBA, FACHE, associate chief financial officer at PPMC, summarized PPMC’s pride in helping prepare the military for future deployment. “We as a health system are able to provide not a simulation, but a real-life example, a testing ground for these men and women to practice in.” He said being part of the program gives him “a feeling of patriotism and connection to the grander mission of saving those individuals that are risking their lives for all of us.”