Appendix 3
United States Military Levels of Medical Care and the Joint Trauma System
U.S. Military medical care is divided into levels and defined utilizing North Atlantic Treaty Organization (NATO) terminology.1,2 These levels are termed Roles and are based on capability and resources. The levels are organized to conduct treatment, provide evacuation back to the next higher level of care, and conduct resupply forward as required. The term forward refers to the levels of care closer to the POI, (i.e. Role 1 medical care is “forward” of Role 2). The treatment capability of each lower level is replicated at the next higher level, e.g. a Role 3 facility will have the ability to carry out most Role 2 functions. It should be noted that patients are not necessarily evacuated in a linear fashion and may bypass a given level based on medical condition or tactical considerations. For example, a patient may be evacuated from the POI to a Role 3 facility, bypassing Role 2.
Role 1 medical support is that which is assigned to a Battalion or Company and includes the capabilities for providing pre-hospital care at the POI, triage, early resuscitation, and daily primary medical care as well as disease and injury prevention guidance directly to unit leaders. This support is a national responsibility.
Role 2 support is usually a Brigade level function. It has the responsibility to provide evacuation from Role 1 and includes the functions of Role 1 units. Additionally, these units may have the capability to hold patients until they can be returned to duty or evacuated and may provide emergency dental care, environmental health, and mental health services. Surgical care is routinely integral to the majority of these units. These small surgical units are designed to provide damage control surgery and immediate post-operative care. This level of support may be a national or lead nation responsibility.
Role 3 includes medical, surgical, and hospitalization capability, and may be mission-tailored to provide specialty care as well. The hospitalization capability of a Role 3 facility allows for diagnosis, treatment, and holding of those patients who can be returned to duty within the specified time period designated by the Theater Surgeon. This support may be a national or lead nation responsibility and may be multi-national in nature.
Role 4 provides definitive care of patients who require longer or more extensive care than is available in Role 3 units. This care includes sub-specialty surgical and medical care and rehabilitation services. Role 4 support is usually based in the country of origin or in an Alliance country. In many countries, this care is provided by the national civilian health system.
In the U.S. Military, Role 1 care encompasses immediate care provided by the patient (self-care), first responder (buddy aid, combat life saver), combat medic, and aid stations (physicians and physician assistants) capable of providing basic resuscitative care as well as other care as described above. Role 2 includes all the elements of Role 1 and adds patient holding capability, laboratory and radiology support, dental care, physical therapy, mental health care, preventive medicine, and medical supply. Forward resuscitative or damage control surgery is conducted by small mobile surgical elements that can be attached to a Role 2 unit. Role 3 consists of deployable hospitalization care with surgical capability that is roughly equivalent to a small community hospital with some specialty services as dictated by mission (i.e. burn or neurosurgical services). Role 4 care is provided at fixed facilities in two different ways. The first distinction is care in an intermediate location with increased access to specialty care such as the Landstuhl Regional Medical Center in Germany and the U.S. Naval Hospital on Okinawa. Role 4 care in the United States is conducted with full specialty/subspecialty access in locations such as the Walter Reed National Military Medical Center in Washington D.C., the San Antonio Military Medical Center in San Antonio, Texas and the Veterans Health Administration, among others.
Joint Trauma System
“The Joint Trauma System (JTS) is an organized approach to providing improved trauma care across the continuum of the Levels of Care to trauma patients, especially in the battlefield environment. JTS is dedicated to the reduction of morbidity and mortality of combat casualties at all levels of care and to providing the right care to the right patient at the right place at the right time throughout the continuum of care.”3
The JTS is patterned after the model developed by the American College of Surgeons Committee on Trauma. This model encompasses the treatment continuum from injury prevention through rehabilitation and return to duty while also including the unique aspects of military trauma. The JTS is also responsible for the creation, maintenance, and revision of the JTS Clinical Practice Guidelines (CPG) based on current evidence.4-5
The JTS provides oversight, training, guidance, and assistance to subordinate theater level trauma systems and registries. Eventually, the JTS will maintain the master Department of Defense (DoD) trauma registry once it is implemented. This registry will consolidate all wartime/conflict casualty data as well as capture peacetime trauma patients throughout the DoD. (Oral communication, Ms. Mary Spott, July 2011)
Joint Theater Trauma Registry
The Joint Theater Trauma Registry (JTTR) was established in 2004 to capture, maintain, and report all battlefield injury demographics, care, and outcomes for both military and civilian casualties who required inpatient care. 3, 6-8 The JTTR has provided the ability to view and analyze our casualty demographic in ways that were unavailable in prior conflicts. This information in turn has provided the basis for many studies and quality improvement of our combat casualty care. Currently, the JTTR is the only theater trauma registry in use. In the future, the JTTR will be theater specific and relay all trauma data in the master DoD trauma registry (Oral communication, Ms. Mary Spott, July 2011) .
References
1. North Atlantic Treaty Organization. NATO Logistics Handbook. Brussels, BE: Senior NATO Logisticians' Conference, Secretariat, NATO Headquarters; 2007.
2. Rödig E. NATO Joint Medical Support – Reality and Vision. Research and Technology Office, North Atlantic Treaty Organization, RTO-MP-HFM-109. 2004.
3. U.S. Army Institute of Surgical Research. Joint Trauma System. Available at http://www. usaisr.amedd.army.mil/jts.html. Accessed Oct 9, 2011.
4. Holcomb JB. The 2004 Fitts Lecture: Current Perspective on Combat Casualty Care. Journal of Trauma Injury Infection & Critical Care October. 2005;59(4):990-1002.
5. Eastridge BJ, Costanzo G, Jenkins D, et al. Impact of joint theater trauma system initiatives on battlefield injury outcomes. American Journal of Surgery. Dec 2009;198(6):852-857.
6. Beekley AC, Starnes BW, Sebesta JA. Lessons learned from modern military surgery. Surg Clin North Am. 2007 Feb 2007;87(1):157-184.
7. Eastridge BJ, Jenkins D, Flaherty S, Schiller H, Holcomb JB. Trauma system development in a theater of war: Experiences from Operation Iraqi Freedom and Operation Enduring Freedom. Journal of Trauma-Injury Infection & Critical Care. Dec 2006;61(6):1366-1372; discussion 1372-1363.
8. U.S. Army Institute of Surgical Research. Frequently Asked Questions (FAQs) for the Joint Trauma System (JTS) and Joint Theater Trauma Registry (JTTR). https://www.us.army.mil/ suite/doc/21307930&inline=true. Accessed Oct 9, 2011.
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