Discover the Most Common Surgeries in Military Hospitals

Continuous surgical volume allows emergency department (ED) physicians to maintain, enhance, and refine critical lifesaving skills. Due to the location and patient population of military medical institutions, the surgical volume in these facilities is not high. Although literature does not specify the exact surgical volume needed to achieve proficiency, the Accreditation Council for Graduate Medical Education (ACGME) in the United States has set minimum requirements for resident physicians to graduate. There are few related studies, and even fewer targeting ED physicians. Research on surgeons indicates that higher surgical volume correlates with better treatment outcomes. Limited studies on military medical personnel show a discrepancy between the surgical volume of military ED physicians and actual needs. This study further reflects the overall low surgical volume and significant differences in the types of surgeries across various medical institutions.

Most military personnel are young and healthy, resulting in fewer emergency cases in military medical institution EDs, which in turn leads to fewer required emergency procedures. Despite the downsizing of military forces in Iraq and Afghanistan, the harsh environments and increasing demand for prolonged battlefield care necessitate that medical personnel be proficient in trauma care skills. Regular reassessment of surgical volume in military medical institution EDs is crucial for testing and maintaining necessary clinical battlefield skills.

Data on emergency surgeries closely related to trauma care from the EDs of seven Army medical institutions between 2014 and 2016 were collected. These procedures included airway surgery, central venous catheterization, and intubation. The seven medical institutions were Evans Army Community Hospital (EACH), Irwin Army Community Hospital (IACH), General Leonard Wood Army Community Hospital (GLWACH), Bayne-Jones Army Community Hospital (BJACH), Brooke Army Medical Center (BAMC), William Beaumont Army Medical Center (WBAMC), and Carl R. Darnell Army Community Hospital (CRDACH).

During the survey period, these institutions performed a total of 1,450 procedures, including 973 intubations, 473 central venous catheterizations, and 4 airway surgeries. The annual average for intubations and central venous catheterizations was 69.5 and 38.8, respectively. Approximately 40.5 intubations and 19.7 central venous catheterizations were performed monthly. Most of these procedures were conducted by BAMC. Excluding BAMC, the annual average for intubations drops to 28.1, and for central venous catheterizations, to 13. All four airway surgeries were performed by BAMC.

The survey revealed significant variation in surgical volumes across the seven medical institutions over two years. Opportunities for medical personnel to practice surgical skills in the EDs of different Army medical institutions vary greatly.

Compared to previously published data, BAMC and BJACH (the two institutions with publicly available data) showed a significant increase in the number of intubations, while the number of central venous catheterizations remained stable, and the number of airway surgeries decreased.

Junior ED physicians require more procedures to maintain their skills compared to more senior ED physicians. Most military ED physicians are junior, young, and inexperienced, generally leaving for civilian practice after completing four years of initial service. During missions, younger doctors are typically deployed to front-line positions, while more senior doctors take on leadership roles. Although the relationship between maintaining surgical skills and surgical volume is not clear, deploying inexperienced and under-trained young doctors in relatively isolated military operations is a concern.

Most surveyed medical institutions did not perform a single airway surgery in two years, highlighting the challenges of maintaining clinical skills due to low surgical volume. In contrast, 97% of civilian hospitals perform corresponding airway surgeries annually. Navy hospitals face similar issues. Military medical departments should consider measures such as allowing medical personnel to work in civilian settings to increase surgical volume.

Since 1996, BAMC has been able to accept civilian trauma patients, who are usually uncommon in military medical institutions. Although this model may not be fully replicable for other military hospitals.

According to Defense Health Agency directives, the number of non-combat medical specialties (obstetrics, dermatology) is being reduced, which will increase the opportunity for ED physicians to see non-emergency patients, but may also result in fewer surgeries. Additionally, a relatively large number of Physician Assistants (PAs) working in pre-hospital battlefield environments perform procedures similar to those of ED physicians in this study. ED physicians have low surgical volume, and PAs have even less, raising concerns about their clinical readiness in harsh environments.

This study is based on surgical codes, but some procedures may not have been recorded, leading to incomplete data.

Furthermore, military ED physicians also participate in deployment missions. Even without considering deployments, their surgical volume is insufficient. The study did not account for military medical personnel working part-time in civilian settings outside their official duties, but this likely would not make a significant difference.

The survey of seven military medical institution EDs over two years revealed low surgical volumes and significant differences in surgical volumes between institutions. Insufficient surgical volume may affect the maintenance of clinical trauma care skills. Future research should clarify the relationship between surgical volume and skill maintenance and propose the necessary surgical volume for each military ED physician to maintain clinical readiness skills.