Trauma Surgeons Warn Civilian Systems Lack Readiness

The ACS Committee on Trauma (COT) 2025 Annual Meeting convened jointly with the Advanced Trauma Life Support^® (ATLS^®) Global Symposium, March 12–16, in Chicago, Illinois, offering inspirational stories and best practices, as well as warnings about a changing geopolitical landscape.

More than 700 participants from 45 countries attended. The COT Annual Meeting, which is open to COT members only, recognized the 10th anniversary of the Future Trauma Leaders (FTL) Program, an initiative that provides in-depth training and mentoring opportunities for early career trauma and acute care surgeons. The ATLS Global Symposium, which expanded this year to 2.5 days of programming, focused on the launch of the ATLS Course Manual (11th edition), with sessions providing best practices for trauma education from around the world.

Role of Civilian Trauma Centers during Military Conflict

In addition to central and regional COT updates, 15 Spotlight Discussions were presented with the goal of enhancing collaboration and eliciting feedback on topics, including prehospital blood protocols, pediatric trauma, injury prevention, and National Trauma Emergency Preparedness System (NTEPS) development.

This year’s Special Session, “A Bias for Action: Preparing the US Healthcare System for Large-Scale Combat Operations (LSCO),” was inspired by a Spotlight Discussion from the COT meetings held during the 2024 Clinical Congress. It addressed the critical role civilian trauma centers will play in managing modern warfare-related injuries. Conflicts with peer or near-peer adversaries could result in a substantial number of casualties during the initial phase, with estimates suggesting the repatriation of 1,000 to 3,000 casualties to the US per day for the first 100 days of combat.

“Our civilian beds will be overwhelmed fairly quickly if this happens—and not just trauma beds,” said session moderator Jeffrey D. Kerby, MD, PhD, FACS, Chair of the ACS COT. “When you look at hospital capacity across the country, the total capacity of Level I trauma centers is 17,000 beds a day—so 1,000 patients a day returning to the US means we have 17 days of capacity,” he added, noting that the US trauma system would still need to maintain care for civilian patients as well.

US Army Colonel (retired) John B. Holcomb, MD, FACS, a professor of surgery at The University of Alabama at Birmingham and the Uniformed Services University of the Health Sciences in Bethesda, Maryland, noted that—until now—virtually all military combat events resulted in expected injury patterns, including extremity, truncal, junctional, head, burn, and psychological—depending on the setting (urban, rural, sea, and trench).

New warfare-related injury patterns, including hyperbaric- and hypersonic-related injuries, are now being reported from Ukraine, said Dr. Holcomb, with larger numbers of tympanic membrane (TM) injuries in survivors, likely a result of blast overpressure.

“If it’s enough blast overpressure to rupture the TM, they probably have an injury to their brain as well,” suggested Dr. Holcomb. He also described an increase in amputations and renal failure cases related to extremely prolonged evacuation times, due to limited, if any, air evacuation options.

Citing observations from colleagues recently or currently deployed in an LSCO situation, Dr. Holcomb said that combat has shifted from artillery to drone use. “It’s a different war. Even within the last 18 months—this has turned into a drone war. Unfortunately, any kind of electronic warfare countermeasures don’t work because some of these drones are controlled by fiber-optic cable.”

Paraphrasing something he heard from a young major on the front lines, Dr. Holcomb explained that if a drone can see it, a drone can kill it. “There is something known as ‘clearing the battlefield’ for the medics, a military practice since at least the Civil War. But today, if you clear the battlefield, and you’ve got a drone up there observing with medics moving the severely injured—you’ve just created more deaths,” he said.

Drones also are deployed to attack military aid stations, which provide initial medical care to the wounded, and the Forward Surgical Team units, which offer more advanced mobile surgical care closer to the front lines.

“Imagine a drone flying into your forward surgery team tent and blowing up inside—this can easily be done with these devices.  The answer is to go underground. It’s a World War II message,” Dr. Holcomb said, referring to the necessity of building subterranean healthcare facilities in combat zones to keep patients and physicians safe. 

Preparing to effectively manage patient care within the scale of contemporary warfare also will depend on a national trauma care infrastructure—specifically NTEPS 2.0—with the capacity to care for large numbers of conflict casualties on a daily basis.

“In 20 years of war in southwest Asia, there were roughly 50,000 wounded heroes—20 years, 50,000 wounded heroes in an LSCO. Today, with estimates of the repatriation of at least 1,000 casualties per day to the US, we will have 50,000 wounded heroes is just 50 days,” said John H. Armstrong, MD, FACS, Chair of the ACS COT Advocacy Pillar, chair of the US Defense Health Board’s Trauma and Injury Subcommittee, and a retired US Army colonel.

A regionalized system of care is essential for wide-scale disaster preparedness, noted Dr. Armstrong, as evidenced by the healthcare profession’s response to the COVID-19 pandemic. During this public health emergency, trauma surgeons and emergency medicine physicians helped establish Regional Medical Operations Coordination Centers (RMOCCs) in their states and regions to facilitate resource distribution alignment with emergency medical services, healthcare systems, and other agencies.

The five core elements of NTEPS 2.0, which are part of the request to the US Congress to establish a national trauma system, include public health readiness, standards, performance improvement, research, and public outreach.

“We should not be despondent. We have a good story to tell, and we need to leverage all the vehicles of advocacy to ensure Congress establishes NTEPS. The clock is ticking,” Dr. Armstrong warned.

The sessions also included presentations describing the challenges related to transitioning civilian hospitals to treat severe trauma during the LSCO in Ukraine; an overview of the National Disaster Medical System Pilot Program; and an outline of the National Academies and RMOCCs Action Collaborative.

Building High-Functioning Trauma Systems

A session on “Improving Trauma Systems during Challenging Times” featured three panels addressing universal challenges associated with building and maintaining high-functioning trauma systems, including protracted conflicts, global pandemics, and limited healthcare funding.

The first panel, “Conflict and Trauma Systems—The Intersection of Improving Care for Those Injured in Conflict and to Develop Trauma Systems for Civilians”—outlined the importance of battle injury data and registries, which help drive innovation and implementation of new policies and procedures that ultimately improve patient care.

Jeffrey A. Bailey, MD, FACS, a professor of surgery at Washington University in St. Louis, Missouri, and a retired US Army colonel, spoke specifically about the evolution of Joint Trauma System (JTS) data. “This is the secret sauce of the JTS: delivery of trauma care, input that data into a registry, analyze the data, and then through process improvement, develop best practices. It’s pretty simple.”

US Army Colonel (retired) Brian J. Eastridge, MD, FACS, a professor of surgery at The University of Texas Health Science Center at San Antonio and Medical Director of the Military Health System Strategic Partnership ACS, described what a large-scale combat involving the US could look like in the future.

“Tomorrow's war is going to be much different. We're expecting LSCO with a near-peer adversary, which is something we haven't done in 75 years,” he said. “It's going to be fought in multiple domains that we haven't been in in the last several years, including the addition of sea, space, and cyber. And there is going to be an imminent threat to your home.”

Another key difference regarding LSCOs of the future is lower numbers of military physicians and surgeons.

“Are we prepared as a medical community?” asked Dr. Eastridge. “I think the answer is actually no. If you look at World War II, they started off with about 1,500 physicians and 500 surgeons. By the end of 1945, there were 55,000 physicians in the military. Today, we have about 500 surgeons in the US military. Even if they were to deploy all the active duty and all the reserve component, that's still not enough physicians.”

The remaining two panels featured a townhall format with panelists addressing questions posed by the audience, sparking thought-provoking discussions on a variety of trauma care topics. In “Success in Adapting EMS Systems,” the speakers outlined their biggest successes in prehospital care, including getting whole blood out into the community. They also described the importance of viewing EMS team members as clinicians and highlighted challenges, including low compensation and high turnover.

The “Show Me the Money/Advocacy for Trauma System Funding” panelists outlined how the ACS prioritizes its advocacy efforts, offered best practices for taking on an advocacy-related role, and summarized College resources, such as SurgeonsVoice and Action Alerts, that help members engage with lawmakers at state and federal levels.

For more information about the COT Annual Meeting, visit The House of Surgery podcast web page and listen to episode 59 (dropping in mid-April).

Recommendations for Successful ATLS Promulgation

The 2025 ATLS Global Symposium drew course directors, instructors, site coordinators, and others to the meeting, which featured sessions on the ATLS 11 revision, developing trauma education simulations, and other programming, as well as the “Fostering Successful Global ATLS Programs” session that described best practices for overcoming challenges to successfully promulgate the ATLS course.

The panel of international ATLS instructors included Mentor Ahmeti, MD, FACS, Geoffrey Anderson, MD, MPH, FACS, Samir Ballouz, RN, BSN, MSc, IHM, Christopher M. Dodgion, MD, MSPH, MBA, FACS, and Adam Goldstein, MD.

Each panelist offered their perspectives on teaching the ATLS Course in areas with limited resources or in regions experiencing military conflict, including Ukraine, Israel, Lebanon, Kosovo, and sub-Saharan Africa. Notably, almost half of the ATLS courses offered annually take place outside the US and Canada, and the global trauma education community participates in all aspects of course design and content updates.

In lieu of formal presentations, panelists responded to questions posed by Dany Westerband, MD, FACS, the session moderator.

“There are a lot of physicians in Ukraine who don't do trauma in their daily lives, and they were getting flooded with trauma patients,” said Dr. Anderson, when asked about his experiences with bringing ATLS to the eastern European country. “The need was immediate and urgent, and so we put together a suite of courses, including the flagship ATLS Course—which they asked for by name.”

Dr. Anderson worked closely with the Ukraine Ministry of Health and the ACS COT starting in 2022 to overcome logistical barriers in order to offer the course to physicians in Ukraine. He traveled to Ukraine from Boston, Massachusetts, with a team of US physicians to teach ATLS, offering critical knowledge and skills to those who likely would be treating trauma patients.

Working in tandem with Tamer Jreis, MD, Dr. Goldstein also provided ATLS training in a region experiencing severe military conflict. They bring Israeli and Palestinian physicians together to engage in ATLS training through a program called Operating Together.

“We started Operating Together 3 years ago,” explained Dr. Goldstein. “We brought 10 Israelis and 10 Palestinians together for the ATLS courses. And even during the war, we've managed to do seven courses now. There have been many challenges, as you can imagine, but ultimately, it’s about community. It's about looking above everything that we see on social media and in politics. It’s about humanity. ATLS really is the perfect building block to number one, improving trauma care, and then secondary, which is no less important, building the community.”

Dr. Goldstein also described the logistical challenges of organizing the courses, including the long distances (30-40 kilometers) that Palestinian physicians would have to travel to attend the course. With early morning travel start times combined with long travel distances, physicians were arriving exhausted before the intensive training session started. To remedy this, Palestinian physicians were invited to arrive the night before the course.

“The idea is that eventually there will be a sustainable Palestinian trauma system,” Dr. Goldstein said, underscoring the tenacity and courage of the physicians taking the ATLS Course, given the tensions in the region impacting everyone.

“During the war, as you all can imagine, the television is on everywhere, and everyone is on their phones getting alerts,” said Dr. Goldstein. “The bravery, and what everyone is going through, on both sides in the most extreme situation, while simply focusing on improving trauma care—that’s it. Nothing else comes up. And that is extraordinary because everyone has been affected by the war.”

A notable discussion topic addressed during the session centered around advice for individuals or organizations that are considering promulgating the ATLS Course.

“The key to success is identifying and establishing relationships with your local champions and making sure that you have the leadership on board to support the course,” said Dr. Dodgion. “If you don’t know people in the area, contact the COT Region Chiefs. The programs that we promulgated in Ethiopia and Rwanda wouldn't have been successful without the immense support of Region 17. For both courses, we had ongoing support from the region after initial promulgation.”

A recap of the 2025 ATLS Global Symposium is featured in episode 58 of the The House of Surgery podcast.

The 2026 COT Annual Meeting and ATLS Global Symposium will be held March 11–15, in Birmingham, Alabama.

Tony Peregrin is the Managing Editor of Special Projects in the ACS Division of Integrated Communications in Chicago, IL.