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April 6, 2020

How to Partner With the Military in Responding to Pandemics—A Blueprint for Success

Author Affiliations
  • 1University of California, San Francisco, San Francisco
  • 2Hartford Healthcare, Hartford, Connecticut
  • 3Uniformed Services University, Bethesda, Maryland
JAMA Surg. 2020;155(7):548-549. doi:10.1001/jamasurg.2020.1227

The rapid emergence and spread of coronavirus disease 2019 (COVID-19) is presenting challenges to medical clinicians not previously encountered in our lifetime. As the US Navy hospital ships are preparing to launch (USNS Comfort and Mercy) and governors are calling for military field hospitals to be used, there are several unanswered questions to be considered, such as who will staff these military installations, who will direct them, and what services will they provide. Many military medical clinicians are currently deployed to Iraq, Afghanistan, and Syria, as well as other areas of the world, and are unlikely to be called back anytime soon. Others will be needed to keep the 54 military treatment facilities (MTFs) open to care for the 9.4 million military beneficiaries and their families. Additionally, as key members of the health care community, military medical personnel will be needed to treat patients with COVID-19 who are seen at MTFs. In 2007, we described the unique partnership developed between the US Department of Defense and several civilian professional surgical societies to assist in the care of combat casualties alongside military medical personnel at the US Army Hospital in Landstuhl, Germany.1 It is now time to consider a similar such program in the US for this and future national emergencies.

The 2017 US National Defense Authorization Act called for the establishment of military-civilian partnerships for the purpose of training and sustaining essential trauma knowledge points and skills for a deployment-ready medical force.2 These partnerships will be funded through the recently passed US Pandemic and All Hazards Preparedness and Innovation Act (also known as the Mission Zero Act).3 For the past 5 years, the American College of Surgeons (ACS), in partnership with the US Military Health System, has been working to define the knowledge points and skills for the combat casualty care team as well as develop the criteria for selecting and evaluating military-civilian partnerships formed to provide this training.4 These blue book criteria, although originally designed for trauma, can easily be adapted to military-civilian partnerships formed to respond to mass casualty incidents or to offload civilian hospitals during crises caused by infectious diseases.5 An example of a combined military-civilian disaster response occurred in Haiti in 2010. The USNS Comfort was deployed to Port-au-Prince with US Navy personnel and civilian medical volunteers to care for the injuries resulting from the earthquake. Over a 40-day period, 927 operative procedures were performed on the ship through this collaborative effort.6

Over the past 2 decades of war, the US Military has provided trauma care to injured troops with the highest recorded survival rates.7 Much of this care is provided by forward-looking medical teams in austere environments, including field hospitals. Thus, it would make sense for military assets to be used in areas of the US hit hardest by the COVID-19, but these military platforms are designed for the care of combat casualties, not infectious disease. On the other hand, a portable military platform that is augmented with civilian medical personnel could offload large civilian trauma centers, freeing up staff, beds, and equipment in those civilian hospitals for the care of patients with COVID-19. The addition of civilian trauma teams to military surgical personnel would also help ensure that MTFs are left with adequate staffing. However, for such a program to be successful, several criteria outlined in the blue book need to be considered.

Institutional Commitment

A formal agreement must exist between the civilian trauma center and the deployed military asset. This agreement would include plans for how military medical personnel would be granted privileges and credentials through the partnering institution as well as coverage for malpractice. These personnel will also need access to the electronic medical record. Federalization of all licenses for the military teams must be granted and there should be an agreement as to how billing for procedures performed at the military asset will be handled.

Governance and Administration

We suggest that the ideal leadership model of these military platforms be flexible depending on the location. A coleadership model, with military personnel reporting to their leadership and civilian personnel to the trauma director, is proposed. Similarly, the trauma program manager must have a military copartner. Patients treated in the military facility would still be entered into the ACS National Trauma Data Bank and the ACS trauma risk-adjusted quality and safety program.

Human Resources

In addition to the 2 directors cited previously, other members of the trauma faculty, as well as trauma specialists in other aligned fields (eg, anesthesia, orthopedics, neurosurgery, emergency medicine, critical care, radiology, and vascular surgery) must support this new trauma care facility and be willing to work within the guidelines outlined for treating these patients. Nurses, advanced practice clinicians, and other allied health professionals should also be included in the plans.

Physical Resources

Once established, the number of patients that can be treated in this temporary trauma facility must be determined. How many operating rooms will be included and how many intensive care unit beds will be available? Other facilities essential to caring for the trauma patient must be close by, such as the blood bank, radiology (radiography, computed tomography scans, and interventional facilities), and laboratory services. Restocking of supplies and surgical equipment should be considered as well. Communication with prehospital personnel is essential so that trauma patients can be delivered to the new temporary emergency facility. There must also be a plan to house and feed military personnel deployed to this location (with the exception of the US Navy ships that are self-contained).


The civilian trauma teams will need an orientation to the facilities provided by the military (eg, ventilators and resuscitation equipment). Conversely, military medical personnel will have to know the trauma protocols and practice management guidelines of the partnering institution. Should the deployed military teams not be previously trained in trauma, the educational program developed through the ACS partnership with the US Department of Defense (the Military Health System Strategic Partnership, ACS) can be used to address knowledge gaps.


A weekly evaluation of the entire program by all involved personnel will be essential to its success. This could be done at the local level or by connecting similar settings nationwide via teleconferencing. These evaluations would include not only trauma patient outcomes, use of resources, lessons learned, and opportunities for improvement but also the success of the partnerships in fulfilling its mission: to enhance the care of patients with COVID-19 by augmenting trauma care.

This pandemic can be viewed as a catalyst to the formation of more permanent military-civilian partnerships. While we are currently in unchartered water, one thing that we do know is that the trauma care provided by US military medical teams is among the best in the world and that partnering with them could mitigate the effect of this pandemic by freeing up beds, equipment, and staff while still responding to the major cause of death in the US: trauma.

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Article Information

Corresponding Author: M. Margaret Knudson, MD, Department of Surgery, Zuckerberg San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Ave, Ward 3A, San Francisco, CA 94110 (peggy.knudson@ucsf.edu).

Published Online: April 6, 2020. doi:10.1001/jamasurg.2020.1227

Conflict of Interest Disclosures: None reported.

Moore  EE, Knudson  MM, Schwab  CW, Trunkey  DD, Johannigman  JA, Holcomb  JB.  Military-civilian collaboration in trauma care and the senior visiting surgeon program.   N Engl J Med. 2007;357(26):2723-2727. doi:10.1056/NEJMsr073207PubMedGoogle ScholarCrossref
US Congress. National Defense Authorization Act for fiscal year 2017. Accessed March 20, 2020. https://www.congress.gov/bill/114th-congress/senate-bill/2943/text
US Department of Health & Human Services. Pandemic and All Hazards Preparedness and Innovation Act. Accessed March 20, 2020. https://www.phe.gov/Preparedness/legal/pahpa/Pages/pahpaia.aspx
Knudson  MM.  A perfect storm: 2019 Scudder oration on trauma.   J Am Coll Surg. 2020;230(3):269-282. doi:10.1016/j.jamcollsurg.2019.11.009PubMedGoogle ScholarCrossref
American College of Surgeons. Military-civilian partnerships for trauma training, sustainment and readiness. Accessed March 20, 2020. http://www.facs.org/military
Walk  RM, Donahue  TF, Stockinger  Z,  et al.  Haitian earthquake relief: disaster response aboard the USNS comfort.   Disaster Med Public Health Prep. 2012;6(4):370-377. doi:10.1001/dmp.2012.67PubMedGoogle ScholarCrossref
Howard  JT, Kotwal  RS, Stern  CA,  et al.  Use of combat casualty care data to assess the US military trauma system during the Afghanistan and Iraq conflicts, 2001-2017.   JAMA Surg. 2019;154(7):600-608. doi:10.1001/jamasurg.2019.0151PubMedGoogle ScholarCrossref
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