Trauma is the leading cause of death for Americans between the ages of one and forty-four. In this age group, trauma claims more lives each year than cancer. Despite its impact, trauma research receives only a small portion of federal biomedical funding. The National Institutes of Health allocates approximately three percent of its support to trauma, a percentage that has remained largely unchanged for decades.
In the United States, this funding imbalance has shaped the understanding and treatment of trauma. Policymakers and institutions have often treated trauma as sudden and unavoidable. It is commonly framed as an accident or an isolated act of violence rather than the outcome of system design. As a result, trauma care has historically been reactive rather than strategic.
That perspective is beginning to shift.
Across both military and civilian medicine, leaders are increasingly viewing trauma care as a measure of national preparedness rather than solely as an emergency response. The way a medical system performs during moments of extreme stress now serves as an indicator of its overall resilience. Trauma care has become a test of whether systems can function effectively when conditions are unpredictable and resources are strained.
At the center of this shift is Dr. Martin A. Schreiber, a trauma surgeon whose career has included extensive experience in United States combat hospitals overseas as well as in some of the highest acuity civilian trauma centers in the country. His work reflects a broader reassessment underway in American trauma care. That reassessment treats preventable death not as an unavoidable outcome, but as evidence of system failure.
The goal that has emerged from this reevaluation is simple to describe and difficult to achieve. The objective is zero preventable trauma deaths.
A System Built for Stability
Modern American trauma care developed primarily during periods of peace when high acuity trauma was not occurring on the battlefield resulting in rapid advances. Surgical training programs were structured around predictable patient volumes, and hospitals were designed to prioritize efficiency, throughput, and cost control. Trauma teams became highly effective at managing high acuity trauma in high volumes, but in general, they do not manage mass casualties secondary to high powered weapons seen on the battlefield over and over again.
In contrast, military providers become expert providers during times of conflict but most military treatment facilities do minimal amounts of trauma care during peace time. Over time, this phenomenon produces what military planners refer to as the Walker Dip. Clinical readiness declines when surgeons and trauma teams do not regularly treat complex and severe injuries. Skills gradually erode, team coordination weakens, and decision-making under extreme pressure becomes less intuitive.
For the military, the consequences are immediate and significant. Combat surgeons cannot maintain readiness without consistent exposure to real trauma cases. For civilian hospitals, the effects are less visible but equally serious. Trauma care remains technically competent, but it becomes increasingly fragile when confronted with large-scale or prolonged crises.
This gap in readiness does not result from individual failure. It reflects a structural limitation in the system’s design and it highlights the potential benefits of military, civilian partnerships.
When Data Challenged Doctrine
For more than fifty years, trauma care followed a fixed sequence of priorities. Clinicians were trained to secure the airway first, support breathing second, and address circulation third. This approach, known as the ABC framework, was taught universally and rarely questioned.
The logic behind this sequence was straightforward. Without oxygen, a patient cannot survive.
That certainty began to erode as modern battlefield medicine generated large amounts of outcome data. Military physicians treating combat injuries observed a consistent pattern across conflicts. Airway failure did not cause the majority of preventable deaths. They resulted from uncontrolled bleeding.
As Dr. Martin Schreiber has emphasized in his research, exsanguinating hemorrhage represents the most common cause of preventable death following trauma. Severe bleeding can cause death within minutes especially if stopping bleeding is not the immediate focus of the provider. Often, patients arrived with a clear airway and ongoing respiration, yet they died because blood loss was not controlled early enough and airway was prioritized over bleeding. Intubating a patient and placing them on positive pressure ventilation can worsen shock and result in cardiac arrest.
Experience on the battlefield caring for innumerable casualties with lower extremity injuries from improvised explosive devices like Dr. Schreiber and thousands of others received, resulted in a shift from focusing on the airway first to stopping bleeding. This was especially true when patients had no evidence of injury above the abdomen.
This evidence forced clinicians to reconsider long standing priorities. Researchers reintroduced and extensively studied tourniquets, which had previously faced skepticism due to concerns about limb damage. Researchers found that tourniquets effectively stopped life threatening bleeding and significantly improved survival. Hemostatic dressings designed to accelerate clotting produced similar benefits.
By the middle of the 2010s, military trauma protocols formally changed. The new sequence ultimately became known as MARCHPAWS. The letter M refers to massive hemorrhage. Under this approach, clinicians control life-threatening bleeding before addressing airway management, breathing support, or circulation.
Civilian trauma systems adopted this change more slowly. Long-established training models and institutional practices are difficult to revise. However, by 2024 and 2025, a broad body of research from civilian and military-aligned studies reached the same conclusion. When clinicians prioritize hemorrhage control first, mortality decreases in both combat and civilian trauma settings. The civilian algorithm was changed from ABC to x-ABC with the x standing for exsanguinating hemorrhage.
No single study defines this transition. Instead, the conclusion emerges from consistent findings across trauma surgery, emergency medicine, and large-scale outcome research. The sequence of care directly influences survival and highlights how bidirectional information transfer between military and civilian counterparts enhances care moving toward zero preventable deaths in both settings.
This shift has begun to reshape civilian emergency response. First responders now routinely carry tourniquets as standard equipment. Bleeding control training is taught not only to medical professionals but also to civilians in schools, workplaces, and public spaces in a course called Stop the Bleed. In modern trauma care, clinicians focus first on stopping life-threatening blood loss before it becomes irreversible.
Integration as Infrastructure
Once trauma leaders recognized the value of battlefield lessons, a practical challenge emerged. Military medicine needed a way to sustain hard-earned knowledge during peacetime, and civilian systems needed access to that experience without becoming militarized.
The solution took the form of integration.
Through the Army Military Civilian Trauma Team Training program, known as AMCT3, fully trained military trauma teams are embedded in high-volume civilian trauma centers for extended rotations. The program has been significantly shaped by the leadership and military civilian partnerships advanced by Dr. Martin Schreiber. Surgeons, nurses, medics, and technicians train together in real clinical environments, gaining experience through sustained exposure to complex trauma cases rather than relying on simulations.
The first AMCT3 team on the west coast was embedded at Oregon Health & Science University in Portland in 2019 and led by Dr. Schreiber. This team consisted of a surgeon, emergency medical doctor, emergency room nurse, ICU nurse and certified registered nurse assistant. Since that time additional trauma surgeons, a cardiac surgeon and operating room technician have also been embedded. Military teams consisting of operating room technicians, licensed practical nurses and combat medics have also rotated through this program in one of the highest acuity trauma environments in the country. The program emphasizes team readiness rather than individual performance. Teams prioritize effective communication, clearly defined roles, and swift decision-making during time constraints.
For the military, civilian hospitals provide patient volume that peacetime military treatment facilities cannot offer. For civilian systems, military teams bring experience managing mass casualties, operating in resource-constrained environments, and executing protocols with precision.
The outcome is not a blending of professional identities. Instead, integration strengthens the overall system. Trauma care functions as infrastructure rather than isolated heroics or individual expertise. Coordinated readiness replaces episodic response.
Preparing for Systemic Shock
Military planners increasingly describe the future in terms of large scale combat operations. This concept extends beyond traditional warfare. It includes pandemics, natural disasters, and mass-casualty events in the United States.
In these situations, civilian hospitals serve as the backbone of the national medical response. Whether formally designated or not, they function as the fourth echelon of military medicine by absorbing large volumes of critically injured patients.
Despite this reality, trauma research remains fragmented. Funding is dispersed across agencies and disciplines, and no centralized institute within the National Institutes of Health focuses exclusively on trauma science.
Dr. Schreiber and other trauma leaders have warned that this fragmentation creates strategic risk. When research efforts lack coordination, lessons learned in combat settings reach civilian practice too slowly. During high acuity military conflicts, advances in trauma care are largely made by combat medical experience. However, during interwar periods, civilian medicine has to be responsible for medical advances. By integrating civilian and military programs, advances in care can be advanced in both realms and the Walker Dip can be mitigated.
The consequences of not invoking military and civilian integration are devastating. Preventable deaths accumulate not because solutions are unavailable, but because systems fail to absorb and apply them at scale.
Rethinking Readiness
After more than thirty years in trauma surgery, Dr. Martin Schreiber now focuses less on innovation and more on structure. He argues that administrative boundaries separating military and civilian medicine do not reflect clinical reality.
Trauma does not distinguish between war and peace, and it does not recognize institutional categories. A system designed to treat trauma must therefore prioritize continuity rather than separation.
Mission Zero is not a slogan. It serves as a benchmark that frames preventable death as evidence of system failure rather than individual error. Readiness does not exist as a fixed achievement attained through occasional training. It requires a continuous process supported by exposure, integration, and accountability.
The Golden Hour, long treated as an unchanging concept, is now understood as flexible and dependent on early decisions, coordinated teams, and shared standards rather than technology alone.
The central question facing American trauma care is no longer whether zero preventable trauma deaths is achievable.
The question is whether the system is willing to organize itself as if that goal truly matters.
