The foundation of trauma nursing is intricately linked to wartime experiences. Beginning in the era of Florence
Nightingale who is noted to have started the profession of nursing, and continuing up to current day conflicts, military nurses have provided frontline injury care. In an early publication on the role of trauma nursing, Beachley notes that military nurses established the first principles for nursing management of devastating traumatic injuries: triage, rapid evacuation, surgical intervention, stabilization, and early rehabilitation.¹,² As early as the 1800s, there is documentation of the role of trauma nursing in the United States. This was initiated when General George Washington requested at the start of the Revolutionary War that the Second Continental Congress provide for the establishment of “female nurses to attend to the sick.”²,³ In 1901, the Army Nurse Corps was permanently established and at this time it was restricted to women. In 1904 by an Act of Congress, the American Red Cross was reorganized with a provision for a flexible nursing reserve, with chapters in all states who could be mobilized in times of national emergency.³,⁴ In 1908, the U.S. Navy Nurse Corps was established. By the end of World War I, their numbers had increased to 1,286. A total of 2,000 regular Army nurses and 10,186 reserve nurses were on active duty at 198 stations worldwide by June 1918. In World War II, more than 50,000 nurses served in the Army Nurse Corps. There were 200 military nurses killed by hostile fire during World War II and at least three Army nurses were awarded the Distinguished Service Cross, the nation’s second highest military honor. In 1943, the first class of Army Nurses Corps flight nurses graduated from the School of Air Evacuation at Bowman Field, Kentucky and the Air Force Nurse Corps was established in 1949. Captain Lillian Kinkela Keil, a member of the Air Force Nurse Corps, flew more than 200 air evacuation missions during World War II as well as 25 transatlantic crossings. She returned to service during the Korean conflict and flew several hundred more missions as a flight nurse in Korea.⁴,⁵ Important lessons learned from the nurses who were caring for injured patients at altitude, with unique environmental considerations like vibration and noise, helped inform the process of developing civilian air medical transport teams. Models utilizing flight nurses to support civilian health care systems developed successfully from the military model.⁶ In his report titled the
Department of the Army’s Vietnam Studies, Medical Support 1965-1970, Major General Spurgeon H. Neel noted that the Vietnam War witnessed an evolution in trauma and combat casualty care. Progress in medical evacuation advanced the concept of intensive care nursing as a standard approach. This was followed by trauma care specialization and the eventual development of shock/trauma units. Rapid aerial evacuation, rapidly available whole blood, well-established forward hospitals, advanced surgical techniques, and improved medical/nursing management contributed to the prevention of deaths from battle wounds. The hospital mortality rate during the Vietnam War was 2.6% per 1,000 patients compared to 4.5% during World War II.⁶

During the Korean War, the use of helicopters to transport the injured directly from the battlefield to the Mobile Army Surgical Hospital (MASH) units decreased the time from injury to surgical treatment. The MASH units were portable hospitals that were positioned near the fighting zone to allow for prompt treatment of injured soldiers. See Table 2 for key combat advances in care of the critically injured. Resuscitation concepts learned on the battlefield were transferred to civilian health care. Nurses who had served in the military became a lead voice to share the knowledge and skills obtained. The aftermath of the Vietnam War saw the greatest growth in trauma civilian trauma systems. More than 6,000 nurses and medical specialists served in Vietnam including Navy Nurses assigned to the USS. Repose and the USS. Sanctuary Hospital Ships offshore. In addition, nurses were assigned to various ground hospitals including the casualty staging facility, a 50-bed unit which cared for patients awaiting transport to one of the evacuation hospitals.⁷

Nurses continue to play important roles in modern military operations including deployments to Croatia (Operation Provide Promise, 1992) and Somalia (Operation Restore Hope, 1993). Military nurses remain a significant component of the military medical team with sustained efforts to support and care for the wounded in Desert Storm and currently in the service of injured soldiers/civilians in support of the Iraq War through Operation Enduring Freedom.

Virginia “Ginny” Cardona, one of the early leaders in modern trauma nursing, recounts the following reflections on the impact of military approaches being integrated into civilian injury care. Rapid evacuation and transport of injured in Vietnam helped form new roles for nurses in civilian settings like that of the flight nurse. Rapid assessment and triage skills were tested and refined in Vietnam and led to creation of a triage nurse role in civilian care. Cardona also observed that the role of nurses took a slightly different turn in that prevention of complications became highlighted as primarily a nursing role. The experience in Vietnam allowed for better understanding about root causes of mortality from injuries and an appreciation that mortality was often related to sequelae versus the injury itself. This highlighted the imperative role of nurses in vigilant, ongoing assessments and identification of early/subtle changes in the patient’s condition that allowed for early intervention and improvements in outcome. (R.N. Virginia Cardona, personal communications, 2007.)

A natural course of action for many nurses returning from tours of duty as wartime medical support was a gravitation to civilian hospitals receiving injured patients. Ginny Cardona RN recounts that the nurses deployed in the Vietnam War in 1960s brought back the message of “priorities of care” for the injured, that is, rapid assessment, triage, and transport/evacuation. These nurses recognized scars of battle went beyond the physical wounds (posttraumatic stress disorder [PTSD]/psychosocial component) and sought new approaches to manage the devastation caused by sophisticated weaponry. Clinical challenges, like injuries not seen frequently in civilian care (burn injuries, bayonette wounds, mangled extremities, etc.), with innovations in management like replacement of massive blood loss, provision of medications to fight infections, and provision of pain relief, were issues that nurses serving time in Vietnam were instrumental in implementing. The Vietnam War served as an impetus for radical changes in medical approaches to injury. Some of the changes eventually led to new career tracks for civilian nurses such as the initiation of air evacuation medical transport systems staffed with flight nurse. The influences on civilian resuscitation by military clinicians were also dramatic. Hospital-based clinicians had traditionally limited exposure to “catastrophes.” The military nurses offered guidance in the civilian arena to provide care in austere environments. The nurses with military experience often led efforts to improve care of injured through their understanding of the principles of maximizing resources and the importance of quick decision making. These nurses appreciated the importance of a system of care that included effective field triage, initial care, and efficient transport in addition to the definitive surgical care resources. The
early trauma centers at Shock Trauma in Baltimore and Cook County in Chicago were in inner city/urban environments. There were not yet sophisticated diagnostics or blood transfusion, so the development of patient care plans relied primarily on the physical examination and ongoing assessments/monitoring. Military nurses helped to promote the practice of team nursing exemplifying the “can do” attitude. (R.N. Elizabeth Scanlan, personal communications, 2007.)

A key event that would serve as a foundation point in the development of modern trauma care came in 1960 when Dr. R Adams Cowley received a U.S. Army grant to research the effects of shock in the civilian setting. He was able to demonstrate that rapid resuscitation of severely injured patients within an hour of the injury led to a reduced mortality and morbidity. The data generated from close monitoring of patient responses in the final hours before death in the two-bed shock research unit led to the concept of the “golden hour.”

A unique feature of this early shock/resuscitation research unit was a model with dedicated nursing staff who partnered with Dr. Cowley to provide high-level, ongoing clinical assessments and measurements of changing patient conditions. Nurses in this era were a constant presence at the bedside as physician teams were transient. The physician teams had to rely on the keen assessments and judgments of the clinical bedside nurses. Another important milestone in the development of a clinical specialty in trauma came with the establishment of the physician group known as the American Association for the Surgery of Trauma (AAST) in 1938 in the period between World War I and World War II. The AAST provided a physician network to share research and expertise in surgical approach to assessment and management of injuries. As these physicians continued to collaborate with nurse colleagues to optimize care of the injured, the nursing community began to develop pockets of interest in nursing care of the traumatic injuries.

Corpsmen (nursing colleagues/partners) returning from Vietnam played an important role in both the Maryland and Illinois systems. Fifty corpsmen were hired in Illinois to coordinate the activities to assist with hospital readiness for trauma designation, and in clinical care and emergency medical services (EMSs). The corpsmen partnered with eight regional nurses known as trauma coordinators to educate clinicians in Illinois regarding injury management.

Civilian casualties of war are often children, yet the knowledge and skills around the care of injured children were scarce. The nursing profession was again informing the development of trauma care in the United States. Most of the early work in traumatic injury was focused on adults. Yet with the military-trained nurses integrating into civilian health care systems, it was soon recognized that there was scarce pediatric trauma nursing expertise. In 1985, the Department of Defense (DOD) contracted with Margaret Widener-Kokiberg at the Maryland Institute for Emergency Medical Services (MIEMSS) in Baltimore and Children’s National Medical Center in Washington, D.C. to develop pediatric trauma standards and to help grow the knowledge base. (R.N. Margaret Widener, personal communications, 2007.)

In 1979, the civilian military contingency hospital system was conceived in anticipation of the number of casualties that might occur if another large conflict arose. Military planners realized that military hospitals did not have capacity to receive wounded from combat, so partnerships with civilian hospitals would be required for clinical care and education. Several nurse leaders including Peggy Trimble and Carole Katsaros Briscoe from Maryland’s system went to the Pentagon to meet with leaders in the civilian military contingency hospitals offering to support training needs. Their proposal was based on the MIEMSS Field Nursing model that originated in Maryland. This led to nurse participation in the Disaster Management Assistance Teams (DMAT) that were part of the U.S. Public Health Service.⁸

In 2000, through the efforts of air force nurse Lt. Col. Annette Gablehouse, United States Air Force (USAF), the military surveyed the country’s large university-based centers with high volumes of critically injured patients for the potential of serving as training sites for military personnel pending deployment in an immersion experience. The Center for the Sustainment of Trauma and Readiness Skills (CSTARS) program was formed for this purpose and continues to be co-led by military nurses based at civilian hospitals who coordinate the incoming military personnel training before deployment for active duty.

Trauma nursing as a specialty was initiated in the United States at the Shock Trauma Center of the University of Maryland at Baltimore and at Cook County Hospital in Chicago. The first known/titled shock trauma nurses were Elizabeth Scanlan, RN and Jane Tarrant, RN who pioneered the role in a two-bed shock/trauma research center with Dr. R Adams Cowley in Baltimore, the first of its kind to support the study of trauma. Nurses in this unit were doing sophisticated patient physiologic monitoring, which was translational research in its infancy (see Fig. 1). It is clear from the personal interviews with pioneering trauma nurses that there was a sense of pride, pioneering spirit, and the gravity of understanding that what they were doing had never been done before and would impact future practice. Scanlan and Cowley were early examples of the high-level physician and nurse collaboration/coleadership with equal responsibility in the mission of providing care and developing a system. This interdisciplinary leadership remains the ideal in trauma carepresently.

In March 1966, under the direction of Dr. Robert Freeark and Norma Shoemaker, RN, the trauma center
at Cook County opened. In this model, injured patients coming to Cook County bypassed the ED and went straight to a specialty trauma/resuscitation unit. In 1970, the Illinois legislature funded development of a trauma system. In 1971, Terry Romano, RN was hired as the first trauma nurse coordinator to direct education for nurses working in the developing Illinois trauma system. Dr. David Boyd and Terry Romano, RN together played a critical role in developing trauma care systems in the United States. Using medical corpsmen in a civilian setting, Dr. Boyd deployed these personnel, paired with nurses, to the hospitals that were going to be designated in the newly developing Illinois trauma system. Romano developed a Trauma Nurse Specialist (TNS) Course and based the curriculum on concepts that Norma Shoemaker had implemented in nursing practice at Cook County. (R.N. Teresa Romano, personal communications, 2007.) This curriculum was published in the American Journal of Nursing in 1973 and is one of the earliest articles outlining the role of the trauma nurse.

These nurses were titled trauma coordinators and each was assigned to one of the regional trauma centers in Illinois to teach the TNS Course. The corpsmen were recognized as some of the early precursors to the trauma coordinator role. Dr. Boyd and Terry Romano developed trauma center criteria, and in 1 year reviewed and designated 50 hospitals as trauma centers. The work in Illinois was the model for preparing distinct areas in the hospital for critical patients and initiating priority admission processes for multisysteminjured patients in EDs (see Table 4).

Cohorting of patients was a key factor leading to specialization/expertise in trauma and surgical critical care nursing. In a 1986 publication, Beachley noted that a need for a specific body of knowledge for trauma nursing was first recognized and documented in the landmark report: Accidental Death and Disability: The Neglected Disease of Modern Society.⁹ This specific body of knowledge for trauma nursing included the human physiologic and psychological responses to traumatic injury, a relationship of mechanism of injury to severity of injury, complexity of the therapeutic regimen for the multiply injured patient, and the importance of restoration of body function. Pioneers like Boyd and Cowley modeled the approach of dual physician-nurse leadership to promote trauma program/system development. In 1970, under the leadership of Dr. Cowley and Elizabeth Scanlan, RN, a National Institute of Health (NIH) grant-funded program (with state matching funds) was started with the opening of the Center for the Study of Trauma at MIEMSS that included a 12-bed shock trauma/critical care unit. Dr. Philip Milatello (attending physician) remembers that this unit allowed trauma nursing to become a specialty and a career, preceding the development of trauma surgery. Nurses became observers and analysts with their physician colleagues in an unprecedented way. (M.D. Philip Milatello, personal communications, 2007) Shortly after this came the release of the American College of Surgeons,’ Resources for Optimal Care of the Injured Patient in 1976. This document outlined for the first time the essential resources required for facilities to provide comprehensive trauma care, and also the importance of data systems to track/analyze trauma patient care. Several key movements in trauma care/systems originated on the west coast of the US. San Diego and Los Angeles counties were two of the early areas that truly regionalized injury care and studied the impact of this approach. In addition, nursing specialty roles like that of Trauma Nurse Practitioner were first seen at the Harborview Medical Center in Seattle, Washington and at Oregon Health Sciences University Hospital in Portland. These early models created a strong foundation for a very robust role for Advanced Practice Nurses in Trauma.