New precision medicine tools translate lessons 
learned on the battlefield to civilian health care

CAPT Eric A. Elster, MD, FACS
CAPT Eric A. Elster, MD, FACS

In 2007, the U.S. Department of Defense launched a research study looking at ways to improve outcomes of wounded military personnel. In the decade since, the study has evolved into the Surgical Critical Care Initiative (SC2i), a groundbreaking public-private partnership to translate lessons learned on the battlefield to civilian practice.

“The Surgical Critical Care Initiative stemmed from our experience with wounded warriors coming back from Iraq and Afghanistan in the early days of Operation Enduring Freedom and Operation Iraqi Freedom,” explained U.S. Navy CAPT Eric A. Elster, MD, FACS, professor and chairman, department of surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD.

Dr. Elster will discuss the genesis and current status of the SC2i during Tuesday’s Excelsior Surgical Society/Edward D. Churchill Lecture, Battlefield to Bedside: Bringing Precision Medicine to Surgical Care.

“In the early days of the conflicts, we were seeing a lot of extremity injuries and we observed that, despite these wounds looking good visually and clinically, when we were to close the wounds, a significant percentage of the wounds would fail,” Dr. Elster said. “That suggested there was something going on with these patients that we couldn’t see or measure with the tools we had at hand. So we decided to launch a research study to see if we could figure out what was happening at the molecular level.”

Beginning in 2007, 275 wounded military personnel with extremity injuries were enrolled in the study. Blood samples and wound effluent obtained from each patient were subjected to multiple biologic assays in an attempt to identify biomarkers that could potentially be used to predict outcomes for individual patients.

“As we analyzed more and more data, we made the fundamental observation that it wasn’t just the physically destructive nature of these injuries that set patients up for wound failure. The body’s response to the injury was also intimately related to wound failure and other complications, such as infection and the development of heterotopic ossification,” Dr. Elster said. “We were able to measure that in a relatively high-fidelity fashion and then take that data and use machine-learning algorithms to build models that started to predict outcomes.”

In 2013, the research team submitted a proposal to expand the program beyond the military health system to include civilian institutions and all critically ill surgical patients. The following year marked the official launch of the SC2i, which was designed to develop precision medicine clinical-decision support tools (CDSTs) that will enhance complex decision making in both military and civilian health care systems.

To date, SC2i has enrolled approximately 1,400 patients and has already deployed two CDSTs—one that predicts the likelihood that a wounded service member will develop an invasive fungal infection and another that assesses the need to activate a massive transfusion protocol. Another tool designed to time the closure of traumatic wounds will soon go through an U.S. Food and Drug Administration validation trial.

“These tools are not only likely to substantially improve clinical outcomes, but by virtue of anticipating complications and eliminating the need for additional procedures, save quite a bit of money annually as well,” Dr. Elster said. “In a recently developed white paper, we estimate those savings could amount to up to $10 billion annually across all SC2i tools.”

Other tools now available or in development include models for predicting blood clots, pneumonia, and sepsis. The SC2i consortium also is working to transition the tools from web- and smartphone-based applications to tools that can be embedded in electronic health records. Visit the SC2i website at for more information.

“As we continue to expand and enhance SC2i, one of the many important lessons we’ve learned is that this effort requires surgical leadership,” Dr. Elster said. “When it comes to using these tools and these modeling techniques, surgeons need to be working side-by-side with the basic scientists measuring the biomarkers, and the bioinformatics people and statisticians building the models.”

This lecture is named for the Excelsior Surgical Society, a group of 80 medical officers who met for the first time in 1945 at the Excelsior Hotel, Rome, Italy. The lecture honors Colonel Edward C. Churchill, a famous surgeon and consultant to the U.S. Army in the World War II Italian Theatre, who presented the first keynote address at the meeting.