C3 Global Trauma Network: Cape-Colorado-Combat 

Picture of HEET TeamThe C3 Global Network aims to conduct innovative trauma care research predominantly in international settings, to answer questions regarding optimal trauma care that are both globally needed, and locally relevant.

Through the support of federal and foundation research grant funding, we employ rigorous and contemporary approaches and clinical trial design, implementation science, and patient-level outcome research.

While the C3 network has a core of military-relevant combat trauma research activities in the Western Cape area of South Africa, we perform work in other relevant global health settings including places like Kenya, Ethiopia, and Ghana. We collaborate closely with local stakeholders and partners including ministries of health, EMS agencies, universities, and health institutions.  

Our Team

Period Title Funding Agency: Brief Description
2020-2024Epidemiology and Outcomes of Combat-Relevant Prolonged Trauma Care: a Prospective Multicenter Prehospital Study in South AfricaUS Department of DefenseThe overall objective of this proposal is to conduct an epidemiologic trauma study to assess the effect of time and early resuscitation on morbidity and mortality of trauma patients in the Western Cape Province of South Africa. There will be 10 research sites and about 30,000 patients enrolled. Findings will help fill civilian and military scientific gaps in trauma care and help strengthen the trauma care system in the Western Cape of South Africa.
2019-2021 Establishing the Epidemiology and Outcomes of Combat-Relevant Prolonged Trauma Care: a Prospective Multicenter Prehospital Pilot Study in South Africa. The Office of the Assistant Secretary of Defense for Health Affairs, through the Defense Medical Research and Development Program
The overall objective of this proposal is to conduct a pilot study that will directly inform a future large-scale (primary) study to prospectively describe the outcomes of patients with combat-relevant injuries in an austere setting that features a high prevalence of penetrating injuries and long durations of field care.
2018 – 2020 A Quasi-Experimental Trial of Pre-Hospital Bundled Care to Improve Outcomes in Hemorrhagic Shock NIH, Funding Institute is NHLBI.Measure pre-hospital quality of traumatic shock care due to bundled versus non-bundled shock care.
Assess in-hospital clinical outcomes due to bundled versus non-bundled pre-hospital shock care.
2018-2020 Implementing an Evidence-Based Bundled Trauma Care Intervention (‘EMS-TruShoC’) to Reduce Heart, Lung, and Blood Organ System Failure in Resource-Limited Settings. NIH NHLBI K12 IMPACT (Implementation to Achieve Clinical Transformation (IMPACT): The Colorado Training Program) The overall purpose of this proposed research is to scale-up an evidence-based trauma intervention, termed Emergency Medical Services Traumatic Shock Care (EMS-TruShoC), in a resource-limited setting.
2018-2020 ‘EMS-TruShoC’ – A Prospective Trial of Low-Dose, High-Frequency, On-Site Training to Improve Trauma Field Care in Austere Settings. Defense Health Agency (J9, Research and Development Directorate; US Department of the Air Force (59th Medical Wing) EMS-TruShoC is a promising low-cost, high-impact, pragmatic solution for training of US Air Force, military, and civilian medics in resource-limited and remote settings, mirroring the austere combat environment with an emphasis on prolonged field care. This project seeks to implement EMS-TruShoC in an austere setting, and assess the resultant educational and clinical outcomes.
2018 Carnegie Africa Diaspora Program Fellowship Carnegie Corporation of New York Mini-grant to support travel and presentation to an academic conference
2017-2019 Implementation of a Novel Prehospital Shock Care Intervention in a Resource Constrained African Setting. Emergency Medicine Foundation (EMF)The goal of this study is to formally develop an innovative prehospital shock trauma care (training) intervention to improve recognition and management of shock, then implement the package in an emergency medical services (EMS) system in South Africa while assessing implementation outcomes.
2017-2018 Improving the Quality of Prehospital Traumatic Shock Care in Resource-Limited Settings Falck FoundationThe goal of this study is to conduct a pilot intervention to assess the feasibility of implementing a novel educational on-site training program (EMS-TruShoC), and assessing educational outcomes, in a resource-limited ambulance station in the Western Cape Province of South Africa.
2017-2018 Improving Early Traumatic Shock Care in Resource Limited Settings (Validation of a Quality of Traumatic Shock Care Chart Abstraction Instrument) University of Colorado, Department of Emergency Medicine (Pilot Grant) Validating A Novel Instrument to Quantify Prehospital Traumatic Shock
2014-2015 Epidemiology and Inpatient Management of Patients Hospitalized for Acute Asthma: 37th Multicenter Airway Research Collaboration (MARC-37) Study Novartis to the Massachusetts General Hospital Characterizing Hospitalized Asthma Patients To Determine Concordance Of Their Inpatient Care With National Asthma Guidelines, And To Characterize The Post-Hospitalization Asthma Care.
2014-2015 Assessing the Effectiveness and Outcomes of an Emergency First Aid Responder (EFAR) System Carnegie Corporation of New York Studying the Effectiveness and Outcomes of the EFAR Program in Western Cape, South Africa.
2014-2015 Assessing the Effectiveness and Outcomes of an Emergency First Aid Responder (EFAR) System University of Colorado, Department of Emergency Medicine (Seed Grant)studying the effectiveness and outcomes of the EFAR program in Western Cape, South Africa.
2012-2013 Emergency Medical Services (EMS) Assessment of Ashanti Region, Ghana NIH Fogarty International Center Conducting a mixed-methods regional EMS system assessment.
  1. Mould-Millman CNK, Sasser SM, Wallis LA. “Prehospital Research in Sub-Saharan African: Establishing Research Tenets.” Academic Emerg Med. 2013. Volume 20, Issue 12, pages 1304–1309, December 2013. PMID: 24341586
  2. Mould-Millman CNK, Rominski SD, Oteng R. “Ambulance of Taxi: Prehospital Transports in the Ashanti Region of Ghana.” African Jour of Emerg Med. 2014. Volume 4, Issue 1, Pages 8–13, March 2014
  3. Mould-Millman NK, Naidoo R, de Vries S, Stein C, and Wallis LA. "AFEM Consensus Conference, 2013. AFEM Out-of-Hospital Emergency Care Workgroup Consensus Paper: Advancing Out-of-Hospital Emergency Care in Africa-Advocacy and Development." African Journal of Emergency Medicine, April 2014. 4, 90–95
  4. Martel J, Oteng R, Mould-Millman NK, Bell SA, Zakariah A, Oduro G, Kowalenko T, Donkor P. “The Development of Sustainable Emergency Care in Ghana: Physician, Nursing and Prehospital Care Training Initiatives.” The Journal of emergency medicine 47.4 (2014): 462-468. PMID: 25066956
  5. Laurence B, Mould-Millman NK, Scannapieco F. Hospital admissions for pneumonia more likely with concomitant dental infections. Clinical oral investigations (2014): 1-8. PMID: 25359325
  6. Faul M, Sasser SM, Lairet J, Mould-Millman NK, & Sugerman DE (2014). Trauma Center Staffing, Infrastructure, and Patient Characteristics that Influence Trauma Center Need. West J Emerg Med. 2015 Jan;16(1):98-106. doi: 10.5811/westjem.2014.10.22837. Epub 2014 Nov 11. PMID: 25671017
  7. Reynolds, TA, Calvello EJ, Broccoli MC, Sawe HR, Mould-Millman NK, Teklu S, & Wallis LA (2014). AFEM consensus conference 2013 summary: Emergency care in Africa–Where are we now? African Journal of Emergency Medicine, 4(3), 158-163.
  8. Mould-Millman NK, de Vries S, Stein C, Kafwamfwa M, Dixon J, Yancey A, Laba B, Overton J, McDaniel R, Wallis LA. Developing emergency medical dispatch systems in Africa–recommendations of the African Federation for Emergency Medicine/International Academies of Emergency Dispatch Working Group. African Journal of Emergency Medicine. 2015 Sep 30;5(3):141-7.
  9. Hasegawa K, Bittner JC, Nonas SA, Stoll SJ, Watase T, Gabriel S, Herrera V, Camargo Jr CA, Aurora T, Brenner B, Brown MA. MARC-37 Investigators (Mould-Millman NK). Children and adults with frequent hospitalizations for asthma exacerbation, 2012-2013: a multicenter observational study. The Journal of Allergy and Clinical Immunology: In Practice. 2015 Sep 1;3(5):751-8.
  10. Hasegawa K, Ahn J, Brown MA, Press VG, Gabriel S, Herrera V, Bittner JC, Camargo Jr CA, Aurora T, Brenner B, Calhoun W. MARC-37 Investigators (Mould-Millman NK). Underuse of guideline-recommended long-term asthma management in children hospitalized to the intensive care unit: a multicenter observational study. Annals of Allergy, Asthma & Immunology. 2015 Jul 1;115(1):10-6.
  11. Mould-Millman NK, Oteng R, Zakariah AN, Osei-Ampofo M, Oduro G, Barsan W, Kowalenko TK. “Assessment of Emergency Medical Services in the Ashanti Region of Ghana.”  Ghana Med J. 2015 Sep;49(3):125-35. PMID: 26693186
  12. Mould-Millman NK, Rominski SD, Bogus J, Zakariah AN, Akoriyea SK, Achena CB, Ginde AA, Campbell TB. “Barriers to Accessing Emergency Medical Services in Accra, Ghana.” Glob Health Sci Pract. 2015 Dec 17;3(4):577-90. doi: 10.9745/GHSP-D-15-00170. PMID: 26681705.
  13. Mould-Millman NK, Stein C, Wallis LA. Time to standardise levels of care amongst Out-of-Hospital Emergency Care providers in Africa. Afr J Emerg Med. 2016 Mar;6(1):54-55. doi: 10.1016/j.afjem.2015.12.002. Epub 2016 Feb 4.  PMID: 30456066
  14. Hasegawa K, Tsugawa Y, Clark S, Eastin CD, Gabriel S, Herrera V, Bittner JC, Camargo Jr CA, MARC-37 Investigators (Mould-Millman NK). Improving quality of acute asthma care in US hospitals: changes between 1999-2000 and 2012-2013. Chest. 2016 Jul 1;150(1):112-22.
  15. Bittner JC, Hasegawa K, Probst BD, Mould-Millman NK, Silverman RA, Camargo CA Jr. Smoking status and smoking cessation intervention among U.S. adults hospitalized for asthma exacerbation. Allergy Asthma Proc. 2016 Jul;37(4):318-23. doi: 10.2500/aap.2016.37.3952. PMID: 27401318
  16. Schmid KM, Mould-Millman NK, Hammes A, Kroehl M, García RQ, McDermott MU, Lowenstein SR. Barriers and Facilitators to Community CPR Education in San José, Costa Rica. Prehosp Disaster Med. 2016 Aug 5:1-7. PMID: 27491645
  17. Stein C, Mould-Millman NK, De Vries S, Wallis L. Access to out-of-hospital emergency care in Africa: Consensus conference recommendations. Afr J Emerg Med. 2016 Sep;6(3):158-161. doi: 10.1016/j.afjem.2016.08.008. Epub 2016 Sep 6.  PMID: 30456085
  18. Laurence B, Mould-Millman NK, Nero KE Jr, Salter RO, Sagoo PK. Depression and hospital admission in older patients with head and neck cancer: analysis of a national healthcare database. Gerodontology. 2017 Jun;34(2):284-287. doi: 10.1111/ger.12247. Epub 2016 Aug 31. PMID: 27578498
  19. Mould-Millman NK, Dixon JM, Sefa N, Yancey A, Hollong BG, Hagahmed M, Ginde AA, Wallis LA. The state of Emergency Medical Services (EMS) systems in Africa. Prehosp Disaster Med. 2017 Jun;32(3):273-283. doi: 10.1017/S1049023X17000061. Epub 2017 Feb 23. PMID 28228178
  20. Mould-Millman, NK; Meese, H; Alattas, I; Ido, M; Yi, I; Oyewumi, O; Colman, M; Frankel, M; Yancey, A. The Accuracy of Prehospital Identification of Stroke in a Large Stroke Belt Municipality. Prehospital Emergency Care. 2018 Mar 29:1-9. doi: 10.1080/10903127.2018.1447620. PMID: 29596006
  21. Nicolson B, McCollough C, Wachira B, and Mould-Millman NK. Emergency Medical Services (EMS) Training in Kenya: Findings and Recommendations from an Educational Assessment. Afr J Emerg Med. 2017 Dec;7(4):157-159. doi: 10.1016/j.afjem.2017.06.002. Epub 2017 Aug 8. PMID: 30456131
  22. Sultan M, Abebe Y, Tsadik AW, Jennings CA, Mould-Millman NK. Epidemiology of ambulance utilized patients in Addis Ababa, Ethiopia. BMC health services research. 2018 Dec;18(1):997. doi: 10.1186/s12913-018-3820-4. PMID: 30587188
  23. Schmid KM, García RQ, Fernandez MM, Mould-Millman NK, Lowenstein SR. Teaching Hands-Only CPR in Schools: A Program Evaluation in San José, Costa Rica. Annals of Global Health. 2018 Nov 5;84(4). PMID: 27491645
  24. Mould-Millman NK, Dixon J, Burkholder TW, Sefa N, Patel H, Yaffee A, Osisanya A, Oyewumi T, Botchey I, Osei-Ampofo M, Sawe H, Lemery J, Cushing T, Wallis LA. 15 years of Emergency Medicine Literature in Africa: A Scoping Review. Afr J Emerg Med. 2019 Mar;9(1):45-52. doi: 10.1016/j.afjem.2019.01.006. Epub 2019 Jan 18. Review. PMID: 30873352
  25. Sultan M, Abebe Y, Tsadik AW, Ababa A, Yesus AG, Mould-Millman NK. Trends and barriers of emergency medical service use in Addis Ababa; Ethiopia. BMC Emergency Medicine. 2019 Dec;19(1):28. doi: 10.1186/s12873-019-0242-5. PMID: 30999840
  26. Zaidi A, Mould-Millman NK, Dixon J, Rodriguez K, Raji Z, LeBeau S, De Vries S, Ginde A, Wallis LA,. The Burden of Acute Injuries at a District Hospital in the Western Cape Province of South Africa. Afr J Emerg Med. 2019;9 (Suppl):S14-S20. doi: 10.1016/j.afjem.2019.01.007. Epub 2019 Jan 19.  PMID: 31073509
  27. Schauer SG, April MD, Naylor JF, Mould-Millman NK, Bebarta VS, Becker TE, Maddry JK, Ginde AA. Incidence of hyperoxia in combat wounded in Iraq and Afghanistan: a potential opportunity for oxygen conservation. Mil Med. 2019 May 29. pii: usz125. doi: 10.1093/milmed/usz125. [Epub ahead of print] PMID: 31141134
  28. Mould-Millman NK, Dixon J, Lamp A, de Vries S, Beaty B, Finck L, Colborn K, Moodley K, Skenadore A, Glasgow RE, Havranek EP. A single-site pilot implementation of a novel trauma training program for prehospital providers in a resource-limited setting. Pilot and Feasibility Studies. 2019 Dec 1;5(1):143.
  29. Dixon J, Comstock G, Whitfield J, Richards D, Burkholder TW, Leifer N, Mould-Millman NK, Hynes EJ. Emergency department management of traumatic brain injuries: A resource tiered review. African Journal of Emergency Medicine. 2020 Jun 16. https://doi.org/10.1016/j.afjem.2020.05.006 
  30. Bedard AF, Mata LV, Dymond C, Moreira F, Dixon J, Schauer SG, Ginde AA, Bebarta V, Moore EE, Mould-Millman NK. A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes. International journal of emergency medicine. 2020 Dec;13(1):1-9.
  31. Mould-Millman NK, Dixon JM, Burkholder T, Pigoga JL, Lee M, de Vries S, Moodley K, Meier M, Colborn K, Patel C, Wallis LA. Validity and reliability of the South African Triage Scale in prehospital providers. BMC Emerg Med. 2021 Jan 15;21(1):8. doi: 10.1186/s12873-021-00406-6. PMID: 33451294.
  32. Mould-Millman NK, Mata L, Schauer SG, Dixon J, Keenan S, Holcomb JB, Tobin JM, Moore E, de Vries S, Bedard A, Bebarta VS. Defining Combat-Relevant Endpoints for Early Trauma Resuscitation Research in a Resource-Constrained Civilian Setting. Medical Journal (Fort Sam Houston, Tex.). 2021 Jul 1(PB 8-21-07/08/09):3-14. 
  33. Mould‐Millman NK, Dixon J, Lee M, Meese H, Mata LV, Burkholder T, Moreira F, Bester B, Thomas J, de Vries S, Wallis LA. Measuring quality of pre‐hospital traumatic shock care—development and validation of an instrument for resource‐limited settings. Health science reports. 2021 Dec;4(4):e422.
  34. Nee-Kofi Mould-Millman, MD; Julia M. Dixon, MD, MPH; Bradley van Ster, BTech; Fabio Moreira, BEMC; Beatrix Bester, BTech, MPhil; Charmaine Cunningham, PhD, MBA, BSocSc; Shaheem de Vries, MBChB, MPhil; Brenda Beaty, MS; Krithika Suresh, PhD; MAJ Steven G. Schauer, DO, MS; Lt Col. Joseph K. Maddry, MD; Lee A. Wallis, MD; Col. Vikhyat S. Bebarta, MD; Adit A. Ginde, MD, MPH. Clinical Impact of a Prehospital Trauma Shock Bundle of Care in South Africa. In press at African Journal of Emergency Medicine (AFJEM-D-21-00134R1). Accepted 08-Oct-2021.
  35. Dixon J, Burkholder T, Pigoga J, Lee M, Moodley K, de Vries S, Wallis L, and Mould-Millman NK. Using the South African Triage Scale for prehospital triage: a qualitative study. BMC Emergency Medicine (2021) 21:125. https://doi.org/10.1186/s12873-021-00522-3
  36. Mould-Millman NK, Keenan S; Dixon J, Steyn E, Lategan HJ, de Vries S, Mata LV, Patel C, Schauer SG, Fisher AD, April MD, Ginde AG, Bebarta VS. An Innovative Civilian Research Model to Inform Combat-Relevant Prolonged Casualty Care. U.S. Army Medical Journal. In press. Accepted 14-Oct-2021.

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