Increasing threats with mass casualties in the civilian environment, and the rising incidence of severe multisystem polytrauma due to terror, has contributed to concern, especially in the Nordic countries and Western Europe, regarding lack of experience and expertise in the management of such trauma [
1]. Surgeons have a key competence and may lead the trauma team, but those in European countries are often subspecialized, and may lack the understanding and skills necessary for management of the complex trauma patient. This requires a multifaceted approach in the hemodynamically unstable patient presenting with multiple injuries and requires the setting priorities of care, supporting a team approach, and the leadership, and expertise necessary for advanced management. These variables can impact patient survival [
1]. Studies have shown that clinicians often rely on pattern recognition and heuristics to assess injuries rapidly, but an overreliance on these approaches can result in diagnostic errors [
2,
3]. In stressful environments such as trauma centers, clinicians often adopt these strategies to reduce cognitive load [
3,
4]. Trauma care is often characterized by uncertainty resulting in insecurity, and as such, gaps between knowledge and routine practice may result [
2,
3]. In addition, a low level of evidence for many recommendations probably complicates matters further [
2]. Surgeons primarily having an elective practice, may lack understanding of the multifaceted nature and management priorities in the trauma patient with competing multiple injury patterns [
5,
6]. Managing these trauma patients requires the appreciation of the spectrum of injury, working under time pressure with limited equipment and resources, and integration of the decisions and the actions required [
5]. This context of trauma might be extremely challenging for surgeons in environments where expertise, experience, or volumes are low. Experienced international trauma surgeons responsible for the training of those with less experience in trauma state that the mindset and the management priorities differ considerably compared to those who do have high-volume experience. In the military environment, human resources are very limited, so many civilian surgeons, anesthesiologists, and nurses work both in the civilian and austere or military medical environments. However, there is a lack of research on what the difficulties of teaching and training in the management of these patients actually are [
7]. The aim was to study what international experienced trauma surgeons describe as challenges in education specific to surgical decision-making in trauma, and the mindset required, as well as training in the technical skills needed, to manage these particularly difficult trauma patients.