- Email: [email protected]
Forward surgical team (FST) workload in a special operations environment: the 250th FST in operation ENDURING FREEDOM
GARY P. WRATTEN SURGICAL SYMPOSIUM
Forward Surgical Team (FST) Workload in a Special Operations Environment: The 250th FST in Operation ENDURING FREEDOM LTC Ronald J. Place, MC, USA, LTC Robert M. Rush, Jr, MC, USA, and LTC Edward D. Arrington, MC, USA 250th Forward Surgical Team (Airborne), Combined Joint Special Operation Task Force—South, Kandahar, Afghanistan PURPOSE: Forward Surgical Teams (FST) deploy to support
conventional combat units of at least regimental size. This report examines the injuries and treatments of an FST in an environment of unconventional tactics, limited personal protection, and extended areas of responsibility during Operation ENDURING FREEDOM. METHODS: A prospective evaluation of the personal protec-
tive measures, mechanisms of injury, types of injuries, and times to treatment in Operation ENDURING FREEDOM. Additionally, per-surgeon caseloads, operative interventions, and outcomes are examined. The first phase of this deployment involved co-locating with an Air Force Expeditionary Medical Squadron at Seeb Air Base, Oman (SABO). The second phase involved stand-alone operations at Kandahar International Airport (KIA). Participants include U.S. Special Forces, conventional U.S forces, coalition country special forces, and antiTaliban Afghan soldiers. RESULTS: During the deployment, the FST performed 68
surgical procedures on 50 patients (19 SAB, 31 KIA). There were 35 orthopedic cases (2 to 28 per surgeon), 30 general surgery cases (2 to 10 per surgeon), and 3 head/neck cases. Mechanism of injury included non-battle injury (13), bomb blast (13), gunshot wounds (8), mine (8), and grenades (5). Primary injuries were to the extremities in 27, torso in 9, and head/neck in 11. Three patients had appendicitis. Five patients were wearing body armor, whereas 4 wore helmets. The mean Relative Trauma Score was 7.4. Thirty-one patients were treated at KIA with a mean time to operative treatment of 2.7 ⫾ 2.7 hours, whereas 19 were treated in SABO with a mean time to operative treatment of 12.4 ⫾ 15.1 hours. Nine patients Correspondence: Inquiries to LTC Ronald J. Place, MC, USA, Landstuhl Regional Medical Center, CMR 402 BOX 1756, APO, AE 09180; Fax: 011-49-6371-867619; email: [email protected] The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the United States Government, the Department of Defense, or the Department of the Army.
418
received transfusions. Three nonoperative patients died of wounds. CONCLUSION: Despite the lack of personal protective gear,
most patients had extremity wounds as their primary injuries. In this special operations environment, time to operative treatment was significantly longer than expected. (Curr Surg 60: 418-422. Published by Elsevier Inc. on behalf of the Association of Program Direcctors in Surgery.) KEY WORDS: Forward Surgical Team, Special Forces, evacuation times, mechanism of injury, Operation ENDURING FREEDOM
INTRODUCTION The Army Forward Surgical Team (FST) is the newest organizational concept originating from the employment of medical assets in Operation DESERT SHIELD and Operation DESERT STORM. Medical lessons learned on a small scale from Grenada and Panama, and then reinforced in Iraq, have driven enhanced forward surgical capability within the airborne, air assault, and special operations units.1 The Mobile Army Surgical Hospital (MASH) was felt to be too large to be tactically responsive to a more fluid battlefield.2 The need for tactically mobile surgical assets led to the development of the FST. Army doctrine states that FSTs deploy to support conventional maneuver brigades or regiments and, in certain circumstances, Special Forces’ groups.1 Although used in military operations other than war, the FST had never been used in support of American armed conflict. The rationale for the FST comes from the estimate that 10% to 15% of the “Wounded-In-Action” will require urgent surgical intervention to control hemorrhage or provide stabilization sufficient for evacuation.1 There are 57 specific injury criteria that require emergent resuscitative surgery by an FST. These include major chest or abdominal wounds, continuing hemorrhage, severe shock, wounds causing airway compromise
CURRENT SURGERY • Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery
0149-7944/03/$30.00 PII S0149-7944(02)00718-3
or respiratory distress, and acutely deteriorating level of consciousness with closed head injury.1 During Operation ENDURING FREEDOM (OEF), the 250th FST (Airborne) deployed in support of the Combined Joint Special Operations Task Force-South. The purpose of this study was to prospectively evaluate the friendly force’s injuries and treatments in an environment of unconventional tactics, limited personal protection, and potentially long transport times using an airborne FST.
MATERIAL AND METHODS
TABLE 1. Mechanism of Injury Compared with Injury Site Mechanism Bomb blast 13 (28%) Mine 8 (17%) Grenade 5 (11%) BLAST SUBTOTAL 26 (55%) Gunshot 8 (17%) Non-Battle Injury 13 (28%) TOTAL 47 (100%)
Head/ Neck 4 1 1 6
(9%) (2%) (2%) (13%)
1 (2%) 4 (9%) 11 (23%)
Torso 2 1 1 4
(4%) (2%) (2%) (9%)
4 (9%) 1 (2%) 9 (19%)
Extremity 7 6 3 16
(15%) (13%) (6%) (34%)
3 (6%) 8 (17%) 27 (57%)
On October 6, 2001, the 250th FST (ABN) received a warning order for movement to Southwest Asia in support of OEF. In addition to other preparatory actions, surgeons from the FST developed a 40-point database to track patients treated in the Triage/Trauma Management section, through the operating room until evacuation. The database collection was subdivided into phases. Phase I involved integration of the FST into an Air Force Expeditionary Medical Squadron (EMEDS) hospital at Seeb Air Base near Muscat, Oman (SABO) from October 20, 2001 through December 25, 2001. In Phase II, the FST forward deployed to provide medical care at the headquarters of CJSOTF-South on the Kandahar International Airport (KIA) grounds from December 25, 2001 through April 2, 2002. Stationed at SABO during the first phase were 9 general surgeons, 4 orthopedic surgeons, and 1 Oral/Maxillofacial surgeon. Stationed at KIA during the second phase were the 3 general surgeons and 1 orthopedic surgeon assigned to the 250th FST. In addition to demographic data, measurements gathered included the time from injury to first medical response and any life-saving aid that was administered. An additional calculation included the time from injury to operative treatment (TOT). This was defined as the difference between the time of injury and arrival to the FST. Because all emergent patients were resuscitated on the operating table, arrival in the facility was equal to the start of the operative time. The use of any body armor or protective headgear was documented. Severity of injury was determined by calculating a revised trauma score using vital signs gathered on arrival to the FST. The mechanism of injury was obtained from the transferring medical provider (flight physician or medic). Specific mechanisms were defined as follows. Gunshot wounds were all wounds felt to be consistent with a high-velocity rifle. Bomb blasts were all wounds caused by aircraft delivered munitions, both enemy and friendly fire. Grenade blasts were those wounds caused by thrown or rocketpropelled grenades. Mine injuries were from both anti-tank and anti-personnel mines. Non-battle injuries were those injuries sustained by combatants during the performance of their duties but not related to combat munitions. Injuries were identified and then grouped for reporting purposes (based on the most serious injury) into extremity, torso, and head/neck. Similarly, surgical interventions were grouped based on the primary operation. In cases in which a major torso or head/neck injury was associated with a major extremity in-
At SABO, surgeons evaluated 41 patients, 19 for significant trauma. At KIA, 155 patients were evaluated, 43 for significant trauma. Nineteen were surgically treated at SABO, whereas 31 received surgery at KIA. Mechanism of injury for the 47 operative trauma patients from both locations included 13 bomb blast injuries, 13 non-battle injuries, 8 gunshot wounds, 8 mine injuries, and 5 grenade blast injuries. Blast injuries (bomb, mine, and grenade) accounted for 55% of the injuries. Air evacuation into SABO was used in 90% of the cases (non-battle injury from the base by ground) but in only 23% for KIA. The total number of patients meeting any of the 57 criteria for resuscitative surgery and treatment by an FST at both locations was 22 (47%). During the deployment, the FST performed 68 surgical procedures on 50 patients. Those treated in SABO had a mean TOT of 12.4 ⫾ 15.1 hours. Those surgically treated at KIA had a mean TOT of 2.7 ⫾ 2.7 hours. Although less than 5% of the patients treated at SABO were evaluated in less than 3 hours, 67% of those at KIA were. Table 1 shows the relationship between mechanism of injury and injury location. Primary injuries were to the extremities in 27 (58%), torso in 9 (19%), and head/neck in 11 (23%). In addition, 3 patients had appendicitis. Five patients were wearing body armor, whereas 4 wore helmets. The mean revised trauma score (⫾ standard deviation) was 7.4 ⫾ 1.1 with no significant difference at each location. The number of surgical patients seen per day ranged from 0 to 8 at SABO and 0 to 5 at KIA. The number of operative procedures performed per day ranged from 0 to 12 at SABO and 0 to 7 at KIA. Figure 1 graphically represents the number of surgical patients evaluated per day, whereas Figure 2 reflects the
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jury, a change in providers could occur and count as multiple procedures. In addition, if patient transport was delayed and the patient required subsequent operations, this would count as an additional procedure. From this, per-surgeon caseload was determined. If blood products were used at any time, this was noted. Total time treated in the post-anesthesia care unit (PACU) and time to evacuation was also recorded.
RESULTS
FIGURE 1. Surgical patients seen per day at SABO and KIA.
procedures performed per day at each facility. Surgeons at SABO performed a mean of 1 procedure per 5 weeks, whereas surgeons at KIA performed a mean of 1 procedure per 2 weeks. There were 35 cases with an orthopedic surgeon as the primary surgeon (51%). General surgeons performed 30 cases (44%), including all of the torso, most of the head/neck, and some of the extremity cases with a range of 2 to 10 per provider. OralMaxillofacial surgeons performed 3 cases (5%). There were 11 traumatic torso procedures (17%), 12 head and neck procedures (18%), and 42 extremity procedures (65%). Three of the operations (2 extremity and 1 torso) were major vascular inju-
ries. Most extremity procedures (24 out of 42—57%) were for fragment injuries and only required wound debridement. Seven patients required amputations, and 8 received fasciotomies. Nine patients received transfusions (18%). The maximum number of units transfused in a 24-hour period was 16 units at SABO and 14 at KIA. Three soldiers were dead on arrival. Two more died of wounds while at the FST from head wounds, whereas a third died of multi-organ failure at an evacuation location. The mean time spent in the PACU at SABO was not measured as there was an inpatient ward and an intensive care unit for further patient care. As these care areas did not exist at
FIGURE 2. Operative cases per day at SABO and KIA. 420
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The mission of the United States Army FST is to provide rapidly deployable immediate surgical capability, enabling patients to withstand further evacuation to facilities staffed to provide definitive care. Usual personnel assigned to the FST are shown in Table 2. The FST is designed to complement and augment surgical capabilities for brigade-sized task forces.1 In some circumstances, that doctrine is extended to Special Forces Groups. OEF involved the use of large number of United States and coalition country special operation forces. During the first phase, the fluid nature of the battlefield prevented the use of conventional medical units. Therefore, all casualties were evacuated from the battlefield by Special Forces’ medics to a staging area for transport to hospital ships in the Gulf of Oman, or to fixed facilities in SABO and Kharsi Khanabad, Uzbekistan for resuscitative care. Although the FST was located on the Arabian Peninsula, the evacuation of casualties from southern Afghanistan to SABO led to a TOT of greater than 12 hours. With the seizure and control of KIA, the 250th FST (ABN) forward deployed to this location. Now located in the same country as the combatants, this medical treatment facility was responsible for resuscitative surgical care for coalition members based at KIA but performing missions throughout the entire southern third of Afghanistan. This is significantly different from the Army doctrine that states the FST should be one terrain feature away from the battle.1 Even after joining the special operations task force at their central location, this widespread area of responsibility with concomitant longer evacuation travel times led to longer TOT than would be expected. At KIA, the TOT still averaged nearly 3 hours. Although only 3 patients died of wounds during their evacuation and prior to arrival to the FST, the high revised trauma score may explain why the majority of the patients were
easily resuscitated and then evacuated to other treatment facilities. The total numbers of surgical patients seen and operative procedures performed were low. However, even in this lowintensity, special operations environment, the FST cared for up to 5 injured patients at 1 time and performed up to 7 surgical procedures per day. Some may say this is a gross under-utilization of resources. However, it seems clear that if U.S. service members put their lives at risk to protect American freedoms, optimal medical resources should be available for their care. A frequent misconception of many military personnel and most civilians is that exposure to the treatment of motor vehicle collisions and gunshot wounds in urban trauma centers is sufficient training for combat surgeons.3 This is often not the case, especially for the emergent wounds seen by this FST. U.S. military surgeons must consider themselves part of a unique continuum of care in the treatment of casualties providing only a portion of the patients overall care as they move along the evacuation conveyor belt.3 FST surgeons often provide only the resuscitative procedures required to save life or limb before evacuating patients to fixed facilities for more definitive care. Many of the wounds seen by combat surgeons are from aircraft delivered ordinance, grenades, or mines and cannot be duplicated, even in civilian trauma centers. The 250th FST (ABN) spent 1 month at a level 1 trauma center for a trauma refresher course and saw a significantly different patient population.4 The preponderance of blast injuries (55%) seen in OEF are comparable to those seen during the Soviet Union-Afghanistan War (Soviet War) from 1980 to 1988. In the first year of the Soviet War, over 60% of all wounds were gunshot wounds.5 Throughout the course of the war, mujahideen guerrillas captured mortars and made use of land mines. By the final year of the war, blast injuries from fragmentary devices account for over 70% of all injuries. This ratio continued in the Balkans, with the Croatian Army reporting 63% of their injuries from blast wounds.6 Fragment injuries from mortars and mines produce multiple wounds that are often more difficult to treat than gunshot wounds. From the Vietnam War through Operation DESERT STORM, innovations were made in weaponry as well as improvements in protective headgear and body armor.7 In part due to these improvements, 50% to 70% of all operative injuries were orthopedic.8-10 During the Soviet War, Soviet troops wore body armor and protective helmets. Extremity wounds remained stable throughout the conflict at 71%.5 As OEF involved a largely special operations environment, most of the coalition combatants did not wear body armor or helmets. Despite the lack of personal protective gear, there was still a preponderance (58%) of extremity injuries. Reasons for this ratio may be due to the firing accuracy of the Taliban/Al Qaida soldiers, significant number of blast injuries, or from the relatively small patient numbers. TOT compared favorably with the Soviet experience. Mean TOT was under 3 hours with 67% of patients evaluated within 3 hours of injury. This is much higher than the Soviet’s 48% to
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TABLE 2. Forward Surgical Team Members Commander (general surgeon/orthopedic surgeon) General surgeons (3 if commander is orthopedic surgeon) Orthopedic surgeon (unless commander) Nurse Anesthetists Intensive care nurse/Head nurse Emergency room nurse Operating room nurse Administrative Officer Team Sergeant Intensive care licensed practical nurse Operating room technician Emergency medical Technicians
1 2 1 2 1 1 1 1 1 3 3 3
KIA, total PACU time was calculated to be 10.3 ⫾ 20 hours. In addition, 41% spent more than the stated maximum of 6 hours in the PACU. Time to evacuation at SABO was 60 ⫾ 19 hours compared with 29 ⫾ 21 hours for KIA.
DISCUSSION
53% within 3 hours.5 This quicker treatment is despite the 23% air evacuation rate for OEF. The air evacuation rate was 68% for the Soviet War and up to 75% for Operation DESERT STORM.10 On the other hand, the TOT is much slower than the 45 minutes provided by an Air Force Air Transportable Hospital during Operation DESERT STORM and the 1.5 hours experienced by the Croatians in their recent reports.6,10 This may be due to the large land area supported by a single FST or the desire of the special operations soldiers to not bring attention to their position for noncritical patients. Although this is not tracked in any recent reports, the 18% transfusion rate was higher than expected. Due to the high volume of extremity injuries, the operative caseload of the 250th FST orthopedic surgeon greatly exceeded that of the general surgeons. However, most of the injuries were treated by debridement. As the general surgeons increased their experience, they largely took over the management of uncomplicated extremity soft tissue cases. Changing the staffing of the team to increase the availability of “extremity surgeons” by changing out one of the general surgeons for an orthopedist may decrease the resuscitative capability of the team and would be detrimental to the stated mission of the FST—resuscitation. In addition, only 47% of the patients met the criteria for surgical care at the FST. The patients not meeting “resuscitative surgery criteria” were treated at the FST as there was not a comprehensive military surgical facility within the area of operations. This is similar to the experience of the 5th MASH in the former Yugoslavia, where just over 60% of their patients met criteria for urgent operative care in their facility.11 On over 80% of the days, there were no operative patients to be seen. This may be due to the FST’s support of coalition special forces. On no occasion did the volume of patients reach the doctrinally stated maximum of 10 per day. However, with no definitive treatment facility for subsequent evacuation located within Afghanistan and a limited number of aircraft available for patient transport, 41% of the patients remained in the FST longer than the doctrinally stated 6-hour maximum with a mean of over 10 hours. This could have been a factor with a vigorous casualty load.
However, it was significantly faster in the KIA phase than that seen during the Soviet War. Longer evacuation times into the FST may have led to the relatively high transfusion rate, whereas limited outgoing evacuation aircraft may have increased the PACU times. However, patient outcomes did not appear to be negatively effected.
REFERENCES 1. Field Manual 8-10-25 Employment of Forward Surgical
Teams. Headquarters, Department of the Army. Washington, D.C.: U.S. Government Printing Office; December 30, 1997. 2. Steinweg KK. Mobile surgical hospital design: lessons
from 5th MASH surgical package from Operations DESERT SHIELD/DESERT STORM. Mil Med. 1993; 158:733-739. 3. Zimble J. Military medicine: an operational definition.
Mil Med. 1996;161:183-188. 4. Place RJ, Porter C, Azarow K, Beitler A. Trauma experi-
ence comparison of Army Forward Surgical Team surgeons at Ben Taub hospital and Madigan Army Medical Center. Curr Surg. 2001;58:90-93. 5. Grau LW, Jorgensen WA. Handling the wounded in a
counter-guerrilla war: the Soviet/Russian experience in Afghanistan and Chechnya. Army Medical Department J. Jan/Feb 1998. 6. Butkovic-Suldo S, Brkic K, Puntaric D, Petrovickis Z.
Medical Corps support to a brigade action during an offensive action including a river crossing. Mil Med. 1995; 160:408-411. 7. Oreck SL. Orthopedic surgery in the combat zone. Mil
Med. 1996;161:458-461. 8. Leedham LS, Newland C, Blood CG. A descriptive anal-
ysis of wounds among U.S. Marines treated-at secondechelon facilities in the Kuwaiti Theater of Operations. Mil Med. 1993;158:508-512. 9. King KF. Orthopedic aspects of war wounds in South
CONCLUSIONS Despite the lack of personal protective gear, most of the injured friendly forces had extremity wounds as their primary injuries. Most wounds were blast injuries from bomb blasts, mines, and grenades. Non-battle injuries and gunshot wounds caused the remainder of the wounds. Time to operative treatment was longer than most recent conflicts even when forward deployed.
422
Vietnam. J Bone Joint Surg. 1969;51B:112-117. 10. Wiedeman JE, Jennings SA. Applying ATLS to the Gulf
War. Mil Med. 1993;158:121-126. 11. Hrutkay JM, Hirsch E, Hockenbury R. Orthopedic Sur-
gery at a MASH deployed to the former Yugoslavia in support of the United Nations protective force. Mil Med. 1995;160:199-202.
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Forward Surgical Team (FST) Workload in a Special Operations Environment: The 250th FST in Operation ENDURING FREEDOM LTC Ronald J. Place, MC, USA, LTC Robert M. Rush, Jr, MC, USA, and LTC Edward D. Arrington, MC, USA 250th Forward Surgical Team (Airborne), Combined Joint Special Operation Task Force—South, Kandahar, Afghanistan PURPOSE: Forward Surgical Teams (FST) deploy to support
conventional combat units of at least regimental size. This report examines the injuries and treatments of an FST in an environment of unconventional tactics, limited personal protection, and extended areas of responsibility during Operation ENDURING FREEDOM. METHODS: A prospective evaluation of the personal protec-
tive measures, mechanisms of injury, types of injuries, and times to treatment in Operation ENDURING FREEDOM. Additionally, per-surgeon caseloads, operative interventions, and outcomes are examined. The first phase of this deployment involved co-locating with an Air Force Expeditionary Medical Squadron at Seeb Air Base, Oman (SABO). The second phase involved stand-alone operations at Kandahar International Airport (KIA). Participants include U.S. Special Forces, conventional U.S forces, coalition country special forces, and antiTaliban Afghan soldiers. RESULTS: During the deployment, the FST performed 68
surgical procedures on 50 patients (19 SAB, 31 KIA). There were 35 orthopedic cases (2 to 28 per surgeon), 30 general surgery cases (2 to 10 per surgeon), and 3 head/neck cases. Mechanism of injury included non-battle injury (13), bomb blast (13), gunshot wounds (8), mine (8), and grenades (5). Primary injuries were to the extremities in 27, torso in 9, and head/neck in 11. Three patients had appendicitis. Five patients were wearing body armor, whereas 4 wore helmets. The mean Relative Trauma Score was 7.4. Thirty-one patients were treated at KIA with a mean time to operative treatment of 2.7 ⫾ 2.7 hours, whereas 19 were treated in SABO with a mean time to operative treatment of 12.4 ⫾ 15.1 hours. Nine patients Correspondence: Inquiries to LTC Ronald J. Place, MC, USA, Landstuhl Regional Medical Center, CMR 402 BOX 1756, APO, AE 09180; Fax: 011-49-6371-867619; email: [email protected] The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the United States Government, the Department of Defense, or the Department of the Army.
418
received transfusions. Three nonoperative patients died of wounds. CONCLUSION: Despite the lack of personal protective gear,
most patients had extremity wounds as their primary injuries. In this special operations environment, time to operative treatment was significantly longer than expected. (Curr Surg 60: 418-422. Published by Elsevier Inc. on behalf of the Association of Program Direcctors in Surgery.) KEY WORDS: Forward Surgical Team, Special Forces, evacuation times, mechanism of injury, Operation ENDURING FREEDOM
INTRODUCTION The Army Forward Surgical Team (FST) is the newest organizational concept originating from the employment of medical assets in Operation DESERT SHIELD and Operation DESERT STORM. Medical lessons learned on a small scale from Grenada and Panama, and then reinforced in Iraq, have driven enhanced forward surgical capability within the airborne, air assault, and special operations units.1 The Mobile Army Surgical Hospital (MASH) was felt to be too large to be tactically responsive to a more fluid battlefield.2 The need for tactically mobile surgical assets led to the development of the FST. Army doctrine states that FSTs deploy to support conventional maneuver brigades or regiments and, in certain circumstances, Special Forces’ groups.1 Although used in military operations other than war, the FST had never been used in support of American armed conflict. The rationale for the FST comes from the estimate that 10% to 15% of the “Wounded-In-Action” will require urgent surgical intervention to control hemorrhage or provide stabilization sufficient for evacuation.1 There are 57 specific injury criteria that require emergent resuscitative surgery by an FST. These include major chest or abdominal wounds, continuing hemorrhage, severe shock, wounds causing airway compromise
CURRENT SURGERY • Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery
0149-7944/03/$30.00 PII S0149-7944(02)00718-3
or respiratory distress, and acutely deteriorating level of consciousness with closed head injury.1 During Operation ENDURING FREEDOM (OEF), the 250th FST (Airborne) deployed in support of the Combined Joint Special Operations Task Force-South. The purpose of this study was to prospectively evaluate the friendly force’s injuries and treatments in an environment of unconventional tactics, limited personal protection, and potentially long transport times using an airborne FST.
MATERIAL AND METHODS
TABLE 1. Mechanism of Injury Compared with Injury Site Mechanism Bomb blast 13 (28%) Mine 8 (17%) Grenade 5 (11%) BLAST SUBTOTAL 26 (55%) Gunshot 8 (17%) Non-Battle Injury 13 (28%) TOTAL 47 (100%)
Head/ Neck 4 1 1 6
(9%) (2%) (2%) (13%)
1 (2%) 4 (9%) 11 (23%)
Torso 2 1 1 4
(4%) (2%) (2%) (9%)
4 (9%) 1 (2%) 9 (19%)
Extremity 7 6 3 16
(15%) (13%) (6%) (34%)
3 (6%) 8 (17%) 27 (57%)
On October 6, 2001, the 250th FST (ABN) received a warning order for movement to Southwest Asia in support of OEF. In addition to other preparatory actions, surgeons from the FST developed a 40-point database to track patients treated in the Triage/Trauma Management section, through the operating room until evacuation. The database collection was subdivided into phases. Phase I involved integration of the FST into an Air Force Expeditionary Medical Squadron (EMEDS) hospital at Seeb Air Base near Muscat, Oman (SABO) from October 20, 2001 through December 25, 2001. In Phase II, the FST forward deployed to provide medical care at the headquarters of CJSOTF-South on the Kandahar International Airport (KIA) grounds from December 25, 2001 through April 2, 2002. Stationed at SABO during the first phase were 9 general surgeons, 4 orthopedic surgeons, and 1 Oral/Maxillofacial surgeon. Stationed at KIA during the second phase were the 3 general surgeons and 1 orthopedic surgeon assigned to the 250th FST. In addition to demographic data, measurements gathered included the time from injury to first medical response and any life-saving aid that was administered. An additional calculation included the time from injury to operative treatment (TOT). This was defined as the difference between the time of injury and arrival to the FST. Because all emergent patients were resuscitated on the operating table, arrival in the facility was equal to the start of the operative time. The use of any body armor or protective headgear was documented. Severity of injury was determined by calculating a revised trauma score using vital signs gathered on arrival to the FST. The mechanism of injury was obtained from the transferring medical provider (flight physician or medic). Specific mechanisms were defined as follows. Gunshot wounds were all wounds felt to be consistent with a high-velocity rifle. Bomb blasts were all wounds caused by aircraft delivered munitions, both enemy and friendly fire. Grenade blasts were those wounds caused by thrown or rocketpropelled grenades. Mine injuries were from both anti-tank and anti-personnel mines. Non-battle injuries were those injuries sustained by combatants during the performance of their duties but not related to combat munitions. Injuries were identified and then grouped for reporting purposes (based on the most serious injury) into extremity, torso, and head/neck. Similarly, surgical interventions were grouped based on the primary operation. In cases in which a major torso or head/neck injury was associated with a major extremity in-
At SABO, surgeons evaluated 41 patients, 19 for significant trauma. At KIA, 155 patients were evaluated, 43 for significant trauma. Nineteen were surgically treated at SABO, whereas 31 received surgery at KIA. Mechanism of injury for the 47 operative trauma patients from both locations included 13 bomb blast injuries, 13 non-battle injuries, 8 gunshot wounds, 8 mine injuries, and 5 grenade blast injuries. Blast injuries (bomb, mine, and grenade) accounted for 55% of the injuries. Air evacuation into SABO was used in 90% of the cases (non-battle injury from the base by ground) but in only 23% for KIA. The total number of patients meeting any of the 57 criteria for resuscitative surgery and treatment by an FST at both locations was 22 (47%). During the deployment, the FST performed 68 surgical procedures on 50 patients. Those treated in SABO had a mean TOT of 12.4 ⫾ 15.1 hours. Those surgically treated at KIA had a mean TOT of 2.7 ⫾ 2.7 hours. Although less than 5% of the patients treated at SABO were evaluated in less than 3 hours, 67% of those at KIA were. Table 1 shows the relationship between mechanism of injury and injury location. Primary injuries were to the extremities in 27 (58%), torso in 9 (19%), and head/neck in 11 (23%). In addition, 3 patients had appendicitis. Five patients were wearing body armor, whereas 4 wore helmets. The mean revised trauma score (⫾ standard deviation) was 7.4 ⫾ 1.1 with no significant difference at each location. The number of surgical patients seen per day ranged from 0 to 8 at SABO and 0 to 5 at KIA. The number of operative procedures performed per day ranged from 0 to 12 at SABO and 0 to 7 at KIA. Figure 1 graphically represents the number of surgical patients evaluated per day, whereas Figure 2 reflects the
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jury, a change in providers could occur and count as multiple procedures. In addition, if patient transport was delayed and the patient required subsequent operations, this would count as an additional procedure. From this, per-surgeon caseload was determined. If blood products were used at any time, this was noted. Total time treated in the post-anesthesia care unit (PACU) and time to evacuation was also recorded.
RESULTS
FIGURE 1. Surgical patients seen per day at SABO and KIA.
procedures performed per day at each facility. Surgeons at SABO performed a mean of 1 procedure per 5 weeks, whereas surgeons at KIA performed a mean of 1 procedure per 2 weeks. There were 35 cases with an orthopedic surgeon as the primary surgeon (51%). General surgeons performed 30 cases (44%), including all of the torso, most of the head/neck, and some of the extremity cases with a range of 2 to 10 per provider. OralMaxillofacial surgeons performed 3 cases (5%). There were 11 traumatic torso procedures (17%), 12 head and neck procedures (18%), and 42 extremity procedures (65%). Three of the operations (2 extremity and 1 torso) were major vascular inju-
ries. Most extremity procedures (24 out of 42—57%) were for fragment injuries and only required wound debridement. Seven patients required amputations, and 8 received fasciotomies. Nine patients received transfusions (18%). The maximum number of units transfused in a 24-hour period was 16 units at SABO and 14 at KIA. Three soldiers were dead on arrival. Two more died of wounds while at the FST from head wounds, whereas a third died of multi-organ failure at an evacuation location. The mean time spent in the PACU at SABO was not measured as there was an inpatient ward and an intensive care unit for further patient care. As these care areas did not exist at
FIGURE 2. Operative cases per day at SABO and KIA. 420
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The mission of the United States Army FST is to provide rapidly deployable immediate surgical capability, enabling patients to withstand further evacuation to facilities staffed to provide definitive care. Usual personnel assigned to the FST are shown in Table 2. The FST is designed to complement and augment surgical capabilities for brigade-sized task forces.1 In some circumstances, that doctrine is extended to Special Forces Groups. OEF involved the use of large number of United States and coalition country special operation forces. During the first phase, the fluid nature of the battlefield prevented the use of conventional medical units. Therefore, all casualties were evacuated from the battlefield by Special Forces’ medics to a staging area for transport to hospital ships in the Gulf of Oman, or to fixed facilities in SABO and Kharsi Khanabad, Uzbekistan for resuscitative care. Although the FST was located on the Arabian Peninsula, the evacuation of casualties from southern Afghanistan to SABO led to a TOT of greater than 12 hours. With the seizure and control of KIA, the 250th FST (ABN) forward deployed to this location. Now located in the same country as the combatants, this medical treatment facility was responsible for resuscitative surgical care for coalition members based at KIA but performing missions throughout the entire southern third of Afghanistan. This is significantly different from the Army doctrine that states the FST should be one terrain feature away from the battle.1 Even after joining the special operations task force at their central location, this widespread area of responsibility with concomitant longer evacuation travel times led to longer TOT than would be expected. At KIA, the TOT still averaged nearly 3 hours. Although only 3 patients died of wounds during their evacuation and prior to arrival to the FST, the high revised trauma score may explain why the majority of the patients were
easily resuscitated and then evacuated to other treatment facilities. The total numbers of surgical patients seen and operative procedures performed were low. However, even in this lowintensity, special operations environment, the FST cared for up to 5 injured patients at 1 time and performed up to 7 surgical procedures per day. Some may say this is a gross under-utilization of resources. However, it seems clear that if U.S. service members put their lives at risk to protect American freedoms, optimal medical resources should be available for their care. A frequent misconception of many military personnel and most civilians is that exposure to the treatment of motor vehicle collisions and gunshot wounds in urban trauma centers is sufficient training for combat surgeons.3 This is often not the case, especially for the emergent wounds seen by this FST. U.S. military surgeons must consider themselves part of a unique continuum of care in the treatment of casualties providing only a portion of the patients overall care as they move along the evacuation conveyor belt.3 FST surgeons often provide only the resuscitative procedures required to save life or limb before evacuating patients to fixed facilities for more definitive care. Many of the wounds seen by combat surgeons are from aircraft delivered ordinance, grenades, or mines and cannot be duplicated, even in civilian trauma centers. The 250th FST (ABN) spent 1 month at a level 1 trauma center for a trauma refresher course and saw a significantly different patient population.4 The preponderance of blast injuries (55%) seen in OEF are comparable to those seen during the Soviet Union-Afghanistan War (Soviet War) from 1980 to 1988. In the first year of the Soviet War, over 60% of all wounds were gunshot wounds.5 Throughout the course of the war, mujahideen guerrillas captured mortars and made use of land mines. By the final year of the war, blast injuries from fragmentary devices account for over 70% of all injuries. This ratio continued in the Balkans, with the Croatian Army reporting 63% of their injuries from blast wounds.6 Fragment injuries from mortars and mines produce multiple wounds that are often more difficult to treat than gunshot wounds. From the Vietnam War through Operation DESERT STORM, innovations were made in weaponry as well as improvements in protective headgear and body armor.7 In part due to these improvements, 50% to 70% of all operative injuries were orthopedic.8-10 During the Soviet War, Soviet troops wore body armor and protective helmets. Extremity wounds remained stable throughout the conflict at 71%.5 As OEF involved a largely special operations environment, most of the coalition combatants did not wear body armor or helmets. Despite the lack of personal protective gear, there was still a preponderance (58%) of extremity injuries. Reasons for this ratio may be due to the firing accuracy of the Taliban/Al Qaida soldiers, significant number of blast injuries, or from the relatively small patient numbers. TOT compared favorably with the Soviet experience. Mean TOT was under 3 hours with 67% of patients evaluated within 3 hours of injury. This is much higher than the Soviet’s 48% to
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TABLE 2. Forward Surgical Team Members Commander (general surgeon/orthopedic surgeon) General surgeons (3 if commander is orthopedic surgeon) Orthopedic surgeon (unless commander) Nurse Anesthetists Intensive care nurse/Head nurse Emergency room nurse Operating room nurse Administrative Officer Team Sergeant Intensive care licensed practical nurse Operating room technician Emergency medical Technicians
1 2 1 2 1 1 1 1 1 3 3 3
KIA, total PACU time was calculated to be 10.3 ⫾ 20 hours. In addition, 41% spent more than the stated maximum of 6 hours in the PACU. Time to evacuation at SABO was 60 ⫾ 19 hours compared with 29 ⫾ 21 hours for KIA.
DISCUSSION
53% within 3 hours.5 This quicker treatment is despite the 23% air evacuation rate for OEF. The air evacuation rate was 68% for the Soviet War and up to 75% for Operation DESERT STORM.10 On the other hand, the TOT is much slower than the 45 minutes provided by an Air Force Air Transportable Hospital during Operation DESERT STORM and the 1.5 hours experienced by the Croatians in their recent reports.6,10 This may be due to the large land area supported by a single FST or the desire of the special operations soldiers to not bring attention to their position for noncritical patients. Although this is not tracked in any recent reports, the 18% transfusion rate was higher than expected. Due to the high volume of extremity injuries, the operative caseload of the 250th FST orthopedic surgeon greatly exceeded that of the general surgeons. However, most of the injuries were treated by debridement. As the general surgeons increased their experience, they largely took over the management of uncomplicated extremity soft tissue cases. Changing the staffing of the team to increase the availability of “extremity surgeons” by changing out one of the general surgeons for an orthopedist may decrease the resuscitative capability of the team and would be detrimental to the stated mission of the FST—resuscitation. In addition, only 47% of the patients met the criteria for surgical care at the FST. The patients not meeting “resuscitative surgery criteria” were treated at the FST as there was not a comprehensive military surgical facility within the area of operations. This is similar to the experience of the 5th MASH in the former Yugoslavia, where just over 60% of their patients met criteria for urgent operative care in their facility.11 On over 80% of the days, there were no operative patients to be seen. This may be due to the FST’s support of coalition special forces. On no occasion did the volume of patients reach the doctrinally stated maximum of 10 per day. However, with no definitive treatment facility for subsequent evacuation located within Afghanistan and a limited number of aircraft available for patient transport, 41% of the patients remained in the FST longer than the doctrinally stated 6-hour maximum with a mean of over 10 hours. This could have been a factor with a vigorous casualty load.
However, it was significantly faster in the KIA phase than that seen during the Soviet War. Longer evacuation times into the FST may have led to the relatively high transfusion rate, whereas limited outgoing evacuation aircraft may have increased the PACU times. However, patient outcomes did not appear to be negatively effected.
REFERENCES 1. Field Manual 8-10-25 Employment of Forward Surgical
Teams. Headquarters, Department of the Army. Washington, D.C.: U.S. Government Printing Office; December 30, 1997. 2. Steinweg KK. Mobile surgical hospital design: lessons
from 5th MASH surgical package from Operations DESERT SHIELD/DESERT STORM. Mil Med. 1993; 158:733-739. 3. Zimble J. Military medicine: an operational definition.
Mil Med. 1996;161:183-188. 4. Place RJ, Porter C, Azarow K, Beitler A. Trauma experi-
ence comparison of Army Forward Surgical Team surgeons at Ben Taub hospital and Madigan Army Medical Center. Curr Surg. 2001;58:90-93. 5. Grau LW, Jorgensen WA. Handling the wounded in a
counter-guerrilla war: the Soviet/Russian experience in Afghanistan and Chechnya. Army Medical Department J. Jan/Feb 1998. 6. Butkovic-Suldo S, Brkic K, Puntaric D, Petrovickis Z.
Medical Corps support to a brigade action during an offensive action including a river crossing. Mil Med. 1995; 160:408-411. 7. Oreck SL. Orthopedic surgery in the combat zone. Mil
Med. 1996;161:458-461. 8. Leedham LS, Newland C, Blood CG. A descriptive anal-
ysis of wounds among U.S. Marines treated-at secondechelon facilities in the Kuwaiti Theater of Operations. Mil Med. 1993;158:508-512. 9. King KF. Orthopedic aspects of war wounds in South
CONCLUSIONS Despite the lack of personal protective gear, most of the injured friendly forces had extremity wounds as their primary injuries. Most wounds were blast injuries from bomb blasts, mines, and grenades. Non-battle injuries and gunshot wounds caused the remainder of the wounds. Time to operative treatment was longer than most recent conflicts even when forward deployed.
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Vietnam. J Bone Joint Surg. 1969;51B:112-117. 10. Wiedeman JE, Jennings SA. Applying ATLS to the Gulf
War. Mil Med. 1993;158:121-126. 11. Hrutkay JM, Hirsch E, Hockenbury R. Orthopedic Sur-
gery at a MASH deployed to the former Yugoslavia in support of the United Nations protective force. Mil Med. 1995;160:199-202.
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