The combat experience of military surgical assets in Iraq and Afghanistan: a historical review

The American Journal of Surgery (2012) 204, 377–383

Review

The combat experience of military surgical assets in Iraq and Afghanistan: a historical review Andrew J. Schoenfeld, M.D.* Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 N. Piedras St., El Paso, TX 79920, USA KEYWORDS: Military; Trauma surgery; Combat support hospital; Forward surgical team

Abstract BACKGROUND: The Forward Surgical Team and Combat Support Hospital have been used extensively only during the past decade in Iraq and Afghanistan. The scope of their operational experience and historical development remain to be described. METHODS: The literature was searched to obtain publications regarding the historical development of Forward Surgical Teams and Combat Support Hospitals, as well as their surgical experiences in Iraq and Afghanistan. Relevant publications were reviewed in full and their results summarized. RESULTS: The doctrine behind the use of modern military surgical assets was not well developed at the start of the Iraq and Afghanistan conflicts. The Forward Surgical Team and Combat Support Hospital were used in practice only over the past decade. Because of the nature of these conflicts, both types of modern military surgical assets have not been used as intended and such units have operated in various roles, including combat support elements and civilian medical treatment facilities. CONCLUSIONS: As more research comes to light, a better appreciation for the future of American military medicine and surgery will develop. Published by Elsevier Inc.

Since the advent of the age of gunpowder, as the lethality of military munitions have increased, so has the desire to move medical elements closer to the battlefront to treat and manage combat casualties more effectively. Although before the 19th century wounded soldiers were treated only at the end of a battle and medical assets were kept back in

The author is an employee of the US Federal Government and the US Army. The opinions or assertions contained herein are the private views of the author and are not to be construed as official or reflecting the views of William Beaumont Army Medical Center, the Department of Defense, US Army, or US government. There are no conflicts of interest to disclose. * Corresponding author. Tel.: ⫹1-330-329-2594; fax: ⫹1-915-5691931. E-mail address: [email protected] Manuscript received July 5, 2011; revised manuscript September 26, 2011

0002-9610/$ - see front matter Published by Elsevier Inc. doi:10.1016/j.amjsurg.2011.09.028

special reserve, beginning with the Napoleonic Wars, Baron Dominique Larrey initiated the concept of battlefield stabilization of the injured and rapid transportation to field hospitals in ambulances volantes.1,2 This notion was refined further by Jonathan Letterman during the American Civil War, who aided the War Department in coordinating an inter-related network of aid stations and hospitals that could treat battlefield casualties in a tiered system from the frontlines to fixed facilities in the rear.1

The historical evolution of military surgical assets: the Forward Surgical Team and the Combat Support Hospital Although medical technicians and litter bearers frequently were encountered at the battlefront in the later 19th

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century, physicians still were not to be found except in the rear. With the start of the first technically modern conflict in 1914 (World War I), however, practitioners came to realize that the initial distance between combat wounded and military surgeons was detrimental to outcomes and survival.1,3,4 As a result, some surgeons began to advocate for small, mobile, military hospitals to move closer to the front and provide a spectrum of emergent medical and surgical interventions immediately behind the combat lines. The first physician to act on such a recommendation, and possibly the man who may be considered the father of the modern military approach to combat surgical services, was Antoine Depage, a surgeon in the Belgian Army during the First World War.3 Between 1915 and 1916 Depage deployed mobile surgical units termed postes avances des hospitaux du front to sites within 3 km of the trenches.3 These advance hospital posts consisted of several automobiles and a trailer that served as the operating room. The units were designed to treat emergent chest and abdominal injuries, as well as to control massive hemorrhage, in soldiers who would not survive transport to a field hospital.3 Soldiers were kept at the advance surgical post for a period of 4 to 5 days, or until they were deemed stable and could tolerate further evacuation to the field hospital. Although Depage presented his experiences at the Interallied Surgical Conference in 1917 and in the United States after the war, his concepts were not adopted by the medical department of any nation.3 It would not be until the Second World War, 25 years after the work of Depage, that the need for advance medical elements was appreciated further, this time in the role of support for novel airborne units. Charles Rob, the surgical consultant to the British 1st Airborne Division, created the first medical assets, termed Forward Surgical Teams (FSTs) to render emergent medical services to paratroopers fighting in North Africa.5,6 The British FSTs were designed to function with limited resources because all practitioners and medical equipment were parachuted into the combat zone along with the fighting force. Within the American Medical Corps, Robert Zollinger of Harvard Medical School espoused a similar idea and developed mobile surgical units in support of US Army elements.2 More robust than the British FST, Zollinger’s surgical teams were capable of performing 100 surgical procedures before exhausting their supplies. Despite Zollinger’s efforts being recognized with the prestigious Legion of Merit,2 his and Dr. Rob’s mobile surgical teams disbanded at the end of World War II and were not revived during the conflicts in Korea or Vietnam. It was not until the mid-1980s that the military’s approach to combat medical services once again was scrutinized. The precipitating event for this new evaluation was the invasion of Grenada, conducted in 1983.1 During this military action, the Army’s standard field medical unit, the famed Mobile Army Surgical Hospital (MASH) was not operational until 4 days after hostilities began. Fortunately, American casualties were slight in this conflict, but it was understood that

the MASH was too cumbersome for the realities of modern warfare. As a direct result of the experience in Grenada, the Army began training surgical squads with airborne capability that were able to support elite elements parachuting into combat. These were trialed with success in the airborne invasion of Panama (1989), but such units were not used in the First Gulf War (1990 –1991), during which the unwieldy MASHs performed unsatisfactorily for a second time. Within the next decade, the MASH was phased out as the Army’s standard field medical unit and new FSTs and Combat Support Hospitals (CSHs) were created in its stead.1,4 –7 The first regular Army FSTs, the 274th Medical Detachment (Airborne) and the 250th Medical Detachment Surgical (Airborne), were brought online in the mid-1990s. Many MASH units were refitted as CSHs and had their lineages transferred to the successor squadrons. One of the field hospitals with a lineage stretching back to the 15th Evacuation Hospital of World War I, for example, was reflagged as the 115th CSH. The last MASH, the 212th, was converted to the 212th CSH in 2003.1 With the advent of the Medical Force 2000 initiative, similar assets were instituted in the Navy, Marines, and Air Force as well.7

The role of combat surgical assets in the evacuation chain The US military presently operates a 5-tiered evacuation system capable of rapidly transporting injured service members from the field of battle to military treatment facilities within the continental United States (CONUS).7 Reminiscent of Letterman’s integrated military medical treatment chain, the current echelons of care system allows soldiers to simultaneously receive care as they are transported through successive levels, ultimately to arrive at a major military installation in Washington, DC; San Antonio; Bethesda; or San Diego, where definitive treatment is rendered. The first echelon of care begins at the time of wounding, when the casualty is treated by a combat medic or transported to a Battalion Aid Station for evaluation.7 From here, injured personnel can be evacuated to echelon II, which consists of the FST for the Army, and similar units in the Navy (Forward Resuscitative Surgical System [FRSS]) and Air Force (Mobile Field Surgical Team, or Expeditionary Medical Support Unit).7,8 Transport to echelon I or II facilities can occur by nondedicated military vehicle, ambulance, or helicopter. Care received en route may range from basic first aid to advanced trauma life support interventions in the event that medics or battalion surgeons are available. The echelon II facilities are intended to stabilize those patients who require immediate surgical procedures necessary to save life and limb, including thoracotomy, laparotomy, open fracture management, and external fixator placement.8 Once stabilized, the wounded can be transferred to

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379 transport, and supplies built-in medical oxygen, as well as 360° access litter stanchions.12 Within the first 6 years of the Global War on Terrorism, more than 2,000 CCAT missions were performed in Iraq and Afghanistan,12 and 20,000 total aeromedical evacuations have been conducted in the past 3 years alone.11

Composition of FST and CSH units

Figure 1 The set-up of an emergency room tent at a Forward Surgical Team. Both beds can accommodate 2 trauma teams working at any one time and the tent’s capacity can be expanded to handle up to 4 traumas.

the third tier (the CSH for the Army and the Theater Hospital for the Air Force), which is the final echelon of care within the combat zone.4,7,9 Naval echelon III facilities are fleet hospitals, typically located on ships outside the war theater.7,10 Transfer to echelon III sites may occur by helicopter or fixed-wing aircraft, depending on the distance between the echelon II and III facilities. Additional surgical procedures may be performed at tier III facilities until the patient is medically able to tolerate fixed-wing air evacuation to echelon IV, Landstuhl Regional Medical Center in Germany. Further procedures are performed here, as deemed necessary, before definitive transfer of the combat wounded to echelon V: Walter Reed National Military Medical Center, San Antonio Military Medical Center, or the Naval facility in San Diego.1,7 A vital addition to military aeromedical transport, capable of expeditiously moving critically injured personnel between echelons II, III, IV, and V, is the Critical Care Air Transport (CCAT) team.11,12 Developed in the mid- to late1990s, the conflicts in Iraq and Afghanistan were the first to witness CCAT teams used on a large scale.11,12 Trained and maintained by the Air Force, the CCAT team consists of a critical care physician, a critical care nurse, and a respiratory therapist.12 The CCAT team is called upon to transfer critically ill, or to stabilize combat-wounded patients between facilities in the war zone, or from echelon III to Germany and/or the United States. While en route, the team is expected to titrate care to the patient’s needs and devices for invasive/noninvasive hemodynamic monitoring, negative pressure wound therapy, and mechanical ventilation are available aboard CCAT aircraft.12 As many as 6 low-acuity patients can be transferred by a single CCAT team and the maximum number of ventilatordependent individuals transported is 3. Most teams fly in a C-130 Hercules aircraft, however, the enhanced C-17 Globemaster III used by some teams allows for transoceanic

According to doctrine, the Army FST and similar units in the Navy and Air Force are composed of 20 soldiers, typically 10 officers and 10 enlisted.8 Physicians assigned to an FST include 3 general surgeons and 1 orthopedic surgeon, with 1 of the 4 serving as the commander. Other individuals comprising the unit include a critical care nurse/head nurse, an operating room (OR) nurse, 2 nurse anesthetists, an emergency room (ER) nurse, 3 vocational nurses, 3 surgical technicians, and 3 combat medics.5,8,13 The FST is intended to be highly mobile and can set up surgeries within an hour.7,8 The team travels together in 6 High-Mobility Multipurpose Wheeled Vehicles that carry all equipment as well as the tents used to establish the facility. The FST operates in 3 interconnected tent shelters that successively serve as the emergency room, the operating room, and the recovery room.6 – 8,12 The engines of the High-Mobility Multipurpose Wheeled Vehicles, or tactical generators, supply the power to run all equipment and heating/cooling systems within the shelters. Casualties are evaluated and triaged in the ER tent (Fig. 1) and those who require emergency procedures are transported to the OR where up to 2 surgeries can be performed simultaneously (Figs. 2 and 3). After surgery, patients may be maintained in the recovery tent for up to 6 hours before they must be transported to the next level of care.7,8 The Air Force and

Figure 2 The set-up of an operating room tent at a Forward Surgical Team. The anesthesia equipment is located centrally, between the 2 operating room litters. Two anesthesiologists, or an anesthesiologist and a nurse anesthetist, can administer anesthesia for 2 surgical procedures simultaneously.

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Figure 3 Two general surgeons exploring a gunshot wound to the neck in the operating room tent of a Forward Surgical Element in Afghanistan. The unit’s nurse anesthetist is positioned at right. The Forward Surgical Elements other operating room table is located behind the CRNA (not pictured), parallel to the table in use.

Army Special Operations units also have used smaller, nondoctrinal versions of the FST, including 5-man Air Force Mobile Surgical Teams and Special Operations Surgical Teams.14 Surgical teams operating in support of Special Operations missions have extremely limited capabilities and undertake interventions only in the event of penetrating neck injury with obvious vascular injury, groin and axillary wounds associated with arterial vascular injury, hemodynamically unstable penetrating abdominal injuries, and penetrating chest trauma with hemothorax.14 The doctrine for the use of FSTs and CSHs was composed within the concept of a linear battlefield, commensurate with conventional Western warfare. The linear battlefield consists of definable front lines, where 2 uniformed forces are engaged in active combat. Lines of supply, medical evacuation, and communication predictably move away from the battlefront into the unit rear, where no hostilities are expected to occur. In contrast, nonlinear warfare, predominant in Iraq and Afghanistan, has no dedicated frontline or uniformed enemy and, consequently, hostilities may erupt suddenly and anywhere within the combat zone. Within the linear battlefield, the FST is located 3 to 5 km behind the combat units the surgical team supports.8,15 Casualties are evacuated directly to the FST from the front, or arrive through the Battalion Aid Stations. Combat units operating within 1 hour of a CSH do not require support from an FST.8 The FST is capable of operating for 72 consecutive hours, or 30 surgeries, before materials and personnel are considered exhausted.7,8 At this point the unit is required to draw back to its supporting CSH for rest and resupply. An FST also may be called back to co-locate with its CSH in the event that the combat sector is not experiencing significant casualties, or if the CSH’s medical re-

sources are overwhelmed owing to a mass-casualty event or substantial inflow of wounded. Echelon III facilities (Army CSH, Naval Fleet Hospital, and Air Force Theater Hospital) may exist in a large series of tents, fixed wooden structures, or buildings.7,9,16,17 The CSH is modular and can be expanded or compressed to house anywhere from 44 to 248 beds.4,7,9 Naval hospital ships may be able to accommodate as many as 1,000 beds.7,10 Typical staffing includes 3 to 4 general surgeons, 2 orthopedic surgeons, 4 anesthesia providers, 1 ER physician, and 3 internal medicine providers.9,16 Radiologists; ear, nose, and throat surgeons; and neurosurgeons also may be available as warranted by the particular mission. Radiology, including ultrasound and computed tomography, are available at a CSH, along with blood bank services, full laboratory capabilities, and a pharmacy.7,9 The CSH maintains up to 8 ORs and is capable of around-the-clock surgical services.4,7,9 In the linear battlefield concept provided for by doctrine, the CSH is co-located with Division Headquarters and collects all casualties from its sector in preparation for evacuation to echelon IV.9 The CSH has a 72hour holding capacity, and also can provide definitive care to service members whose injuries allow return to duty within the 3-day period.7,9 Most recently, CSHs in Afghanistan have begun to establish Forward Surgical Elements in remote locations away from the main hospital site. These nondoctrinal units maintain much of the surgical staffing and laboratory capabilities of an FST, but possess more robust nursing services, including critical care nurses. The Forward Surgical Element also possesses the ability to hold patients for up to 72 hours.

The combat experience of FSTs and CSHs in Operations Enduring and Iraqi Freedom At the time of the terrorist attack on the World Trade Center, relatively few military medical assets were on a war-footing and ready to deploy in a short period. Within 6 weeks of the September 11 attacks, US forces were invading Afghanistan in an effort to oust the Taliban government. Two FSTs, the 274th and 250th, were deployed as the medical assets in support of the combat effort.2,5,6,18 The 250th FST initially was located in Oman and then moved to Kandahar Airfield once that site was secured.2,5,18 The 86th CSH was sent to Uzbekistan as the echelon III facility in support of the mission and a reserve unit, the 339th CSH, established the first US hospital in the combat zone.16 Almost as soon as hostilities began, the medical assets in theater had to convert to nondoctrinal missions because of the asymmetric mode of warfare used in the conflict. Both FSTs and CSHs became fixed facilities that received casualties from coalition and enemy units, as well as civilians, within their respective areas of operations.5,16,18 FSTs continued to evacuate their coalition wounded through the CSHs, but both types of medical assets experienced diffi-

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culties in housing and providing long-term care for enemy personnel and civilians.2,5,6,16 During its initial 5 months in Operation Enduring Freedom, the 250th FST experienced more than 1,400 patient encounters with close to 50 combat casualties.5,18 Twentyfive percent of injuries involved the chest or abdomen, with most resulting from explosive mechanisms.5 More than 40 surgical procedures were performed including laparotomies, reverse saphenous vein grafts, and arterial and vascular repairs.5 In November 2001, a Naval FRSS moved into Camp Rhino, Afghanistan, in support of Marine operations there.10 This unit possessed only 2 general surgeons, 2 anesthesiologists, and 3 surgical technicians. In this operation, American wounded were medically evacuated from Camp Rhino to the United States Ship (USS) Peleliu or USS Bataan, which served as echelon III support sites in the Arabian Sea.10 Once again, the majority of injuries were found to result from explosions, and the unit’s general surgeons treated all combat casualties, including the 54% with musculoskeletal wounds. Twenty-six percent of injuries involved the head or the face, with the remainder located in the neck, thorax, or abdomen.10 Four patients sustained burns and there were 2 vascular injuries.10 In August 2002, the 102nd FST assumed control of the surgical facilities at Kandahar.19 Over a 6-month period, the unit actively supported operations of the 101st and 82nd Airborne Divisions. A total of 112 surgeries were performed on 90 patients, 79% of whom presented because of war trauma.19 Here, the most common mechanism of injury was gunshot. Head and neck trauma accounted for 17% of cases, and the trunk was involved in 8%. Vascular injuries were present in 3% of combat-wounded.19 At approximately the same time, the 48th CSH became the first multicomponent hospital in the combat zone.16 This CSH opened a 28-bed hospital that included space for 12 intensive care unit patients. Between December 2002 and June 2003 the 48th CSH treated 10,679 patients and admitted 477.16 Nearly half of all admissions were combat traumas and 634 surgical procedures were performed. Traumatic amputations occurred in 62 cases, along with 17 laparotomies, 12 tracheostomies, 7 neck explorations, and 4 vascular reconstructions. Limb salvage was attempted in most instances by the general surgeons and orthopedists in attendance; amputations were performed only for severe open fractures or devitalized limbs.16 As the 48th CSH and 102nd FST readied to leave Afghanistan, American forces began the invasion of Iraq at the start of Operation Iraqi Freedom (OIF). Once again, the experienced 274th and 250th FSTs were called upon to support the American war effort.4,5 Between March and May 2003 the OIF conflict operated along linear battlefields and the FSTs and CSHs were used in a doctrinal manner. The 274th followed the American advance through Nasiriyah, Najaf, Karbala, and into Baghdad, treating 132 American and 74 Iraqi casualties.4 The 250th parachuted into Iraq

381 with the 173rd Airborne Brigade, establishing the northern front in the conflict.5 One tibia-fibula fracture and bilateral shoulder dislocations were treated in the immediate drop zone, but there were no other injuries as a result of the combat jump.5 After the initial assault, the FST participated in the liberation of Kirkuk, performing 3 laparotomies, 2 amputations, and 5 major vascular reconstructions.5 The 555th FST supported the 2/3 Infantry Brigade Combat Team as it moved from Kuwait into Southern Iraq and Baghdad.15 Over 24 combat days, this FST treated 79 American and 52 Iraqi combat casualties. Among the Americans, 22% of injuries involved the head or neck, whereas the plurality of wounds (46%) in Iraqi personnel occurred in the chest or abdomen.15 The unit treated major vascular insults to the portal vein, superior mesenteric vein, and vena cava. Reverse saphenous vein grafts were performed to reconstruct popliteal and brachial artery injuries, 1 neck exploration was performed for a zone II injury, small-bowel and gastric perforations were treated, and rectal wounds were managed with primary repair, diversion, and drainage.15 The overall mortality rate for the unit approached 2%, all of whom were severely injured Iraqi prisoners of war.15 Unusual for military medical personnel, because of the rapidity of advance, the 555th FST actually had to engage with the enemy and captured several Iraqis along with weapons caches.15 A similar echelon II unit, following Marine Forces in the Iraq invasion, performed 107 surgical procedures including 20 fasciotomies, 10 laparotomies, 4 colostomies, and 2 vascular shunts.20 By the beginning of May 2003, however, symmetric hostilities had ceased in Iraq and a period of unconventional warfare and unstable peace commenced. As in Afghanistan, combat surgical units were once again used in a nondoctrinal manner, occupying fixed facilities in remote outposts, as well as Baghdad.17,21–25 For example, in August of 2003, the 28th CSH, which mobilized in support of the Iraqi invasion, established permanent residence at Ibn Sina Hospital in Baghdad and was designated the burn care center for OIF.17 The 31st CSH relieved the 28th at Ibn Sina and between 2003 and 2004 treated 3,426 combat-wounded patients.25 Exploratory laparotomies were performed in 17% of the combat-injured, most frequently for bowel repair or resection.25 Vascular procedures occurred in 7% of traumas with the femoral vessels most commonly injured, followed by the brachial and popliteal vessels.25 A Naval FRSS, operating in Ramadi and Fallujah from 2004 to 2005, reported 895 trauma admissions and a 3% mortality rate among all individuals treated.21 Nearly 1,000 surgical procedures were performed by this unit, including 33 thoracotomies, 166 damage control celiotomies, and 62 major vascular repairs.21 However, as the nature of conflict changed in Iraq, the experience of combat surgical units varied significantly by time and location. During approximately the same time that the 31st CSH and Naval FRSS were operating in Baghdad,

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Ramadi, and Fallujah, the 228th CSH was located in Tikrit.24 Here, only 1,054 patients were treated and most admissions were because of disease and not trauma. Eighty percent of patients had cardiovascular, general surgical, gastrointestinal, or infectious disease diagnoses.24 Only 30% of admissions were the result of war-related injuries. Abdominal and thoracic surgery comprised 8% of all procedures performed on coalition forces, and 14% of those were conducted in Iraqis.24 More recently, members of the 86th CSH reported on their experience at Ibn Sina hospital from 2007 to 2009.22 With the OIF conflict winding down, the most common procedures reported by this CSH were appendectomy, hernia repair, and incision and drainage of abscesses. In contrast, the 541st FST, deployed to Afghanistan and used in a nondoctrinal split capacity (two 10-man teams perform surgery in remote locations), reported treating 761 patients with combat-related injuries.11 In this experience, nearly half of the treated population was Afghani, and only a quarter of the combat-injured were American. Extremity wounds represented the majority of injuries and open fractures were present in 26 instances.13 Fourteen individuals had partial-thickness burns and intra-abdominal or perineal wounds were present in 10.13 Because 1 of the 2 remote sites had only general surgeons assigned to it, these practitioners performed all surgical procedures, including those involving the extremities.13 This fact led some investigators to recommend that 2 or more general surgeons should be assigned to remote locations in the event of a split FST. Moreover, they maintained that general surgeons could capably perform any damage-control orthopedic procedures required at an echelon II facility.13 The only other work to document the more recent combat-surgical experiences in Afghanistan was that of Remick,14 describing split-operations of the 772nd FST in support of Special Operations Forces and US Marines from 2008 to 2009. The efforts of this FST represented the first mobile surgical support missions since the 2003 invasion of Iraq.14 The 772nd was able to divide itself into a highly mobile light team and a more robust heavy surgical resuscitation team. The heavy version of the unit supported both Marines in western Afghanistan and an Infantry Brigade Combat Team in the eastern part of the country.14 It should be appreciated that as the nature of combat missions in Iraq and Afghanistan stabilized, the surgical assets within theater did not operate independently, but were organized into an integrated trauma system reminiscent of trauma centers within the United States. The medical and surgical capabilities and staffing for each unit and medical installation were known so that patients with particular injuries could be shuttled to centers that maintained the expertise to meet their needs. Most notably in Iraq, rotating CSHs successively occupied fixed hospital facilities in Baghdad and Balad, facilitating continuity in the types of medical and surgical services provided.22,25 Likewise, specific sites also were assigned injury-specific designations,

for example, Ibn Sina Hospital in Iraq, which became the burn care center for all combat-wounded in that country.22,25 Ibn Sina was to remain the Iraqi burn center, despite the fact that different CSH units rotated through that site every 12 to 15 months. This fact also enabled contiguity in the scope and quality of surgical services available to service members injured in combat during the Iraqi conflict.

Prospects for the future The United States presently is engaged in the longest sustained period of conflict in its history. If the medical histories of prior wars are any indication, the dedicated compendium describing the military medical experience in the Global War on Terror will not be completed for 1 to 2 decades after the conflagration has ended. In the meantime, we are left with the individual reports of echelon II2,5,6,13–15,18 –21 and III16,17,22–26 facilities to appreciate the effect that these recent wars have had on the military’s approach to combat medical treatment. The doctrine behind FSTs and CSHs was still in its infancy when September 11 occurred, and the Global War on Terror was the first time that these combat surgical units were used in practice. Because of the nature of these conflicts, and the type of warfare used by the enemy, neither FSTs nor CSHs have been deployed as the military intended and various units have functioned in the role of combat support elements, medical treatment centers, and civil affairs sites. Moreover, debate still exists regarding which facility is optimal for the asymmetric battlefield. Eastridge et al26 examined the mortality rates of service members presenting for initial treatment at an FST compared with those receiving all their care at a CSH. Despite differences in the presence of medical personnel, as well as supply and capabilities between FSTs and CSHs, these investigators found no statistical difference in survival. Rather, injury severity, especially the presence of head trauma, was found to be the most important factor associated with mortality.26 Nonetheless, they still advocated that, once the maneuver phase of a conflict has ceased, the military treatment advantage swings in favor of the more robust CSH.26 The optimal military medical personnel assigned to FSTs and CSHs, as well as their training, also remains open to contention. As sites of emergent advanced trauma life support–type resuscitation, Nessen et al13 proposed that FSTs should be staffed primarily by general surgeons, although most procedures in recent experience appear to be orthopedic in nature. Schreiber et al24 found that there was no significant difference in procedures performed by general surgeons in a civilian setting relative to those executed at a CSH, although this claim was sharply contested by Army Colonel Lorne Blackbourne. Tyler et al25 reported that military general surgical training was lacking in certain respects when the scope of combat-related procedures was taken into account. Areas of deficiency included musculo-

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Figure 4 Case-fatality rates in Iraq and Afghanistan as compared with historical wars of the United States.

skeletal trauma, cranial injuries, and genitourinary surgery.25 Regardless of these issues, one must recognize that the soldiers and physicians staffing the FSTs and CSHs have done a remarkable job providing medical and surgical care to Americans, enemy prisoners, and local civilians in conflicts where weapon lethality has surpassed that of previous wars.1,4 Despite increases in enemy weapons’ lethality, the case fatality rate for both fronts in the war on terror remains among the lowest in American history (Fig. 4),1,13,15,21,27 which attests to the skills of America’s medical service members and also highlights the efficacy of the echelons of care system.7 Undoubtedly, as more data are published regarding the experiences of combat surgical units, especially in their nondoctrinal assignments, a greater appreciation for the future of the US military’s medical corps will be had.

References 1. Manring MM, Hawk A, Calhoun JH, et al. Treatment of war wounds: a historical review. Clin Orthop Relat Res 2009;467:2168 –91. 2. Pratt JW, Rush RM Jr. The military surgeon and the war on terrorism: a Zollinger legacy. Am J Surg 2003;186:292–5. 3. Helling TS, Daon E. In Flanders fields: the Great War, Antoine Depage, and the resurgence of debridement. Ann Surg 1998;228: 173– 81. 4. Gawande A. Casualties of war—military care for the wounded from Iraq and Afghanistan. N Engl J Med 2004;351:2471–5. 5. Rush RM Jr, Stockmaster NR, Stinger HK, et al. Supporting the Global War on Terror: a tale of two campaigns featuring the 250th Forward Surgical Team (Airborne). Am J Surg 2005;189:564 –70. 6. Peoples GE, Gerlinger T, Craig R, et al. Combat casualties in Afghanistan cared for by a single Forward Surgical Team during the initial phases of Operation Enduring Freedom. Mil Med 2005;170:462– 8.

383 7. Bagg MR, Covey DC, Powell ET IV. Levels of medical care in the Global War on Terrorism. J Am Acad Orthop Surg 2006;14:S7–9. 8. Field Manual 8-1025. Employment of Forward Surgical Teams. Washington, DC: Department of the Army; 1997. 9. Field Manual 8-10-14. Employment of the Combat Support Hospital: tactics, techniques, and procedures. Washington, DC: Department of the Army; 1994. 10. Bilski TR, Baker BC, Grove JR, et al. Battlefield casualties treated at Camp Rhino, Afghanistan: lessons learned. J Trauma 2003;54: 814 –22. 11. Hudson TL, Morton R. Critical care transport in a combat environment: building tactical trauma transport teams before and during deployment. Crit Care Nurse 2010;30:57– 66. 12. Beninati W, Meyer MT, Carter TE. The critical care air transport program. Crit Care Med 2008;36:S370 – 6. 13. Nessen SC, Cronk DR, Edens J, et al. US Army two-surgeon teams operating in remote Afghanistan—an evaluation of split-based Forward Surgical Team operations. J Trauma 2009;66:S37– 47. 14. Remick KN. The surgical resuscitation team: surgical trauma support for U.S. Army Special Operations Forces. J Spec Op Med 2009;9: 20 –5. 15. Patel TH, Wenner KA, Price SA, et al. A U.S. Army Forward Surgical Team’s experience in Operation Iraqi Freedom. J Trauma 2004;57: 201–7. 16. Beitler AL, Wortmann GW, Hofmann LJ, et al. Operation Enduring Freedom: the 48th Combat Support Hospital in Afghanistan. Mil Med 2006;171:189 –93. 17. Stout LR, Jezior JR, Melton LP, et al. Wartime burn care in Iraq: 28th Combat Support Hospital. Mil Med 2003;2007:1148 –53. 18. Place RJ, Rush RM, Arrington ED. Forward surgical team (FST) workload in a Special Operations Environment: the 250th FST in Operation Enduring Freedom. Curr Surg 2003;60:418 –22. 19. Beekley AC, Watts DM. Combat trauma experience with the United States Army 102nd Forward Surgical Team in Afghanistan. Am J Surg 2004;187:652– 4. 20. Walker GJ, Zouris J, Galarneau MF, et al. Descriptive summary of patients seen at the surgical companies during Operation Iraqi Freedom-1. Mil Med 2007;172:1–5. 21. Chambers LW, Green DJ, Gillingham BL, et al. The experience of the US Marine Corps’ Surgical Shock Trauma Platoon with 417 operative combat casualties during a 12 month period of Operation Iraqi Freedom. J Trauma 2006;60:1155– 64. 22. Filliung DR, Bower LM, Hopkins-Chadwick D, et al. Characteristics of medical-surgical patients at the 86th Combat Support Hospital during Operation Iraqi Freedom. Mil Med 2010;175:971–7. 23. Lundy JB, Swift CB, McFarland CC, et al. A descriptive analysis of patients admitted to the intensive care unit of the 10th Combat Support Hospital deployed in Ibn Sina, Baghdad, Iraq, from October 19, 2005, to October 19, 2006. J Intensive Care Med 2010;25:156 – 62. 24. Schreiber MA, Zink K, Underwood S, et al. A comparison between patients treated at a combat Support Hospital in Iraq and a level I trauma center in the United States. J Trauma 2008;64:S118 –22. 25. Tyler JA, Clive KS, White CE, et al. Current US military operations and implications for military surgical training. J Am Coll Surg 2010; 211:658 – 62. 26. Eastridge BJ, Stansbury LG, Stinger H, et al. Forward Surgical Teams provide comparable outcomes to Combat Support Hospitals during support and stabilization operations on the battlefield. J Trauma 2009; 66:S48 –50. 27. Holcomb JB, Stansbury LG, Champion HR, et al. Understanding combat casualty care statistics. J Trauma 2006;60:397– 401.