Army Forward Research Articles

The Key to Combat Readiness Is a Strong Military-Civilian Partnership.

In peacetime, it is challenging for Army Forward Resuscitative Surgical Teams (FRST) to maintain combat readiness as trauma represents <0.5% of military hospital admissions and not all team members have daily clinical responsibilities. Military surgeon clinical experience has been described, but no data exist for other members of the FRST. We test the hypothesis that the clinical experience of non-physician FRST members varies between active duty (AD) and Army reservists (AR). Over a 3-year period, all FRSTs were surveyed at one civilian center. Six hundred and thirteen FRST soldiers were provided surveys and 609 responded (99.3%), including 499 (81.9%) non-physicians and 110 (18.1%) physicians/physician assistants. The non-physician group included 69% male with an average age of 34 ± 11 years and consisted of 224 AR (45%) and 275 AD (55%). Rank ranged from Private to Colonel with officers accounting for 41%. For AD vs. AR, combat experience was similar: 50% vs. 52% had ≥1 combat deployment, 52% vs. 60% peri-deployment patient load was trauma-related, and 31% vs. 32% had ≥40 patient contacts during most recent deployment (all P > .15). However, medical experience differed for AD and AR: 18% vs. 29% had >15 years of experience in practice and 4% vs. 17% spent >50% of their time treating critically injured patients (all P < .001). These differences persisted across all specialties, including perioperative nurses, certified registered nurse anesthetists, operating room (OR) techs, critical-care nurses, emergency room (ER) nurses, licensed practical nurse (LPN), and combat medics. This is the first study of clinical practice patterns in AD vs. AR, non-physician members of Army FRSTs. In concordance with previous studies of military surgeons, FRST non-physicians seem to be lacking clinical experience as well. To maintain readiness and to provide optimal care for our injured warriors, the entire FRST, not just individuals, should embed within civilian centers.

Hyper-realistic and immersive surgical simulation training environment will improve team performance

BackgroundSurgical trauma care requires excellent multidisciplinary team skills and communication to ensure the highest patient survival rate. This study investigated the effects of Hyper-realistic immersive surgical team training to improve...

Using Telemedicine in Mass Casualty Disasters.

The goal of this study is to test an implementation and examine users' perceptions about the usefulness of telemedicine in mass casualty and disaster settings and to provide recommendations for using telemedicine in these settings. Ninety-two US Army Forward Surgical Team (FST) members participated in a high-fidelity mass casualty simulation at the Army Trauma Training Center (ATTC). Telemedicine was implemented into this simulation. Only 10.9% of participants chose to use telemedicine. The most common users were surgeons and nurses. Participants believed it somewhat improved patient care, attainment of expert resources, decision-making, and adaptation, but not the timeliness of patient care. Participants reported several barriers to using telemedicine in the mass casualty setting, including (1) confusion around team roles, (2) time constraints, and (3) difficultly using in the mass casualty setting (eg, due to noise and other conditions). There appear to be barriers to the use and usefulness of telemedicine in mass casualty and disaster contexts. Recommendations include designating a member to lead the use of telemedicine, providing telemedical resources whose benefits outweigh the perceived cost in lost time, and ensuring telemedicine systems are designed for the conditions inherent to mass casualty and disaster settings.

Heart Rate Complexity in US Army Forward Surgical Teams During Pre Deployment Training.

For trauma triage, the US Army has developed a portable heart rate complexity (HRC) monitor, which estimates cardiac autonomic input and the activity of the hypothalamic-pituitary-adrenal (HPA) axis. We hypothesize that autonomic/HPA stress associated with predeployment training in U.S. Army Forward Surgical Teams will cause changes in HRC. A prospective observational study was conducted in 80 soldiers and 10 civilians at the U.S. Army Trauma Training Detachment. Heart rate (HR, b/min), cardiac output (CO, L/min), HR variability (HRV, ms), and HRC (Sample Entropy, unitless), were measured using a portable non-invasive hemodynamic monitor during postural changes, a mass casualty (MASCAL) situational training exercise (STX) using live tissue, a mock trauma (MT) STX using moulaged humans, and/or physical exercise. Baseline HR, CO, HRV, and HRC averaged 72±11b/min, 5.6±1.2L/min, 48±24ms, and 1.9±0.5 (unitless), respectively. Supine to sitting to standing caused minimal changes. Before the MASCAL or MT, HR and CO both increased to ~125% baseline, whereas HRV and HRC both decreased to ~75% baseline. Those values all changed an additional ~5% during the MASCAL, but an additional 10 to 30% during the MT. With physical exercise, HR and CO increased to >200% baseline, while HRV and HRC both decreased to 40 to 60% baseline; these changes were comparable to those caused by the MT. All the changes were P<0.05. Various forms of HPA stress during Forward Surgical Team STXs can be objectively quantitated continuously in real time with a portable non-invasive monitor. Differences from resting baseline indicate stress anticipating an impending STX whereas differences between average and peak responses indicate the relative stress between STXs. Monitoring HRC could prove useful to field commanders to rapidly and objectively assess the readiness status of troops during STXs or repeated operational missions. In the future, health care systems and regulatory bodies will likely be held accountable for stress in their trainees and/or obliged to develop wellness options and standardize efforts to ameliorate burnout, so HRC metrics might have a role, as well.

Heart Rate Complexity in US Army Forward Surgical Teams During Pre-Deployment Training

Mulder, Michelle B. MD; Sussman, Matthew S. MD; Eidelson, Sarah A. MD; Gross, Kirby R. MD, FACS; Buzzelli, Mark D. MD, FACS; Batchinsky, Andriy I. MD; Namias, Nicholas MD, MBA, FACS; Schulman, Carl I. MD, PhD, FACS; Proctor, Kenneth G. PhD Author Information

The Golden Hour Offset Surgical Treatment Team Operational Concept: Experience of the 102nd Forward Surgical Team in Operation Freedom's Sentinel 2015-2016.

Theater Special Operations Force (SOF) medical planners have begun using Army Forward Surgical Teams (FSTs) to maintain a golden hour for U.S. SOF during Operation Freedom's Sentinel required adaptation in FST training, configuration, personnel, equipment, and employment to form Golden Hour Offset Surgical Treatment Teams (GHOST-Ts). This article describes one such FST's experience in Operation Freedom's Sentinel while deployed for 9 months in support of SOF in southern Afghanistan.

Recent Advances in Forward Surgical Team Training at the U.S. Army Trauma Training Department.

U.S. Army Forward Surgical Teams (FSTs) are elite, multidisciplinary units that are highly mobile, and rapidly deployable. The mission of the FST is to provide resuscitative and damage control surgery for stabilization of life-threatening injuries in austere environments. The Army Trauma Training Center began in 2001 at the University of Miami Ryder Trauma Center under the direction of COL T. E. Knuth, MC USA (Ret.), as a multimodality combination of lectures, laboratory exercises, and clinical experiences that provided the only predeployment mass casualty and clinical trauma training center for all FSTs. Each of the subsequent five directors has restructured the training based on dynamic feedback from trainees, current military needs, and on the rapid advances in combat casualty care. We have highlighted these evolutionary changes at the Army Trauma Training Center in previous reviews. Under the current director, LTC J. M. Seery, MC USA, there are new team-building exercises, mobile learning modules and simulators, and other alternative methods in the mass casualty exercise. This report summarizes the latest updates to the state of the art training since the last review.

Identifying Pitfalls in Chest Tube Insertion: Improving Teaching and Performance

Chest tube thoracostomies are common surgical procedures, but little is known about how practitioners learn the skill. This study evaluates the frequency with which correctly performed tasks are executed by subjects during chest tube thoracostomies. In this prospective study, we developed a mobile-learning module, containing stepwise multimedia guidance on chest tube insertion. Next, we developed and tested a 14-item checklist, modeled after key skills in the module. Participants, defined as "novice" (fewer than 10 chest tubes placed) or "expert" (10 or more placed), were assigned to either the video or control group. A trained clinician used the checklist to rate participants while they inserted a chest tube on a TraumaMan simulator. University of Miami, Miller School of Medicine, a tertiary care academic institution. Current medical students, residents, and the United States Army Forward Surgical Team members rotating through the institution. One hundred twenty-eight subjects entered and finished the study. One hundred twenty-eight subjects enrolled in the study; 86 (67%) were residents or US Army Forward Surgical Team members, 66 (77%) were novices, and 20 (23%) were experts. Novices most frequently connected the tube to suction (91%), adequately dissected the soft tissue (82%), and scrubbed or anesthetized appropriately (80%). They least frequently completed full finger sweeps (33%), avoided the neurovascular bundle (35%), and performed a controlled pleural puncture (39%). Comparing the novice video group with the novice control group, the video group was more likely to correctly perform a finger sweep (42%, p<0.001) and clamp the distal end of the chest tube (42%, p<0.001). Of all the steps, experts least frequently completed full finger sweeps (70%) and avoided the neurovascular bundle (75%). Comparing the expert video group with the expert control group, the video group was more likely to correctly perform finger sweeps, the incision, and clamping the distal chest tube (20%, p = not significant). Avoiding the neurovascular bundle, controlled pleural entry, and finger sweeps are most often performed incorrectly among novices. This information can help instructors to emphasize key didactic steps, possibly easing trainees' learning curve.

The 912th Forward Surgical Team in Operation New Dawn: Employment of the Forward Surgical Team During Troop Withdrawal Under Combat Conditions

The Wars in Afghanistan and Iraq witnessed the first widespread use of U.S. Army Forward Surgical Teams (FSTs). Although doctrinally designed to support maneuver brigades in a linear front conflict, FSTs were quickly adapted to fulfill area support and special operation support missions as part of Operation Enduring Freedom and Operation Iraqi Freedom. FST's were also split to cover a greater area in both theaters. We now report further adaptation of the split FST role to meet the unique requirements encountered during the final phase of Operation New Dawn. Maintaining resuscitative surgical capabilities for U.S. Forces withdrawing under combat conditions required changes in techniques, tactics, and procedures. We describe our experience within three different scenarios in which elements of an FST were successfully employed and discuss operational planning considerations.

Mobile Learning Module Improves Knowledge of Medical Shock for Forward Surgical Team Members

Acute trauma care is characterized by dynamic situations that require adequate preparation to ensure success for military health professionals. The use of mobile learning in this environment can provide a solution that standardizes education and replaces traditional didactic lectures. A comparative evaluation with a pre-post test design regarding medical shock was delivered via either a didactic lecture or a mobile learning video module to U.S. Army Forward Surgical Team (FST) members. Participants completed a pretest, were randomly assigned to treatment group by FST, and then completed the post-test and scenario assessment. One-hundred and thirteen FST members participated with 53 in the mobile learning group and 60 in the lecture group (control). The percent mean score for the mobile learning group increased from 43.6 to 70 from pretest to post-test, with a scenario mean score of M = 56.2. The percent mean score for the control group increased from 41.5 to 72.5, with a scenario mean score of M = 59.7. The two-way analysis of variance mean score difference was 26.4 for the mobile learning group and 31.0 for the control, F = 2.18, (p = 0.14). Mobile learning modules, coupled with a structured assessment, have the potential to improve educational experiences in civilian and military settings.

Use of mobile learning module improves skills in chest tube insertion

BackgroundJust-In-Time Learning is a concept increasingly applied to medical education, and its efficacy must be evaluated. Materials and methodsA 3-minute video on chest tube insertion was produced. Consenting participants were assigned to either the video group, which viewed the video on an Apple® iPod Touch immediately before chest tube insertion, or the control group, which received no instruction. Every participant filled out a questionnaire regarding prior chest tube experience. A trained clinician observed participants insert a chest tube on the TraumaMan® task simulator, and assessed performance using a 14-item skills checklist. ResultsOverall, 128 healthcare trainees participated, with 50% in the video group. Participants included residents (34.4%, n = 44), medical students (32.8%, n = 42), and U.S. Army Forward Surgical Team members (32.8%, n = 42). Sixty-nine percent of all participants responded that they had never placed a chest tube, but 7% had placed more than 20. Only 25% of the participants had previously used TraumaMan®. Subjects who viewed the video scored better on the skills checklist than the control group (11.09 ± 3.09 versus 7.17 ± 3.56, P < 0.001, Cohen's D = 1.16). Medical students (9.33 ± 2.65 versus 4.52 ± 3.64, P < 0.001), Forward Surgical Team members (10.07 ± 2.52 versus 8.57 ± 3.22, P < 0.001), anesthesia residents (8.25 ± 2.56 versus 5.9 ± 2.23, P = 0.017), and subjects who had placed fewer than 10 chest tubes (9.7 ± 3 versus 6.6 ± 3.9, P < 0.001) performed significantly better with the video. ConclusionsThe procedural animation video is an effective medium for teaching procedural skills. Embedding the video on a mobile device, and allowing trainees to access it immediately before chest tube insertion, may enhance and standardize surgical education for civilians and military personnel.

Operation Enduring Freedom: Trends in Combat Casualty Care by Forward Surgical Teams Deployed to Afghanistan

This study examined the clinical experience of a U.S. Army Forward Surgical Team (FST) deployed to Afghanistan in 2005 and compared the findings with those of 3 previously deployed FSTs. Medical records of all patients evaluated by the FST were abstracted for analysis. Demographically, the cohort (n = 614) was predominantly male (94%), with a median age of 24, and distributed according to the following: disease (8.6%), nonbattle injury (42%), and battle injury (49%). Combat casualties were mostly Afghan National Army or Police (56%) and U.S. military (21%). Predominant wounding instruments were small arms (34%), improvised explosive devices (33%), and rocket-propelled grenades (15%). Anatomical sites of battle injury were extremities (38%), external soft tissue (35%), and head/neck/torso (28%). Operative procedures for combat injury (n = 227) were primarily orthopedic (45%) or thoracic/abdominal (36%). Combat casualty statistics provide insight to trauma epidemiology, patterns, and trends vital for surgical management. Workload statistics guides the structuring, training, and employment of FSTs.

Predeployment Mass Casualty and Clinical Trauma Training for US Army Forward Surgical Teams

Since the beginning of the program in 2002, 84 Forward Surgical Teams (FSTs) have rotated through the Army Trauma Training Center (ATTC) at the University of Miami/Ryder Trauma Center including all those deployed to Iraq and Afghanistan. The purpose of this study was to provide the latest updates of our experience with FSTs at the ATTC. Before deployment, each FST participates in a 2-week training rotation at the ATTC. The rotation is divided into 3 phases. Phase 1 is to refresh FST knowledge regarding the initial evaluation and management of the trauma patient. Phase 2 is the clinical phase and is conducted entirely at the Ryder Trauma Center. The training rotation culminates in phase 3, the Capstone exercise. During the Capstone portion of their training, the entire 20-person FST remains at the Ryder Trauma Center and is primarily responsible for the evaluation and resuscitation of all patients arriving over a 24-hour period. Subject awareness concerning their role within the team improved from 71% to 95%, indicating that functioning as a team in the context of the mass casualty training exercise along with clinical codes was beneficial. The clinical component of the rotation was considered by 47% to be the most valuable aspect of the training. Our experience strongly suggests that a multimodality approach is beneficial for preparing a team of individuals with minimal combat (or trauma) experience for the rigors of medical care and triage on the battlefield. The data provided by participants rotating through the ATTC show that through clinical exposure and simulation over a 2-week period, FST performance is optimized by defining provider roles and improving communication. The mass casualty training exercise is a vital component of predeployment training that participants feel is valuable in preparing them for the challenges that lay ahead.

US Army Two-Surgeon Teams Operating in Remote Afghanistan—An Evaluation of Split-Based Forward Surgical Team Operations

United States Army Forward Surgical Teams (FSTs) consist of twenty personnel and are the Army's smallest surgical units. Currently, they provide the majority of resuscitative surgical care for combat casualties in Afghanistan where the mission of the FST has been further extended to include "split-based operations." The effectiveness of these 10-person teams is unknown and outcome data has not been previously reported in the literature. This article evaluates the effectiveness of one split FST during a 14-month period in remote Afghanistan. The primary endpoint was died of wounds (DOW) outcomes among United States Forces, Coalition Afghani Forces, and local national citizens. Mortality was evaluated separately for patients who received a blood transfusion. Secondary endpoints of the study included number of blood products transfused, Injury Severity Score (ISS), and mechanism of injury. Seven hundred sixty-one patients were treated and 327 patients underwent an immediate surgery. The average ISS was 12.05, and the DOW percentage was 2.36%. There were 61 patients with an ISS of greater than 24 (mortality = 23.0%), and 47 patients with an ISS of 16 to 24 (mortality = 2.13%). Nine of 121 patients transfused (7.4%) died. A total of 27 patients required massive blood transfusion and on average received 12.6 units of fresh frozen plasma and 18.2 units of packed red blood cell (ratio 1:1.49). Seven of 27 patients who received massive blood transfusion (25.9%) died. Small two-surgeon surgical teams can achieve acceptable DOW rates when compared with other larger surgical units currently operating in the Global War on Terror.

Simulation Training for a Mass Casualty Incident: Two-Year Experience at the Army Trauma Training Center

Civilian and military mass casualty incidents (MCI) are an unfortunate reality in the 21st century, but there are few situational training exercises (STX) to prepare for them. To fill this gap, we developed a MCI STX for U.S. Army Forward Surgical Teams (FST) in conjunction with the U.S. Army Trauma Training Center. After a standardized briefing, each FST has 60 minutes to unpack, setup, and organize a standard equipment cache into an emergency room, operating room, and intensive care unit. In an adjacent room, five anesthetized swine are prepared with standardized, combat-relevant injuries. The number and acuity of the total casualties are unknown to the FST and arrive in waves and without warning. A realistic combat environment is simulated by creating resource limitations, power outages, security breaches, and other stressors. The STX concludes when all casualties have died or are successfully treated. FSTs complete a teamwork self-assessment card, while staff and FST surgeons evaluate organization, resource allocation, communication, treatment, and overall performance. Feedback from each FST can be incorporated into an updated design for the next STX. From 2003-2005, 16 FSTs have completed the STX. All FSTs have had collapses in situational triage, primary/ secondary surveys, and/or ATLS principles (basic ABCs), resulting in approximately 20% preventable deaths. We concluded (1) a MCI can overwhelm even combat- experienced FSTs; (2) adherence to basic principles of emergency trauma care by all FST members is essential to effectively and efficiently respond to this MCI; (3) by prospectively identifying deficiencies, future military or civilian performance during an actual MCI may be improved; and (4) this MCI STX could provide a template for similar programs to develop, train, and evaluate civilian surgical disaster response teams.

The Army Forward Surgical Team: Update and Lessons Learned, 1997–2004

Although the U.S. Army stood up two prototype airborne forward surgical teams (FSTs) in the early 1990s, it officially fielded the first 20-man FST in March 1997. Since then, Army FSTs (of which there are now 14 active and 23 reserve) have deployed on numerous combat, peacekeeping, and disaster-relief missions throughout the world. Although initially designed primarily for forward resuscitative surgery in support of short-term, offensive combat operations, the FST has become one of the Army Medical Department's most frequently deployed "long-term" health care facilities, i.e., long-term for the assigned personnel. The purpose of this article was to review the history of the FST, define its mission, delineate pitfalls in its employment and to make personnel and material acquisition recommendations for the future.

A U.S. Army Forward Surgical Team's experience in Operation Iraqi Freedom.

The Forward Army Surgical Team (FST) was designed to provide surgical capability far forward on the battlefield to stabilize and resuscitate those soldiers with life and limb threatening injuries. Operation Iraqi Freedom represents the largest military operation in which the FST concept of health care delivery has been employed. The purpose of our review is to describe the experience of the 555FST during the assault phase of Operation Iraqi Freedom. During the 23 days beginning 21 March 2003, data on all patients seen by the 555 FST were recorded. These data included combatant status, injuries according to anatomic location, and operative procedures performed. During the twenty-three day period, the 555 FST evaluated 154 patients. There were 52 EPWs, 79 U.S. soldiers, and 23 Iraqi civilians treated. Injuries to the lower extremity and chest (48% and 25%) were the most common in the EPW group. Upper extremity and lower extremity injuries were the most common in the civilian (57% and 39%) and U.S. soldier groups (32% and 30%). The number of injured regions per patient were 1.14 for U.S. soldiers, 1.33 for EPWs, and 1.52 for Iraqi civilians (p < 0.003). EPWs had proportionately more thoracic and abdominal injuries than the other groups (p < 0.05). Majority of the life threatening injuries evaluated involved EPWs. A combination of body armor and armored vehicles used by U.S. soldiers limited the number of torso injuries presenting to the FST. Early resuscitation and stabilization of U.S. soldiers, EPWs, and civilians can be successfully accomplished at the front lines by FSTs. Further modification of the FST's equipment will be needed to improve its ability in providing far forward surgical care.

A Survey of Outpatient Visits in a United States Army Forward Unit during Operation Desert Shield

Reports suggest that deployed soldiers during Operations Desert Shield and Desert Storm remained healthy, but primary care data are limited. We reviewed the outpatient visit surveillance data from the 3d Armored Cavalry Regiment to obtain information regarding soldiers' health in the field. Nontraumatic orthopedic problems accounted for the highest incidence of primary health care visits, followed by unintended injuries, gastrointestinal, respiratory, and dermatologic conditions. Visits for heat injuries, sexually transmitted diseases, unexplained fever, and psychiatric problems were low, probably due to preventive measures. These results suggest that increased prevention to decrease orthopedic problems and unintended injuries may substantially reduce outpatient visits during future deployments. Medical surveillance during future deployments can be improved by taking advantage of current advances in technology to facilitate patient data retrieval and provide timely information to first- and second-echelon medical personnel.

Making Manprint Work: The Lessons of the FAADS Experience

Over the past three years, the U.S. Army Research Institute (ARI) and its support contractor, Horizons Technology, Inc. (HTI), have been involved in a wide-ranging MANPRINT (Manpower and Personnel Integration) effort for the Army's Forward Area Air Defense System (FAADS). Elements of this effort have included: program planning, acquisition management support, studies and analyses, test and evaluation support, and support to the source selection process. The paper presents the observations of several key members of the support team on the requirements for a successful operational MANPRINT program. Several additional perspectives regarding MANPRINT concept definition, research and development needs, and methodological considerations are also provided.

Application of Hardman II Methodology to the Army's Forward Area Air Defense (FAAD) System

HARDMAN II, an automated form of HARDMAN (Hardware vs. Manpower) analysis was applied to two new Army air defense systems for purposes of estimating maintainer workload and maintenance manpower requirements. Estimates showed a shortfall in official manpower allocations. Partially as a result of the HARDMAN II analyses, the Army decided to add more maintainers to the organization supporting both systems.