Forward Surgical Team Research Articles

Defining and predicting surgeon utilization at forward surgical teams in Afghanistan

BackgroundThe forward surgical team (FST) is the US Army's smallest surgical element. These teams have supported current conflicts since 2001. The purpose of this study was to determine if surgeon utilization varied at two different FSTs and to determine factors that may predict the need for a surgeon. MethodData from two FSTs were reviewed. A t-test was used to compare the military injury severity scores (mISS) and the revised trauma scores (RTS). χ2 analysis was used to compare types and mechanisms of injury and to compare life- or limb-saving surgeries (LLSS) and life-saving interventions among the FSTs. Logistic regression was used to determine if mISS, RTS, physiologic parameters, or laboratory values predicted the need for LLSS or life-saving intervention. ResultsThe 541st FST treated a larger volume of patients than the 772nd FST (n = 761 versus n = 311). The 772nd FST performed a significantly higher percentage of LLSS; however, absolute number of LLSS was 31 at both FSTs. The mISS among operative patients were similar, but RTS were significantly different (772nd FST = 7.28 versus 541st FST = 7.58, P = 0.008). The 772nd FST saw a higher percentage of motor vehicle collision and rocket-propelled grenade injuries and thoracic and neurologic injuries, and the 541st FST saw a higher percentage of blast and gunshot wound injuries and abdominal injuries. Lactate level was the most significant predictor of the need for LLSS. ConclusionAlthough percentage of surgical interventions varied between the two FSTs, the absolute number of needed surgical interventions was the same and was small. Lactate level predicted the need for surgical intervention in our population.

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.

Surgical Care of Thermally Injured Patients on the Battlefield

For young adults treated in burn centers in developed nations, the lethal area 50%—that is, the burn size lethal to one-half of a given population—has almost doubled since World War II from 43% of the total body surface area (TBSA) to 75% TBSA. This achievement reflects many factors, of which improvements in wound care, perioperative care, and surgical technique have figured prominently. The challenge deployed military health care providers face is how to translate these advances to the relatively austere and unforgiving environment of the combat zone. Thermal injuries are present in 5% to 20% of combat casualties. Thus, on the attlefield, role IIb (forward surgical teams) and role III (combat support hospitals) acilities frequently care for patients with burns. Most of these patients fall into two ategories: US military casualties and local national casualties. US military casualties ndergo emergency treatment and preparation for aeromedical evacuation to the nited States. Local national casualties, under the rules of engagement for the urrent conflicts in Iraq and Afghanistan, cannot be evacuated to the United States; hese patients must receive care locally. Because local resources in both theaters are imited, US field hospitals often are responsible for providing not only emergency reatment but also definitive care. Here, the author reviews the surgical care of atients with thermal injuries as it is practiced on the current battlefield. Conceptually, urn care can be divided into three distinct, albeit closely overlapping, phases: esuscitation, wound closure, and reconstruction. Operative management may be equired during each of these phases.

Surgeon Utilization Varies Between Forward Surgical Teams in Afghanistan: can we Predict The Need for a Surgeon?

Surgeon Utilization Varies Between Forward Surgical Teams in Afghanistan: can we Predict The Need for a Surgeon?

Thirty Consecutive Uses of a Hemostatic Bandage at a US Army Combat Support Hospital and Forward Surgical Team in Operation Iraqi Freedom

Topical hemostatic agents have generated intense research interest in recent years, prompted in part by the demands of wartime medicine. Numerous animal studies demonstrate variable degrees of efficacy of a variety of agents; however, little clinical data are available in severely traumatized patients. This report describes 30 consecutive uses of the modified rapid deployment hemostat (MRDH) during combat operations in Operation Iraqi Freedom. In a prospective observational fashion, traumatized patients presenting to a combat support hospital or a forward surgical team with difficult to control hemorrhage (due to anatomy, limited resources, or tactical environment) had the MRDH applied to severely bleeding wounds. Basic demographics, wounding mechanism, wound characteristics, circumstances, and efficacy were recorded. Presence of a clinical coagulopathy was also noted. Thirty hemostatic bandages were applied to 19 patients with a wide variety of wounds. All but one application occurred in the operating room. The demographics were mean age 27 years (range, 9-55 years), 95% male, 68% penetrating or fragmentation, and four casualties had a clinical coagulopathy. Hemostasis was achieved following application of the hemostatic agent in 16 of 19 wounds. Rebleeding occurred upon removal in three cases. In all cases, the patient failed conventional interventions at hemostasis before the hemostat was applied. This is the single largest description of the clinical efficacy of the MRDH and the first description during combat operations. The MRDH bandage was an effective hemostat for temporarily controlling hemorrhage in difficult circumstances. Caution should be exercised when removing the dressing as rebleeding may occur.

Simultaneous Surgeries in a Split Forward Surgical Team: A Case Study

The 541st Forward Surgical Team performed split-based operations, with one site in the city of Pol-e-Khumri. One evening, the 10-person team received two pediatric patients simultaneously and conducted simultaneous surgeries. The 3-year-old female sustained severe injuries to bilateral lower extremities and a puncture wound to her right forearm. The 13-year-old sustained fragmentary wounds to her left hand, left foot, right medial calf, and evisceration to her left lower quadrant. The patients presented in extremis after being taken to a civilian hospital initially, spending approximately 1.5 hours receiving no resuscitative therapy. The 3-year-old underwent amputations of bilateral lower extremities and a fasciotomy of the right forearm. The 13-year-old survived an exploratory laparotomy and irrigation and debridement of intra-abdominal wounds. The successful completion of simultaneous surgeries, by a split forward surgical team at a remote location, for two critically ill patients is possible. It should not become the standard of care. Prior planning made this occurrence feasible and safer, but such situations put the patients at risk for complications.

Evaluation and management of combat-related spinal injuries: a review based on recent experiences

The current approach to the evaluation and treatment of military casualties in the Global War on Terror is informed by medical experience from prior conflicts and combat encounters from the last 10 years. In an effort to standardize the care provided to military casualties in the ongoing conflicts, the Department of Defense (DoD) has published Clinical Practice Guidelines (CPGs) that deal specifically with the combat casualty sustaining a spinal injury. However, the combat experience with spine injuries in the present conflicts remains incompletely described. To describe the CPGs for the care of the combat casualty with suspected spine injuries and discuss them in light of the published military experience with combat-related spinal trauma. Literature review. A literature review was conducted regarding published works that discussed the incidence, epidemiology, and management of combat-related spinal trauma. The CPGs, established by the DoD, are discussed in light of actual military experiences with spine trauma, the present situation in the forward surgical teams and combat support hospitals treating casualties in theater, and recent publications in the field of spine surgery. In the conventional wars fought by the United States between 1950 and 1991 (Korea, Vietnam, Gulf War I), the incidence of spine injuries remained close to 1% of all combat casualties. However, in the Global War on Terror, the enemy has relied on implements of asymmetric warfare, including sniper attacks, ambush, roadside bombs, and improvised explosive devices. The increase in explosive mechanisms of injury has elevated the number of soldiers exposed to blunt force trauma and, consequently, recent publications reported the highest incidence of combat-related spinal injuries in American military history. Wounded soldiers are expeditiously evacuated through the echelons of care but typically do not receive surgical management in theater. The current CPGs for the care of soldiers with combat-related spinal injuries should be re-examined in light of data regarding the increasing number of spine injuries, new injury patterns, such as lumbosacral dissociation and low lumbar burst fractures, and recent reports within the field of spine surgery as a whole. American and coalition forces are sustaining the highest spine combat casualty rates in recorded history and previously unseen injuries are being encountered with increased frequency. While the CPGs provide useful direction in terms of the evaluation and management of combat casualties with spine injuries, such recommendations may warrant periodic re-evaluation in light of recent combat experiences and evolving scientific evidence within the spine literature.

Emergency Canine Surgery in a Deployed Forward Surgical Team: A Case Report

Forward surgical teams (FSTs) perform a variety of non-doctrinal functions. During their deployment to Afghanistan, the 541st FST (Airborne) performed emergency surgery on a German shepherd military working dog (MWD). Retrospective examination of a case of veterinary surgery in a deployed FST. A 5 1/2-year-old German shepherd MWD presented with extreme lethargy, tachycardia, excessive drooling, and a firm, distended abdomen. These conditions resulted from gastric dilatation with volvulus. Since evacuation to a veterinarian was untenable, emergency laparotomy was performed in the FST. The gastric dilatation with volvulus was treated by detorsion and gastropexy, and the canine patient fully recovered. Canine surgery can be safely performed in an FST. Based on the number of MWDs deployed throughout the theater, FSTs may be called upon to care for them in the absence of available veterinary care.

Medical Rules Of Engagement Negative Patients: The Dilemma Of Forward Surgical Teams In Counterinsurgency Operations

By definition, Forward Surgical Teams (FSTs) are located far forward in the battlespace to allow for emergent treatment of life and limb threatening trauma sustained by United States and coalition forces as well as those injured according to the medical rules of engagement (MROE). While official doctrine dictates that MROE negative patients are not entitled to care by American military medical assets, experience has shown that some FSTs do not always adhere to that doctrine during counterinsurgency (COIN) operations. Medical civic action programs (MEDCAPS) have been used in modern COIN conflicts in an attempt to gain favor with and influence the host nations? local population. However, the results have frequently been counterproductive to the intended mission. The FST, by doctrine, is not equipped to take part in traditional MEDCAPS. The focus of this paper is to explore the potential role of the FST in COIN operations. Possible roles for the FST in COIN include improving the host nation medical capabilities through education and training. Further, surgery can be a useful commodity to gain positive influence with or to trade for intelligence from key local national leaders.

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.

Management of the Mangled Face by a Forward Surgical Team

A mangled face is an uncommon injury that can occur in a combat zone as a result of blunt trauma, penetrating trauma or explosion injury. Despite the patient?s dramatic disfigurement, attention needs to focus on the basic ABC?s of initial trauma management. We present an injured Afghan civilian with a severe facial injury. Our approach to airway management, breathing evaluation and hemorrhage control are described. In addition we utilized two emergency hemorrhage control modalities that are usually associated with other areas of the body, a circumferential compression sling and a laparotomy sponge packing.

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.

Trauma Evaluation of the Parotid Duct in an Austere Military Environment

Evaluation of the parotid duct from trauma in an austere military environment can be challenging. Appropriate radiologic evaluation of a potential isolated parotid duct injury in this environment has not been reported. The use of a plain X-ray sialogram at the forward surgical team is demonstrated and may be beneficial in this setting.

US Army split forward surgical team management of mass casualty events in Afghanistan: Surgeon performed triage results in excellent outcomes

U.S. Army "split"forward surgical teams (FST) currently provide most of the resuscitative surgical care for combat patients in Afghanistan. These small units typically comprised 10 personnel and two surgeons each, who frequently encounter mass casualty (MASCAL) situations in geographically isolated regions. This article evaluates the effectiveness of one split FST managing 43 MASCAL situations in two separate locations for more than a 14-month period in Afghanistan. An Institutional Review Board-approved review of all admission data of the 541st FST was conducted. Comparison was made between patients treated in MASCAL situations to those of patients treated in non-MASCAL events. Split-based US Army forward surgical elements in a combat environment in Afghanistan. Two hundred eighty-two patients were treated during MASCAL events and 479 in non-MASCAL situations. The primary endpoint was survival outcomes among trauma patients when 5 or more patients arrived simultaneously or if3 or more patients required immediate surgery. Four patients (1.70 percent) died in the MASCAL group compared with 12 (3.30 percent) in the non-MASCAL group. The mortality of patients receiving surgery at the FST was 2.73 percent and the mortality was 0.93 percent in those transferred without surgery. In the MASCAL group, 41 patients (14.5 percent) were critically injured and the critical mortality rate was 6.25 percent. In MASCAL events, 39 percent of patients required surgery compared with 44.9 percent in the non-MASCAL group. The average Injury Severity Score (ISS) of the most severely injured patient was 21.19 and ISS rapidly decreased to scores consistent with mild injury suggesting over triage at the scene. Despite very limited resources, the split FST can achieve, with appropriate triage, acceptable mortality outcomes in MASCAL situations. Over triage at the wounding scene is common and surgical intervention is frequently required.

Celebratory gunfire injury to a United States soldier sustained during Operation Iraqi Freedom (OIF)

This case documents the care of a 22-year-old deployed male, active duty U.S. Army soldier who was referred to a forward surgical team for a “palpable foreign body” in his left posterior arm. The evening prior, his unit had been dispatched to control what was thought to be enemy activity in the city, due to reported multiple instances of gunfire. This soldier, with his unit, arrived on the scene in a small town in Iraq to investigate the situation. Upon arrival, the unit found that the gunfire was celebratory. The citizens of the city were firing weapons into the night sky in celebration of the capture and death of Saddam Hussein's sons. There was no direct gunfire targeted at the soldier or his unit. However, during the mission, the patient felt a sharp pain in the posterior aspect of the left shoulder. He was unsure as to the source of the pain, and had a medic evaluate his shoulder later that evening. The medic who examined him was not overly concerned due to the perceived benign exam findings and advised the soldier to return to duty. The patient continued with his mission until the following day, when he continued to be bothered by the discomfort. He examined the remainder of his arm and palpated a hard mass in his left triceps region, along with a small wound in his posterior upper left arm. This case illustrates the many dangers that our soldiers face while deployed, as well as reinforcing the evidence that celebratory gunfire can become a dangerous event causing significant morbidity and even mortality for those who are unfortunate enough to become a victim.

From Donor to Patient in 20 Minutes

From Donor to Patient in 20 Minutes

Forward Surgical Teams Provide Comparable Outcomes to Combat Support Hospitals During Support and Stabilization Operations on the Battlefield

Forward Surgical Teams (FST) provide forward deployed surgical care within the battle space. The next level of care in theater, the Combat Support Hospitals (CSH), are distinguished from the FST by advanced resource capabilities including more complex diagnostic imaging, laboratory support with blood banking, and intensive care units. This study was intended to assess the effect of FST capability on the outcome of seriously injured casualties in comparison to the CSH. We reviewed all casualty records in the Joint Theater Trauma Registry database from April 2004 to April 2006. The study cohort included all US military battle casualties who were admitted to either a FST or a CSH and were not returned to duty within 72 hours. Data were tabulated and assessed for basic demographics, mechanism of injury, injury severity score, ventilator and critical care days, and mortality. Statistical inferences were made using Chi square and Student's t tests. As of April 2006, the above information was available in the Joint Theater Trauma Registry on 2,617 US military battle casualties who survived to reach care at a FST and/or CSH. Of this population, 77 subsequently died of wounds and 2,540 survived. We found no significant difference in died of wounds rates between the sample populations or rates of ventilator or critical care days between the two groups, nor did controlling for injury severity score alter this picture. The most significant predictor of mortality in both these groups was head injury. The disparity between the availability of the highest level of injury care and the ability to care for injury as soon as possible is an issue of central importance to both the civilian and military trauma care communities. Our analysis demonstrates that despite the operational and logistic challenges that burden the FST, this level of surgical care confers equivalent battlefield injury outcome results compared with the CSH.

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.

The Surgical Resuscitation Team: Surgical Trauma Support For U.s. Army Special Operations Forces

Special Operations Forces need trauma surgical support that is flexible and rapidly mobile. Current operations in the Afghanistan Theater of Operations required the U.S. Army 772nd Forward Surgical Team (FST) to provide support for Special Operations missions and conventional missions on short-notice using its mobile Surgical Resuscitation Team (SRT). The 772nd FST's experience over a 15-month deployment validates the concept of and the requirement for the SRT. This paper provides a framework for planners to design and implement this capability for support of U.S. Army Special Operations Forces (ARSOF).

Ketamine-Based Total Intravenous Anesthesia Versus Isoflurane Anesthesia in a Swine Model of Hemorrhagic Shock

Inhalational anesthetics can cause profound hemodynamic effects including decreases in systemic vascular resistance and cardiac inotropy. Although widely used in uncontrolled hemorrhagic shock (UHS), their consequences compared with other anesthetic regimens are not well-studied. Ketamine-based total intravenous anesthesia (TIVA) may produce less profound cardiovascular depression, and has been used during elective surgery but rarely during traumatic shock. The purpose of this study was to compare the effects of isoflurane (ISO) and TIVA regimens in a swine grade V liver injury model. We hypothesized that TIVA would result in less hypotension and dysfunctional inflammation than ISO. Twenty swine were randomized blindly to receive either 1% to 3% ISO, or intravenous ketamine, midazolam, and buprenorphine for maintenance anesthesia. Six animals acted as controls. After sedation and intubation, randomized anesthesia was initiated and monitored by an independent animal technician. Invasive lines were placed followed by celiotomy and splenectomy. Baseline mean arterial pressure (MAP) was documented and a grade V liver injury created. After 30 minutes of UHS, animals were resuscitated with 8 mL of Ringer's lactate per milliliter blood loss at 165 mL/min. MAP and tissue oxygen saturation (StO2) were continuously recorded. The animals were sacrificed 120 minutes after injury and lung tissue was harvested. Serum cytokines (interleukin-6 [IL-6], IL-8, and tumor necrosis factor-alpha [TNF-alpha]) were quantified with enzyme-linked immunosorbent assay. Lung cytokine mRNA levels were quantified with real time reverse transcriptase polymerase chain reaction. Animal weight, liver injury pattern, and blood loss were similar (p > 0.1). The ISO group had a lower MAP at baseline (p = 0.02), at injury (p = 0.004), and study completion (p = 0.001). After resuscitation, MAP decreased in the ISO group but remained stable in the TIVA group. StO2 was significantly higher in the TIVA group immediately after injury (p = 0.004), but similar between groups throughout the remainder of the study. Animals who received TIVA trended toward higher levels of lactate and lower pH throughout the study, reaching significance at 30 minutes postinjury (p = 0.037 and 0.043). Inflammatory cytokine (IL-6, IL-8, and TNF-alpha) production did not differ between groups, however TNF-alpha mRNA production was significantly lower in the TIVA group (p = 0.04). Although a TIVA regimen produced less pronounced hypotension in a swine model of UHS than did ISO, end-organ perfusion with TIVA appeared to be equivalent or inferior to ISO. In circumstances of limited resources, such as those experienced by forward Army surgical teams, a ketamine-based TIVA regimen may be an option for use in UHS.