Lessons Learned During Prolonged Care of Combat Casualties by a Minimally Manned Surgical Team

ABSTRACT

In the current deployed environment, small teams are dispersed to provide damage control surgical capabilities within an hour of injury. Given the well-developed evacuation system, these teams do not typically have a significant patient hold capability. Improved understanding of the shortfalls and problems encountered when caring for combat casualties in prolonged care situations will facilitate improved manning, training, and equipping of these resource-limited teams. We present the case of two critically injured soldiers who were evacuated to a 10-person split Forward Surgical Team (FST) during a weather system that precluded further evacuation. The casualties underwent damage control procedures necessitating temporary abdominal closures. The FST had to organize itself to provide intensive care significantly longer than traditional timelines for this role of care. Additionally, most team members had scarce critical care experience. An after-action review confirmed that most team members felt that they had not received adequate pre-mission training in postoperative intensive care and were not comfortable managing ventilated patients. In the current mature theaters of operations, there are robust evacuation capabilities, and presentations of scenarios like that are rare. However, as combat casualty care becomes increasingly austere and remote, small surgical teams need to train and be equipped to provide care outside of normal operation and doctrinal limits, including robust team cross-training. Incorporating principles of the prolonged care of combat casualties into the training of military surgeons will improve preparedness for these challenging situations.

INTRODUCTION

In isolated locations across the globe, small military surgical teams are deployed in support of U.S. and Allied Forces involved in a range of stability and counter-insurgency operations. The drawdown of the military’s presence in Afghanistan and the relative sparseness of medical teams to support U.S. Military operations in places such as Africa pose a unique set of challenges. It has been demonstrated that time to capabilities, such as resuscitation with blood, damage control surgery, and critical care, improves survival from combat trauma.^1–3 In areas without a robust system of care, logistical support, and medical evacuation infrastructure, assessing how small teams mitigate the risk of casualties succumbing to traumatic injuries is crucial to inform the current and future trauma systems.

In North Atlantic Treaty Organization doctrine, small surgical teams designed to perform damage control surgery are designated as “Role 2” care (Fig. 1). Many of the U.S. Army Role 2 teams are “split” to provide extended geographical coverage.^4–6 Although splitting these teams has been the norm for decades, it has been done without organization-wide doctrine and often without training and equipment optimized to care for casualties in scenarios where they cannot be rapidly evacuated. During future conflicts, the advantages afforded by a rapid evacuation chain cannot be relied upon and small surgical elements must be prepared to care for causalities for prolonged periods.

We present the case of two seriously injured host nation military personnel cared for by a 10-person damage control surgical team. Both casualties were eligible for evacuation within the coalition medical system, but due to bad weather, they were cared for by the small surgical team for 30 hours before they were evacuated. This situation highlighted several shortfalls in doctrine, organization, materiel, personnel structures, and pre-deployment training in the provision of prolonged casualty care (PCC) in this small, isolated role 2 surgical team.

CASE PRESENTATION

Both patients were cared for in a U.S. Army “split” Forward Surgical Team [FST(−)] (Table I). The FST(−) was in a fixed facility with a single operating room (OR) bed and one anesthesia machine. Four beds were available to hold patients, and the facility had one portable ventilator at each bed. Portable electric suction machines as well as basic intravenous pumps were also available. A basic stock of common medications was available, including sedatives, narcotic pain medications, and basic antibiotics. Oxygen was provided by large “H” cylinders that could be refilled from a portable oxygen generator system. The next level of care was a U.S. Military Role 3 hospital located over 2 hours away by helicopter evacuation.

Patient 1 was a 27-year-old host nation soldier who was wounded by fragments in a mortar attack. He received basic point-of-injury care and was transported to the FST(−). He arrived approximately 2 hours after injury, alert, and hemodynamically stable. He had multiple puncture wounds to his left chest, abdomen, and right forearm. After evaluation, he was taken to the OR where two adjacent small bowel injuries were found. Approximately 6 cm of small bowel was removed, his intestines were left in discontinuity, and he underwent a temporary abdominal closure. His other wounds were debrided and dressed. The patient remained intubated and was taken to the recovery area in stable condition, awaiting evacuation.

Patient 2 was a 24-year-old host nation soldier who was injured later in the same battle. He received a gunshot wound from an unknown range to his right lower chest. Field care at point of injury comprised occlusive dressings to the wounds, but the tactical situation precluded transport to the FST(−) for 4 hours. On arrival, he was alert but confused and hypotensive, with an elevated base deficit. A massive transfusion was activated and he was taken to the OR. In the OR a chest tube was placed, and on laparotomy he had approximately 2 liters of blood in his abdominal cavity and a large stellate liver laceration with active venous bleeding. The liver injury was packed, and a diaphragm laceration was repaired. Ultimately, hemostasis was achieved with a combination of topical hemostatic agents and gauze packing. A temporary abdominal dressing was applied, and the patient was transferred intubated to the recovery area. He received nine units of fresh whole blood, in addition to several units of component therapy, and on return from the OR, his lactic acidosis was mostly resolved.

During the second case, a weather front moved in and excluded the possibility of air evacuation to the role 3 hospital. Ground evacuation was not an option due to the security situation. Weather reports suggested that safe air evacuation might not be possible for several days, so the FST(−) was organized to provide continuous intensive care unit (ICU) care for two intubated, open-abdomen trauma patients.

Only three team members (trauma and critical care surgeon, certified registered nurse anesthetist [CRNA], and ICU nurse) had previous experience caring for ventilated patients, so 8-hour shifts were organized so that one of them was present at all times with another medic. Fortunately, the team’s living quarters were in close proximity to the medical facility and also accessible with two-way radio communication. Standard ICU orders were written for both patients with clear and explicit instructions on when to notify the surgeon or call for extra help.

The next morning, with no expectation that evacuation would be possible in the next few days, the surgeon conferred with role 3 medical supervisors and returned patient 1 to the OR. The abdomen was washed out, a small bowel anastomosis was completed to restore intestinal continuity, and the abdomen was formally closed. The patient was moved, intubated, to the recovery area, with plans to start weaning to extubation.

Several hours after patient 1’s return to the OR, and approximately 30 hours after he arrived at the FST(−), a brief window in the weather opened and both patients were evacuated to the role 3 hospital by helicopter. After arriving at the role 3, patient 1 was extubated and, shortly afterward, returned to host nation control. Patient 2 was taken to the OR at the role 3 the following day. Packing was removed from around the liver, and when hemostasis was confirmed, the abdomen was closed and, shortly afterward, the patient was extubated. He was returned to host nation control a few days later. Unfortunately, no further follow-up information was obtained after the patients left the role 3.

The team conducted an after-action review of the episode, focusing on PCC aspects. One team member collected anonymized feedback comments regarding their experience of the incident. Six of ten (60%) returns highlighted the need for more “ICU training” as part of pre-deployment activities. Three respondents (30%) mentioned the need for more robust cross-training.

DISCUSSION

Prolonged casualty care has been defined as medical care, applied beyond current doctrinal planning timelines in locations and/or conditions where available resources do not meet the definitive needs of the patient. In Afghanistan, a mature theater of operations with a robust evacuation system, it is rare that medical teams are compelled to provide care in these conditions. In a recent review⁷ of length of stay at role 2 facilities in Afghanistan, the average was 2.5 hours for all patients and only 4 hours for patients undergoing operative intervention. However, as the U.S. Military and Allied Forces increasingly prepare to provide damage control surgery in far forward and austere environments, evacuation timelines will increase, and role 2 surgical teams will have expanding requirements to provide prolonged care to combat casualties.

A frequently cited doctrinal capability is that U.S. Army FSTs can hold up to 30 patients for 72 hours.⁸ However, this same doctrine also calls for a FST to be co-located with a medical company to provide this capability—a situation rarely encountered in modern conflicts. Additionally, most FSTs in Afghanistan operate in “split” mode of two, 10-person elements—also not supported by the current doctrine. Currently, most FSTs have been converted to forward resuscitative surgical detachments (FRSDs), to enhance split operations and resuscitative capability,⁹ but FRSDs still have no significant capacity to provide prolonged care. Recently published FRSD doctrine states that a split FRSD (10-person team) should be able to provide postoperative care for four patients for 6 hours before evacuation.¹⁰ We propose that ongoing critical care of combat casualties beyond this 6-hour limit constitutes “Prolonged Care” not currently addressed by doctrine.

The prolonged care of combat casualties in austere settings presents several challenges, some of which were encountered in this scenario with just two patients. Many of the team members had no experience caring for intubated patients. The surgeon and CRNA came from a level 1 trauma center before deployment, and the nurse was a mid-career ICU nurse with recent clinical experience. However, only one of the medics had experience caring for a patient in an ICU environment. Two of the soldiers were surgical technicians who had never trained to provide “any” care outside an OR, aside from basic tactical combat casualty care. As part of pre-deployment training, the FST had attended the Army Trauma Training Detachment in Miami, FL, but this did not include training or exercise in prolonged postoperative care.¹¹ These training deficiencies meant that at least one of three senior providers always had to be located next to the bedside.

Team members created “ICU flow sheets” to record vital signs and patient inputs and outputs, because no suitable forms are part of the FST administrative load-out. Standard postoperative orders were written by hand using the (Admission location, Diagnosis, Condition, Allergies, Vital Signs, Activity, Nursing Care, Diet, IV fluids, Medications, Labs, Special Orders) (ADCA-VAN-DIMLS) mnemonic, which many physicians who trained in the era of computerized order entry systems may not be familiar with. Although these challenges may seem trivial, moving from an entirely electronic health record to paper charting and order writing without prior training could introduce uncertainty and confusion, leading to medical errors and/or omissions.

The situation also demanded the team to consider “diverting” any additional trauma patients away from their facility—a decision antithetical to the primary mission of FSTs in forward locations in support of U.S. and Allied Force personnel. With even one critically ill patient, there is a risk that surgical capability will be seriously degraded. Although the three specialist providers could certainly maintain a rotation schedule so one was always with the casualties, any further casualties would have reduced the capacity of the surgeon, and probably the CRNA, to be immediately available to care for the patients or respond to changes in their clinical status.

RECOMMENDATIONS

Bridging the Gaps to Inform Current and Future Prolonged Casualty Care.

When analyzing the scenario that occurred, the authors identified six recommendations to inform PCC in the future. Some of these recommendations stem directly from the incident and some of them from anticipated conditions in future PCC events.

Have a Strong Foundation in Clinical Medicine

Despite many administrative and military operational training demands, the provision of medical care is at the core of what these teams do. Too often medics spend more time assigned to nonclinical tasks (such as performing vehicle maintenance) than on hospital wards providing care. Prolonged casualty care topics need to be incorporated into regular specialty training for combat medics, as well as the more advanced special operations medics. The topics should not be restricted to role 1 levels, but also include an overview of critical care topics common in postoperative combat casualties, such as basic ventilator management, wound care, management of nasogastric tubes, pulmonary suction, recording of I/O, and recognition and prevention of postoperative complications. This foundational training on clinical trauma care must occur regularly at the home duty station,¹ which means leaders must prioritize this in the regular training cycle. Alternately, the recent Army Military-Civilian Trauma Team Training (AMCT3) program, which embeds surgical teams into high-volume civilian trauma centers, will make significant strides in maintaining clinical proficiency for team members.¹²

Emphasize the Importance of Cross-Training

All team members should undergo thorough cross-training before deployment. A 10-person team charged with a wide range of clinical and military responsibilities in an austere and isolated location is unlikely to succeed if team members have narrow and rigidly defined roles. Team members should be competent in their basic skills and tasks before attending pre-deployment training events, so further training can focus on cross-training, deepening skill sets, and building the team. Physicians need to know how to operate an X-ray machine, and nurses need to have the requisite skills and knowledge to work as an OR technician. Without this redundancy in capability, the team can only manage patients in a serial fashion with limited throughput and for a limited period. Every team member needs to understand the principals of triage and recognize a patient who is decompensating either pre- or postoperatively. Having checklists for essential clinical and operational functions can help facilitate cross-training of small teams. The smaller the team, the more imperative cross-training becomes.

Return to Basics

In the absence of electronic health records, team members must be comfortable with, and practice, the arcane arts of handwritten orders and paper-based vital signs records. Physical exam skills are of critical importance in a low-resource PCC situation, where medical imaging may not be available, and laboratory assays may be limited to handheld point-of-care systems or not available at all. Vital signs may need to be taken manually due to lack of automated monitors. An austere PCC situation will test basic examination skills, critical thinking, clinical judgment, and decision-making abilities like few other modern medical environments. Those intending to work in these environments will be well served by mastery of “the basics.”

Leverage Other Assets

At many locations, teams will be located with other units or organizations that have their own medical personnel. Although these personnel are usually employed to provide integral point-of-injury care for their units, they can also be used to assist when not otherwise engaged. Ideally, this would involve cooperative training before an incident occurs. Ensuring that training for events like this occurs before it becomes a necessity will improve the team’s ability to care for casualties when the team is underresourced. Understanding all capabilities on a forward operating base can be a force multiplier. Rehearsing these types of events and, specifically, employing additional personnel from other local elements to assist with managing medical interventions—from triage to postoperative care—will allow those more highly trained and specialized to keep their focus where necessary.

Make Use of Telehealth Capability

In environments where there is suitable communications bandwidth, telehealth technologies can assist in the provision of remote care for combat casualties. Although not needed in the above scenarios, PCC can significantly benefit from a telehealth capability, especially in the prehospital environment (“Prolonged Field Care”) where medics are holding patients beyond doctrinal timelines in challenging clinical and tactical situations. Leveraging telehealth and emerging technologies will be necessary to extend capabilities and provide guidance for the wide and complex range of clinical scenarios that may be encountered. Providers in a PCC situation can be mentored and supervised in providing critical care, other specialist management, and hands-on skills like physical or respiratory therapy.

Understand the Role of “Crisis Standards of Care”

In allied military healthcare systems, doctrine and strategic policy documents often describe an aim to provide “gold standard” or “world-class” health care, regardless of circumstances. Clearly this is not always possible, and while the team in this scenario was far from implementing “crisis standards of care”, this is a concept that should be understood and prepared for if there is any possibility that deployed medical teams might be overwhelmed. In the described circumstances, additional patients requiring surgical care and ventilator support would have almost certainly dictated a need to “ration” care. Crisis standards of care are well understood in the humanitarian environment but in deployed military trauma systems over recent decades, experience has been limited. In PCC situations, medics and providers must be familiar with crisis standards of care, and the triggers to use them as well as the ethical and legal underpinnings. This is espescially true in multiple-casualty incidents. Optimizing the use of available resources in overwhelming circumstances not only affords the greatest good for the greatest number of casualties, but it may also alleviate some of the inevitable physical and psychological burden inherent in such situations.

CONCLUSION

In both current operations and future conflicts, small mobile teams capable of providing damage control resuscitation and surgery are likely to be a key contributor to the medical support plan. These small medical teams may be compelled to care for casualties for prolonged periods before evacuation to a higher level of care can be arranged. We presented the case of two patients that were held for 30 hours in a small surgical team, and several lessons that might inform leaders, planners, and doctrine writers when preparing for future conflicts.

ACKNOWLEDGMENTS

The authors wish to acknowledge the permanently assigned and PROFIS members of the 555th Forward Surgical Team for their dedication to patient care and performance improvement during their recent multiple combat deployments.

FUNDING

None declared.

CONFLICTS OF INTEREST STATEMENT

All three authors (R.L., S.A., and J.G.) declare no conflicts of interest with regard to this study.

AUTHORSHIP STATEMENT

All three authors (R.L., S.A., and J.G.) conceived of the project design, and the analysis and interpretation of the data. R.L. was responsible for collection of the data.

REFERENCES

Author notes