27 Managing Ballistic Injury in the Military Environment: The Concept of Forward Surgical Support Donald Jenkins, Paul Dougherty, and James M. Ryan Introduction In this chapter, the emphasis is on surgical management in the austere environment of the battlefield. A key difference in management in the military environment is the need to pre-place field medical facilities providing lines or echelons of care. This is in contrast to the nongovernmental organization (NGO) situation where evacuation may not be possible and all types of procedures are done in the same institution (for more detailed discussion, see Chapter 28). Lines or Echelons of Care The nature of war imposes unique considerations upon medical care. In short, care of the wounded in war requires constant backwards evacuation from point of wounding to medical units of increasing sophistication in rear areas. First aid, care under fire, and tactical field care are considered in the Prehospital Care chapter. Following stabilization, the casualty is evacuated to a regimental or battlegroup aid post and for the first time will come under the management of a doctor-led team in a purpose-built medical facility. This historically is 1st Line or 1st Echelon care, but the term Role 1 is now more commonly used (see below).the time from point of wounding to care at this level will vary with the nature of the battle, terrain, distance, and mode of evacuation it may take minutes or hours; the objective, however, is to achieve this as fast as possible within the constraints described. Wound care here consists of application of a sterile field dressing, if not already in place. If in place, it is not removed, as infection rates increase with each time the wound is exposed for examination. The objective is immediate and continued control of hemorrhage, wound stabilization, and pain reduction. If bony injury is suspected, formal limb 535
536 D. Jenkins et al. splintage, including traction splints, may be applied. As all war wounds are heavily contaminated, systemic antibiotics are commenced to delay the onset of wound infection. The choice of agent will be determined by the estimated clinical risk. In the case of the limbs, the most common infecting organisms in the initial stage are gram positive cocci and clostridial species in upper thigh and buttock wounds, gut organisms may be present in addition. Antibiotics are not a replacement for correct surgical wound management. Once stabilized, the casualty is now moved, by land or air transport to a 2nd Echelon medical facility or Role 2 medical facility. Care at 2nd and 3rd Echelon/Role 2 & 3 Historically, care at 2nd Echelon or Role 2 consisted of further stabilization and evacuation by priority to a field surgical facility for life- and limbsaving surgery (3rd Echelon/Role 3). This rather rigid arrangement developed in the days of static general wars. Modern war, characterized by maneuver, mobility, and blurring of forward and rear, has demanded a more flexible approach, taking resuscitative surgical capability forward to 2nd Echelon/Role 2, and even further forward in exceptional circumstances. Therefore, care at 2nd Echelon/Role 2 in modern war may include surgical intervention where there is a threat to life or limb. Less seriously injured casualties are typically reassessed and moved rearward, which might involve evacuation to a role 3 hospital and subsequently to a role 4 in the home base or host nation. In summary, a much more flexible approach is emerging to deal with the problems of the modern nonlinear battlefield. The basic principles of echeloned care are retained, but new terms and concepts are emerging. Note, however, that the principles underpinning the practice of war surgery have not altered. Current Doctrine Forward Surgery The concept of proximity of surgical support is not new. In World War II, the formation of allied mobile tactical forces such as airborne and special forces units required the development of complementary medical support. Surgical teams and personnel were deployed by parachute, glider, or by sea, usually alongside combat teams. Subsequent operations where surgical
27. Managing Ballistic Injury in the Military Environment 537 teams have provided close support to U.S. and U.K. forces include the Falklands war, both Gulf Wars, Afghanistan, and Sierra Leone. Each conflict and deployment has generated lessons about equipment and procedures, as have previous reviews of this subject. Medical facilities in support of operations in modern war need to be mobile and easily deployable by air (using helicopter, fixed wing aircraft, or parachute) and by road. The equipment has to be robust and meet laid down restrictions of dimension, volume, and weight. The same constraints apply to the equipment and supplies needed by the Surgical Teams. This has resulted in the replacement of the terms Lines or Echelons by the term Role (s). Medical facilities in the United States and British Military Medical System are classified into roles according to their equipment, manpower, and training: Role 1 is care under the direction of a doctor (such as a Regimental Aid Post), Role 3 provides hospital-level care, Role 4 is usually care provided away from the conflict, (e.g., care in Continental United States [CONUS] or the UK National Health Service [NHS] and associated military facilities). Role 2 provides additional care and acts as the link between Roles 1 and 3. A Role 2 facility with integral surgical teams is described in U.K. military terminology as Role 2+. This consists of all or elements of a Medical Regiment with added Field Surgical Teams (FSTs) (Forward Surgical Teams in the USA). The terminology can become confusing as some North Atlantic Treaty Organization (NATO) forces Role 2 units have integral surgical support as standard. It is important to look at the basic building blocks of surgical care and review what can realistically be achieved at each level. Structure of the FSTs Personnel An FST consists of one or more surgeons, one or more anesthetists, and a variable number of operating department practitioners (ODPs) or theater nurses. When two FSTs deploy together, this provides the option of: 24-hour surgical care. Broad surgical expertise (pairing general and orthopedic surgeons). Simultaneous resuscitation and anesthesia. An immediate medical response team while still maintaining a surgical capability.
538 D. Jenkins et al. Field Surgery 2004 & Beyond Field surgery is not a new concept, and good outcomes have been described with very limited equipment and resources. In his report of guerrilla surgery, Goulston (see reading list) gives particular credit to the non-medical personnel who were able to administer anesthesia, assist at surgery, sterilize instruments, and provide a certain level of nursing care. Current medical doctrine, however, aims to provide standards of care as close to peacetime standards as possible (allowing for battlefield conditions) and delivered within defined clinical timelines. In military conflicts, the high incidence of penetrating trauma results in significant chest, head, and abdominal injuries and highly contaminated limb injuries. Early surgical intervention, particularly in those who initially survive wounds to critical areas, results in reduced mortality and morbidity. The availability of blood is essential if forward, life-saving surgery is contemplated. During the Falklands Campaign, 600 units of blood were administered, with an average of 5 units per patient on the hospital ship Uganda. Paired UK FSTs generally deploy with 50 units. The developing fields of damage control surgery have major implications for equipment and resources, as does Field Intensive Care (Chapters 10 and 22). The damage control surgery patient will need intensive care management postoperatively and probably during early evacuation as well. To meet these needs and the desired civilian standards is time and resource intensive. Time and resources are in short supply in the rapidly changing military environment. Reconciling these conflicting needs will be a major challenge, but essential to allow advances in the care of military patients to mirror those in the management of civilian trauma. Surgical Management General Principles Adherence to stringent surgical technique and good communication are the keys to the successful use of the echelons or roles of care system for wartime surgical patients. Strict application of the surgical techniques described in earlier chapters is a safe, time-tested way to promote successful outcomes in wartime. Recent experience proves these concepts in modern warfare. Personal experience of two U.S. military surgeons at the outset of Operation Enduring Freedom s ground campaign was a wound infection rate of 0% over 48 hours using the principles of war surgery (outlined in Chapter 9). These cases included numerous open fracture cases, despite average presurgical evacuation time (wounding to surgery) of more than 10 hours. Communication includes not only providing adequate documentation of the care provided for the medical teams further down the echelons, but also
27. Managing Ballistic Injury in the Military Environment 539 Table 27-1. Anatomical distribution of penetrating wounds (as a percent) Conflict Head & Neck Thorax Abdomen Limbs Other World War I 17 4 2 70 7 World War II 4 8 4 75 9 Korean War 17 7 7 67 2 Vietnam War 14 7 5 74 Northern Ireland 20 15 15 50 Falkland Islands 16 15 10 59 Gulf War (UK)** 6 12 11 71 (32)* Gulf War (US) 11 8 7 56 18 Afghanistan (US) 16 12 11 61 Chechnya (Russia) 24 9 4 63 Somalia 20 8 5 65 2 Average 15 9.5 7.4 64.6 3.5 * Buttock and back wounds and multiple fragment injuries not included. Multiple wounds. ** 80% caused by fragments; range of hits 1 45, mean of 9. includes keeping track of evacuation routes and times, the capability of advancing the casualty care en route, and then carefully planning the timing of and need for operations and re-operations. Wounding Demographics and Effects in War Just as with any medical topic, surgeons must understand the pathophysiology of war wounds in order to best care for the patient. The most common pattern of injury seen on a conventional battlefield is the patient with multiple small fragment wounds of the extremity. Table 27-1 illustrates this point well. Summary War and conflict pose unique problems when providing care for the wounded this is all the more so when considering surgical care. Lessons, usually hard learnt, have resulted in the evolution of novel concepts, both in terms of underpinning doctrine and surgical practice. Reading List Bowley DMG, Barker P, Boffard KD. Damage control surgery concepts and practice. J R Army Med Corps. 2000;146:176 182. Clasper JC, Jeffrey PA, Mahoney PF. The forward deployment of surgical teams. Curr Anaesthes Intensive Care. 2003;14:122 125.
540 D. Jenkins et al. Gabriel RA, Metz KS. A history of Military Medicine, Vol II. Greenwood Press; 1992:253. Goulston E. Guerilla surgery. Med J Australia. 1942;Aug 22:134 136. Roberts MJ, Salmon JB, Sadler PJ. The provision of intensive care and high dependency care in the field. J R Army Med Corps. 2000;146:99 103.