Forward Surgical Team Brings Advanced Care Closer

FORWARD OPERATING BASE SHARANA, Afghanistan, May 5, 2011 — A short gur­ney ride from two heli­copter land­ing pads here, an oper­at­ing room and sur­gi­cal team offer the best hope of sur­vival for many ser­vice mem­bers wound­ed in Afghanistan.
“How fast we can get some­one from that Chi­nook or Black Hawk to the triage area, and then to the oper­at­ing room … dra­mat­i­cal­ly improves our capa­bil­i­ty of tak­ing care of peo­ple who are very severe­ly injured,” the team’s leader said.

946th Forward Surgical Team
The 946th For­ward Sur­gi­cal Team per­forms two oper­a­tions simul­ta­ne­ous­ly in its oper­at­ing room at For­ward Oper­at­ing Base Sha­rana in Afghanistan’s Pak­ti­ka province, March 27, 2011.
U.S. Army pho­to by Sgt. Kyle Car­pen­ter
Click to enlarge

Army Lt. Col. (Dr.) Peter D. Ray com­mands the Army Reserve 946th For­ward Sur­gi­cal Team. Since his team hit the ground here Feb. 17, he said, it has treat­ed 73 patients and per­formed 50 sur­gi­cal pro­ce­dures on 38 of those patients. 

The team con­sists of four sur­geons includ­ing Ray, a chief nurse, a non­med­ical oper­a­tions and liai­son offi­cer, two reg­is­tered nurse anes­thetists and addi­tion­al nurs­es, enlist­ed oper­at­ing room tech­ni­cians, prac­ti­cal nurs­es and com­bat medics. 

“We real­ly sup­port the south­east region. We’re what’s known as a full for­ward sur­gi­cal team, which is 20 peo­ple,” Ray said, “[includ­ing] an Air Force advanced-trau­ma life-sup­port aug­men­ta­tion of about five people.” 

The 946th’s mis­sion includes sup­port­ing the 10-per­son for­ward sur­gi­cal team at For­ward Oper­at­ing Base Orgun‑E, south­east of here near the Pak­istan bor­der, Ray said. “If too many patients are com­ing from the bor­der [and] Orgun‑E gets maxed out on what they can do, with­in 11 min­utes they can be in Sha­rana,” he said. “And with the air­field here, we also can col­late peo­ple togeth­er and get them moved to the next high­er lev­el of care.” 

The mil­i­tary med­ical sys­tem has three lev­els of care in Afghanistan. Aid sta­tions are the first lev­el. Ray’s team, the first lev­el of sur­gi­cal assets, is Lev­el 2. Lev­el 3 is for longer-term care and stag­ing for patients mov­ing to Ger­many or back to the states. 

“I pri­mar­i­ly route my patients to the Lev­el 3 facil­i­ty at Bagram [Air­field],” he said. 

The hard­ened sur­gi­cal facil­i­ty here includes a triage area, an oper­at­ing room that can hold up to three sur­gi­cal patients at a time, and an inten­sive care area, Ray explained. The triage beds roll out to the heli­copters to bring patients into the build­ing, where the triage non­com­mis­sioned offi­cer eval­u­ates them. If there are more than three patients, the med­ical com­pa­ny next door steps in to help with triage, Ray said. 

“Usu­al­ly, a for­ward sur­gi­cal team is locat­ed with a ‘Char­lie Med’ com­pa­ny [Com­pa­ny C in a stan­dard brigade sup­port bat­tal­ion], main­ly because we don’t intrin­si­cal­ly have lab­o­ra­to­ry or X‑ray capa­bil­i­ty,” he said. “We usu­al­ly have to bor­row that.” 

The triage area includes a “rapid infuser” machine that replaces blood quick­ly through a soda-straw-sized catheter insert­ed at the groin, shoul­ders or neck, Ray said. Con­trol­ling bleed­ing is one of the most crit­i­cal aspects of lev­el-two care for patient sur­vival, he noted. 

“When peo­ple get hit and they lose an arm or a leg, it can be a few min­utes before some­one can get a tourni­quet on them,” he explained. “And that entire time, they’re los­ing blood volume.” 

The team nor­mal­ly has 30 to 40 units of blood on hand, Ray said, but it can put out a call if it needs more and start receiv­ing spe­cif­ic types of blood from sol­diers on the base with­in 30 minutes. 

“We’ve had to use the ‘walk­ing blood bank’ three times since we’ve been here,” he said. “And all those [patients] sur­vived.” The facil­i­ties at here are unusu­al­ly robust for a for­ward sur­gi­cal team, Ray said. 

“We have six vehi­cles, four tents, our own gen­er­a­tors, and we’re con­sid­ered to be mobile,” he said. In both Iraq and Afghanistan, he added, many for­ward sur­gi­cal teams have worked out of fixed locations. 

“[Sur­gi­cal teams’] use in Afghanistan is unique, because with the moun­tains and the weath­er, you can’t actu­al­ly get peo­ple to that Lev­el 3 facil­i­ty very eas­i­ly some­times,” Ray said. “You need these for­ward sur­gi­cal teams pep­pered around, so that they’re with­in a heli­copter flight to stop the bleed­ing, con­trol the con­t­a­m­i­na­tion and sta­bi­lize them.” The oper­at­ing room equip­ment the team uses here is “way too heavy” to trav­el with, Ray said, but is the same qual­i­ty as that used in the Unit­ed States. 

“When it comes time to do very large cas­es, we feel like we can get pret­ty close to the treat­ment you can get at the emer­gency room of a trau­ma cen­ter in a major city in the U.S.,” he said. “So far, our data bears that out.” Ray said the team has treat­ed a num­ber of sol­diers and returned them to their units with­out need­ing to send them else­where for fur­ther care. 

“The sol­diers do bet­ter if they stay with their bat­tle bud­dies,” he said. “A lot of them are very upset when we have to send them far­ther out.” The team some­times gets only a few min­utes’ notice when patients are inbound, Ray said. 

“The short­est notice we’ve got­ten is four min­utes; the longest is a day or two,” he said, “just depend­ing on what the sever­i­ty of the injury is [and] what the weath­er is. It’s a very dynam­ic process.” 

Two sol­diers from the med­ical com­pa­ny man­age the admin­is­tra­tive process­es for incom­ing patients. Army Sgt. Shay Wil­son explained that when a call comes in that sol­diers need treat­ment, he or Army Spc. Justin Mau­r­er will make the esti­mat­ed 15 or more phone calls required to coor­di­nate and track a patient’s sta­tus and location. 

“We talk to the [sur­gi­cal team] and make sure they can accept the patient,” Wil­son said. “From there, it’s a mat­ter of coor­di­na­tion, find­ing flight times and get­ting the patient here as soon as possible.” 

Army Capt. Aman­da Har­grove, the team’s chief sur­gi­cal nurse, along with two sergeants on the team, pre­pares the tools and sup­plies required for patient care and assists in surgery. 

“I’m the patient advo­cate,” she said. “I work with the sur­geon to posi­tion the patient, prep the patient for surgery, and … pro­vide the sur­geons the tools they need.” Har­grove stays with patients until they wake up after surgery and over­sees their trans­fer to inten­sive care, she said. 

Most of the sur­gi­cal pro­ce­dures the team has per­formed result from rock­et-pro­pelled grenade attacks, road­side bombs or small-arms fire, Har­grove said. Ray said the vol­ume of surg­eries here proves the val­ue of hav­ing an oper­at­ing room close to the front. 

“The folks they’re bring­ing here real­ly do need this sur­gi­cal com­po­nent,” he said. “It’s not just a med­ical receiv­ing facil­i­ty. It’s a place that does surgery to alter the outcomes.” 

Rapid evac­u­a­tion is the key to patient sur­vival, Ray said, not­ing that the envi­ron­ment and ter­rain in Afghanistan can make that difficult. 

“There’s def­i­nite­ly a moti­va­tion [in] all the peo­ple who work at Lev­el 2 to get these guys to where they need to be … as soon as we can safe­ly do that,” he said. Ray said 43 peo­ple applied for the 15 spaces avail­able on the sur­gi­cal team before it deployed. 

“Where I come from, in Mobile [Alaba­ma], this is the kind of team that peo­ple who want to make a dif­fer­ence in med­i­cine want to be in,” he said. “We have real­ly no issues with moti­va­tion or dedication.” 

With the loca­tion, the peo­ple, the blood bank, oper­at­ing rooms and air capa­bil­i­ty his team has avail­able, Ray said, “there’s no bet­ter place to sur­vive than to be brought here.” 

U.S. Depart­ment of Defense
Office of the Assis­tant Sec­re­tary of Defense (Pub­lic Affairs) 

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