The 274th Forward Surgical Team experience during Operation Enduring Freedom

The 274th Forward Surgical Team (FST) was deployed in support of Operation Enduring Freedom from October 14, 2001 to May 8, 2002. During this period, the FST was asked to perform many nondoctrinal missions. The FST was tasked with functioning as a mini-combat support hospital during the earlier phases of Operation Enduring Freedom, performing in-flight surgical procedures and resuscitation of combat wounded, conducting split operations with surgical coverage of both Karshi and Khanabad, Uzbekistan, and Bagram, Afghanistan, and leading the multinational medical coalition assembled for Operation Anaconda and other combat operations staged from Bagram. Overall, the 274th FST took care of approximately 90% of U.S. combat casualties during this period and treated a total of 221 combat casualties. The FST treated 103 total surgical cases, including 73 with combat wounds. At the time, this experience with combat casualties and the surgical care of combat wounds was the largest since the Persian Gulf War. More importantly, this account describes the flow, frequency, and type of combat casualties seen in a low-intensity conflict like that being waged currently in Afghanistan. It is hoped that this depiction will aid in the preparation, equipping, and overall utilization of surgical assets in similar future conflicts.     

Psychiatric medications for deployment: an update

OBJECTIVE: This article discusses issues regarding the usage of psychotropic medications during military deployments, with emphasis on Operation Iraqi Freedom. METHOD: The role of psychotropic medications in the Army combat stress control doctrine is reviewed and compared with operational experiences of psychiatrists who have deployed to Iraq, Bosnia, and Egypt. RESULTS: Many issues regarding psychotropic medications experienced by deployed psychiatrists are not discussed in the Army combat stress control doctrine. CONCLUSION: The advent of new psychotropic medications, the changes in the types of conflicts fought, and the role of National Guard and Reserve forces in current conflicts have all had an impact on the role and usage of psychotropic medications during military deployments.     

Process of care for battle casualties at Walter Reed Army Medical Center: Part I. Orthopedic surgery service

Walter Reed Army Medical Center has been a primary hub in the United States for receiving Army battle casualties from Operation Enduring Freedom and Operation Iraqi Freedom. We detail the process of care that was developed to effect the timely effective management of these casualties.     

Expanding the role of the nurse practitioner in the deployed setting

Today's military is experiencing rapid advances in technology and in manpower utilization. The Army Medical Department is redesigning the structure and function of deployable hospital systems as part of this effort. The transformation of deployable hospital systems requires that a critical analysis of manpower utilization be undertaken to optimize the employment of soldier-medics. The objective of this article was to describe the use of nurse practitioners as primary care providers during deployment. The lived experiences of five nurse practitioners deployed to Operation Iraqi Freedom are presented. Data gathered during the deployment and an analysis of the literature clearly support expanded and legitimized roles for these health care professionals in future conflicts and peacekeeping operations.     

A review of 41 upper extremity war injuries and the protective gear worn during Operation Enduring Freedom and Operation Iraqi Freedom

Forty-one patients with upper extremity war injuries sustained during combat operations Operation Enduring Freedom and Operation Iraqi Freedom were reviewed to report on protective gear availability and usage at the time of injury. Participants treated at the Madigan Army Medical Center occupational therapy clinic from August 2004 until February 2005 completed a questionnaire regarding injuries sustained during deployment. Overall, 6 injuries were to upper extremity regions that were covered with issued protective gear; 21 injuries were to areas not covered with issued protective gear (i.e., participant was not wearing issued gear), and 22 injuries were to regions that were not covered because no protective gear was issued for that body area. Although this study is limited, future research would provide valuable insights about the efficacy of current body armor and the need for additional or modified gear.     

Emergent interfacility evacuation of critical care patients in combat

During the Second Iraq War (Operation Iraqi Freedom), high-intensity, low-utilization medical and surgical services, such as neurosurgical care, were consolidated into a centralized location within the combat zone. This arrangement necessitated intra-theater air medical evacuation of critically ill or injured patients from outlying combat support hospitals (CSH) to another combat zone facility having the needed services. A case series is presented of intratheater transfer of neurosurgical patients in Iraq during 2005-06. Ninety-eight patients are included in the series, with typical transfer distances of 40 miles (approximately 20-25 minutes of flight time). All patients were transported with a CSH nurse in addition to the standard Army EMT-B flight medic. Seventy-six percent of cases were battle injury, 17% were non-battle injuries, and the balance were classified as non-injury mechanisms. Seventy-six percent of cases were head injuries, with the balance involving burns, stroke, and other injuries. At 30 days, 12% of the patients had died, and 9% remained hospitalized in a critical care setting. None of the patients died during evacuation. Intratheater and interfacility transfer of critical care patients in the combat theater often involves severely head-injured and other neurosurgical cases. Current Army staffing for helicopter transport in these case requires a nurse or other advanced personnel to supplement the standard EMT-B flight medic.     

Implications of venom hypersensitivity for a deploying soldier

Venom immunotherapy (VIT) is a life-saving medical treatment for individuals allergic to Hymenoptera species. Delivery of VIT is a complex process that requires proper extract preparation, shipping, storage, refrigeration, and administration by qualified medical personnel in a facility that can manage a life-threatening allergic emergency (anaphylaxis). Successful VIT requires 3 to 5 years of uninterrupted maintenance injections, which may be difficult to maintain during deployments, particularly in combat operations. The complexity of VIT has resulted in service members being deemed nondeployable and has led to interruption or discontinuation of VIT for deployed service members in the past. We report the case of a 34-year-old Army National Guard soldier who successfully received maintenance VIT while deployed to Operation Iraqi Freedom. This case demonstrates that, with proper coordination and appropriate risk assessment, continuation of complex medical care, such as VIT, can be supported in a combat zone.     

Assessment of changes in mental health conditions among sailors and marines during postdeployment phase

Previous research regarding the mental health ramifications of military deployments focused on the U.S. Army population. As part of its deployment health surveillance mission, Navy and Marine Corps Public Health Center conducted a study of the Department of Navy population to identify reported mental health effects associated with Operation Iraqi Freedom, describe mental health care utilization by returning service members previously deployed in support of Operation Iraqi Freedom, and examine the relationships between self-identified risks and provider referral practices. Despite a considerable number of self-reported mental health concerns, referral for mental health consultations and health care utilization were rare. The psychological well-being of service members is essential to the military's optimum functionality and operational readiness; therefore, continued research in this area has significant bearing on future force health protection efforts. Additionally, this study highlights the need for further research on deployment-related mental health concerns.     

Spectrum of care provided at an echelon II Medical Unit during Operation Iraqi Freedom

We describe the types of medical problems encountered at a U.S. Army echelon II medical facility during Operation Iraqi Freedom in the period after completion of major ground combat operations, a time of nation restructuring and intermittent, intense, armed conflict. A total of 4,831 patients were assessed between October 1, 2003 and June 30, 2004, 74% with disease and nonbattle injury presentations, 19% with dental complaints, and 7% wounded in action (WIA). Disease and nonbattle injury evaluations were predominantly musculoskeletal. Improvised explosive devices or mortars caused 78% of the WIA casualties. The most frequent dental evaluations were for restorations (47%). Thirty-eight individuals were admitted to holding beds, most commonly to receive intravenous antibiotic treatment for cellulitis (29%). Three hundred forty-one individuals were evacuated, including 150 WIA. Determining the types of casualties seen at forward echelons of medical care during different phases of conflict can aid medical planning and help predict the type of medical resources required.     

U.S. Army disease and nonbattle injury model, refined in Afghanistan and Iraq

Previous analysis of Operation Desert Shield/Operation Desert Storm data yielded a disease and nonbattle injury (DNBI) model using distinct 95th percentile daily admission rates during the three phases of a war-fighting operation to predict medical requirements. This study refines the model with data from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Inpatient health care records of U.S. Army soldiers deployed to OEF and OIF who were admitted with DNBI diagnoses were analyzed. DNBI admission rates for OEF and OIF were compared with rates for Operation Desert Shield/Operation Desert Storm. DNBI admission rates for OEF and OIF were lower than those for Operation Desert Shield/Operation Desert Storm. Rates among the phases of OIF were distinctly different. DNBI admission rates have been reduced during recent deployments. The concepts of the original model based on Operation Desert Shield/Operation Desert Storm data were validated by experiences during OEF and OIF. Continuous surveillance of DNBI admission rates is recommended.     

Combat casualties in Afghanistan cared for by a single Forward Surgical Team during the initial phases of Operation Enduring Freedom

BACKGROUND: The 274th Forward Surgical Team (FST) was the first FST deployed to Bagram, Afghanistan, to provide surgical care for combat casualties during the initial phases of Operation Enduring Freedom. This is an analysis of the distribution, cause, and severity of wounds for combat casualties and the surgical procedures they required. METHODS: A prospective database was maintained for combat casualties cared for by the 274th FST. The database included demographic data, vital status, mechanism of injury, distribution and severity of wounds, and surgical care provided. RESULTS: The FST cared for 224 combat casualties, including 153 U.S. soldiers, 19 coalition soldiers, 32 Afghan militia forces soldiers, and 20 detainees. Fragments were the most common mechanism of injury (49%), and the extremity was the most common location of injury (58%), whereas gunshot wounds were the most common cause of death (57%). There were few significant head, chest, or abdominal wounds (13%). The FST treated 103 surgical cases (73 with combat wounds), including neurosurgical, thoracic, general, orthopedic, and vascular cases, with a total of 180 procedures. CONCLUSIONS: The distribution, cause, and severity of wounds were similar to those in the Persian Gulf War, despite the obvious differences between these conflicts. The use of modern technologies, such as compact, portable, ultrasound and digital X-ray systems, expanded the capabilities of the FST. Even low-intensity conflicts can produce significant numbers of combat casualties, and the FST must be manned, trained, equipped, and supplied to treat a wide variety of combat wounds.     

Advising and assisting an Iraqi Army medical clinic: observations of a U.S. military support mission

Medical civil-military operations are important for deployed military medical units engaged in counter-insurgency missions. There are few reports on military support for a host nation's military medical infrastructure, and we describe an initiative of the 21st Combat Support Hospital in 2010 during the postsurge phase of Operation Iraqi Freedom and Operation New Dawn. The goal was to incrementally improve the quality of care provided by Iraqi 7th Army medical personnel using existing clinic infrastructure and a low budget. Direct bedside teaching to include screening and treatment of ambulatory patients (sick call), focused pharmacy and medical supply system support, medical records documentation, and basic infection control compliance were the objectives. Lessons learned include the requirement to implement culturally relevant changes, maintain focus on system processes, and maximize education and mentorship through multiple modalities. In summary, a combat hospital can successfully implement an advise and assist mission with minimal external resources.     

美军联合战场创伤系统的发展及应用

联合战场创伤系统是美军为了提高伊拉克和阿富汗战场上的战伤救治效果而建立的一种创伤救治系统。2004年美军开始在伊拉克战场应用该系统,2005年开始在伊拉克和阿富汗战场全面应用。本文梳理了美军联合战场创伤系统的发展历史,探讨了该系统的任务、目标及组织构成,分析了其在伊拉克和阿富汗战场上的应用效果。     

Anger in the combat zone

A U.S. Army Reserve Combat Stress Control prevention team was dispatched to Afghanistan in support of Operation Enduring Freedom to provide preventative mental health care to a U.S. Army airborne division and Special Operations forces. The team's mission was to ensure mental health readiness of units in the area of operations. In Bagram, Afghanistan, the Combat Stress Control team identified anger as a very prevalent emotion in the combat zone. Anger management interventions with individual and group counseling were implemented to help soldiers cope with anger. Of 7,000 military personnel stationed there during the team's rotation, there was not one completed suicide or homicide. This article describes how the 113th Medical Company identified, treated, and controlled anger at Bagram Airbase, Afghanistan, between June 20, 2002, and December 20, 2002, with anger management interventions. This article does not address the psychophysiological features of anger.     

Medical problems of detainees after the conclusion of major ground combat during Operation Iraqi Freedom

After the conclusion of major ground combat operations during Operation Iraqi Freedom, the focus of the mission changed, although intense armed conflict continued. Included in this mission was management of security detainees, including provision of their medical care. We retrospectively reviewed the admission records identified at a short-term holding facility over 2 months and diagnoses of detainees admitted to a combat support hospital over 4 months as a health care service utilization statistics review. Six thousand six hundred thirty-one detainee encounters occurred at the short-term facility with approximately 45% of detainees reporting medical problems during each daily evaluation. Most frequent complaints were neurological (11%), gastrointestinal (10%), and respiratory (8%). Two hundred nineteen detainees' admission diagnoses were retrospectively reviewed from the combat support hospital, 98 (45%) due to gunshot or fragmentary injuries and 121 (55%) to other medical problems. Medical problems included cardiac (29%), gastrointestinal (17%), neurological (14%), musculoskeletal (11%), and pulmonary (6%) disease. Medical problems not traditionally dealt with in a combat theater, including management of transplant recipients, patients with cardiac valve replacement, and cancer patient, were also seen.     

Orthopedic injuries during Operation Enduring Freedom

Orthopedic injuries comprise a majority of combat injuries seen in recent U.S. military conflicts. Interventions in the forward deployed area have played an important role in improving mortality rates of soldiers as well as outcome at a medical center level. A retrospective review was conducted on orthopedic injuries from Operation Enduring Freedom evaluated at Walter Reed Army Medical Center (WRAMC). Patients were grouped into one of five injury categories (open fracture, amputation, arterial injuries, neurological injuries, and soft tissue injury) with evacuation time (days from time of injury to arrival at WRAMC) and procedures performed before arrival at WRAMC evaluated. The average evacuation time for all orthopedic casualties was 7.9 days. There was an average of 2.6 procedures performed per patient before arrival at WRAMC. There was no difference in evacuation time among the injury groups. Those with only soft tissue injuries underwent fewer procedures than the other injury groups; however, there was no difference among the injury groups in terms of procedures performed. The number of procedures performed did not affect the evacuation time. Fifty-six percent of casualties required operative intervention after arrival at WRAMC. With the unavoidable evacuation time that all casualties must endure regardless of severity of the injury, early operative intervention in forward deployed medical assets, such as the forward surgical team and combat support hospital, remains a necessity for rehabilitative and reconstructive efforts of the soldiers at the medical center level.     

Ocular diseases and nonbattle injuries seen at a tertiary care medical center during the Global War on Terrorism

We retrospectively reviewed the records of 107 U.S. military personnel referred to the Walter Reed Army Medical Center ophthalmology service with eye diseases and nonbattle injuries diagnosed during Operation Enduring Freedom and Operation Iraqi Freedom. Ocular diseases and nonbattle injuries ranged from minor to vision-threatening, represented a broad variety of conditions, and required the expertise of a number of ophthalmic subspecialists. The most common diagnoses were uveitis (13.1%), retinal detachment (11.2%), infectious keratitis (4.7%), and choroidal neovascularization (4.7%). Eighty-four patients (78.5%) met Army retention standards and were returned to duty. Twenty patients (18.7%) were referred to a medical evaluation board, seven (6.5%) of whom failed to meet retention standards for eye and vision; the retention status of three patients (2.8%) remains to be determined.     

Deployment risk factors and postdeployment health profiles associated with traumatic brain injury in heavy drinking veterans

Along with post-traumatic stress disorder (PTSD), mild traumatic brain injury (mTBI) is considered one of the "signature wounds" of combat operations in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]), but the role of mTBI in the clinical profiles of Veterans with other comorbid forms of post-deployment psychopathology is poorly understood. The current study explored the deployment risk and postdeployment health profiles of heavy drinking OIF and OEF Veterans as a function of mTBI. Sixty-nine heavy-drinking OIF/OEF Veterans were recruited through a Veterans' Affairs Medical Center and completed questionnaires and structured interviews assessing war-zone experiences, postdeployment drinking patterns, and PTSD symptoms. Veterans with positive mTBI screens and confirmed mTBI diagnoses endorsed higher rates of combat experiences, including direct and indirect killing, and met criteria for PTSD at a higher rate than Veterans without a history of mTBI. Both PTSD and combat experiences independently predicted screening positive for mTBI, whereas only combat experiences predicted receiving a confirmed mTBI diagnosis. mTBI was not associated with any dimension of alcohol use. These results support a growing body of literature linking mTBI with PTSD.     

Army Ranger casualty, attrition, and surgery rates for airborne operations in Afghanistan and Iraq

INTRODUCTION: Although numerous articles have been published documenting parachute injuries, a search of the medical literature revealed none that detail casualty, attrition, and surgery rates for airborne operations conducted into actual combat. This study examines observed airborne casualty, attrition, and surgery rates in U.S. Army Rangers during combat operations in order to identify risk factors attributed to static-line parachute injuries and provide a comparison to estimated attrition rates. METHODS: Data were recorded on standardized manual casualty cards and tracking forms while treatment was provided during two missions into Afghanistan during Operation Enduring Freedom and two missions into Iraq during Operation Iraqi Freedom, and then consolidated onto an electronic database for further analysis. RESULTS: There were 4 airborne missions totaling 634 jumpers that resulted in 83 injuries sustained by 76 Rangers (12%). Of those, 27 Rangers (4%) were unable to continue the mission and were subsequently evacuated. There were 11 Rangers (2%) who required surgery following evacuation. The overall observed attrition rate differed from the estimated rate (p = 0.04). Although observed attrition rates did not differ from estimations in Afghanistan (p = 0.75), attrition rates in Iraq were greater than estimated rates (p = 0.02) and observed rates in Afghanistan (p = 0.05). DISCUSSION: Many factors impact casualty, attrition, and injury patterns. Terrain and equipment load were notable associations analyzed in this study. CONCLUSIONS: Medical, logistical, and operational personnel can optimize support for airborne forces through improved estimation of casualty, attrition, and surgical rates. Risk factors associated with military parachuting can potentially provide further accuracy in estimating attrition and are recommended for integration into current models.     

Combat casualty care: the Alpha Surgical Company experience during Operation Iraqi Freedom

BACKGROUND: Operation Iraqi Freedom was the first large-scale combat operation involving the U.S. Marine Corps since the Persian Gulf War in 1991. Data from a combat surgical company are presented. METHODS: Records of all U.S. and Iraqi combat casualties admitted to the surgical company were reviewed. RESULTS: Fifty-three (57%) of 93 patients suffered penetrating injuries. Most wounds were produced by high-explosive munitions (mines, hand grenades, and rocket-propelled grenades), and the majority (51%) of wounds were to the extremities. The time to surgical care averaged 4.7 hours (range, 1.5-48 hours), and 98% of the patients seen at our facility survived. CONCLUSIONS: The time from injury to surgical care was considered long by civilian standards; however, this did not appear to affect outcomes substantially. A small percentage (5.2%) of injuries were to the torso. Hypothermia was commonly present. Because of the nature of their wounds, all patients required additional surgery after evacuation to rear area facilities. The outcomes of individual patients are not known, although it is known that only one Marine died after reaching medical care and, to date, no Marines have subsequently died of their wounds.