Forward Surgical Team Brings Advanced Care Closer

By Karen Parrish

American Forces Press Service

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.

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.”