Battlefield Medicine, Afghanistan 2011
Guest post from Phil;
This article aims to explore the provision of medical assets, training and equipment in Afghanistan as currently practised.
The provision of medical assets in theatre is given more of a priority than one might immediately think and medical resources or a lack thereof are very often a “go” or “no go” feature of an operation in Afghanistan at the moment. It is also an area where information outside the service is scarce or is not comprehensive enough.
Therefore I think the subject area merits further exploration.
I will concentrate on the patrol medic rather than the MERT and the Field Hospital capabilities in this article.
Medical Organisation and Training
In terms of ongoing operations and the operations likely to be undertaken in the future the two most relevant types of medical units in the Army today are the Medical Regiments and the Field Hospitals with both types of formation having substantial numbers of regular and reserve units.
In the ground environment envisaged in likely future operations the brigade plays a very large role.
Therefore the Army Medical Services launched a project known as Improved Medical Support to Brigade (IMSB) whose goal was exactly that.
During this project various concepts were trialled including Force Support Hospitals and Combat Support Hospitals. Some of this trial work was carried over to the final solutions, the main components of which was the concept of a Medical Regiment supporting each brigade deployment and in turn being supported by a Field Hospital at Theatre Level capable of generating 4 trauma bays, 2 surgical bays and 25 beds in its standard configuration.
The number of Medical Regiments has now been increased to provide each brigade with one and the Field Hospitals reorganised to provide modular 25 bed organisations with the three regular Field Hospitals being able to deploy more than one 25 bed organisation per hospital and the TA Field Hospitals being seized at 25 beds. With the very recent announcement of Army rebalancing the numbers of beds are obviously subject to change but there is no evidence that the concept of a Medical Regiment and a 25 bed modular hospital per brigade are to be changed.
The main building blocks of the AMS are these regiments and hospitals.
The Medical Regiments are essentially organised in the UK to provide close support to the battle groups and to provide critical care stations or mobile surgical groups in the rear.
The organisation and names change with a bewildering frequency and so I will instead concentrate on the organisation of the Medical Regiment on operations in Afghanistan which has remained broadly the same for a number of years.
The regiments themselves are mostly made up of Combat Medical Technicians of the RAMC with smaller numbers of General Duties Medical Officers and smaller numbers still of specialist healthcare personnel such as surgeons, anaesthetists, nurses and pharmacy technicians.
The emphasis in the Field Hospitals is the opposite with the CMTs being in the supporting role with larger numbers of doctors, surgeons etc.
Thus you can see that as you move back in the medical evacuation chain the emphasis changes from more general care to more specialist capabilities. The Field Hospitals are scaled to provide an Emergency Department of 4 trauma bays, 1 surgical facility of 2 bays, an X-Ray section, a laboratory section (for blood and blood products), an intensive care facility of 4 beds, two uneven wards representing 25 beds total and a Support Squadron which can be reinforced with laundry and hygiene units and QM staff.
The hospital itself is run from the Hospital Management Cell, essentially its HQ.
Further medical support is provided by other units in the form of their Regimental Aid Post or Medical Treatment Facility – the name changes but essentially each battalion or regiment is scaled for operations with a Medical Officer and a number of Regimental Combat Medical Technicians, most of who will cascade to the Company Aid Posts on operations.
In practise in peacetime a lot of units will have no dedicated MO since the garrison will provide a Garrison Primary Healthcare Facility.
These structures fit into a medical matrix of roles – of which, traditionally, there are 4.
Role One medical units provide care from the point of wounding and back to the critical care stations or clearance stations which are known as Role Two.
Role Three is care provided by a Field Hospital with additional specialisations (neurosurgery etc) in theatre whilst Role Four is UK based care (Selly Oak).
This is nice in theory but in reality the roles do not work in sequence, for example in Afghanistan you now go from Role One straight to Role Three (the hospital in Bastion), missing out Role Two entirely.
Even then things are not quite this simple. What has been happening is that the sequential trail of casualty evacuation has given way in Afghanistan to a matrix style of care more of which will be explained below. From this confusing array of Roles one can see that the provision of medical support varies greatly depending on the type of operation being conducted which has made the balancing of the AMS particularly challenging. In a traditional war fighting sense the sequential Roles are perfectly necessary, but in Afghan and Iraq some roles were rendered irrelevant by the opportunities of heli-borne medical evacuation.
Currently in Afghanistan the medical capabilities are provided by the Joint Force Medical Group Afghanistan, part of the Joint Force Support Group.
Its core is provided by a Medical Regiment and a Field Hospital from either the TA or the Regular army. The peacetime organisation of the Medical Regiment is swept away as it is subsumed into the JF MED GP. It reorganises itself into an A Squadron, B Squadron, Support Squadron and a Hospital Squadron (this being the Field Hospital). This organisation then mans the matrix of Medical Treatment Facilities dotted around Task Force Helmand and mans the Role Three hospital in Camp Bastion.
The matrix of Medical Treatment Facilities (or the MED LAYDOWN as it is known) varies widely in its scope and capabilities and ranges from one man patrol medics to larger organisations.
Broadly speaking each platoon sized Patrol Base will have at least one medic, a Forward Operating Base a medical section and a Main Operating Base additional doctors and Primary Health Care Facilities; however the precise allocations are decided on a case by case basis as the MED LAYDOWN is generated prior to deployment.
In summary the JF MED GP provides the range of Role One medical care dotted around the PBs and FOBs, it then provides an additional layer of Primary Health Care Facilities in Camp Bastion, Lash G’Kar and Kabul and then it provides the Role Three hospital. A Squadron provides the Close Support element and mans the Role One facilities throughout TFH as part of the MED LAYDOWN: they provide the patrol medics to the combat units. B Squadron provides the Primary Healthcare capabilities, the Ambulance Troop at Bastion and the Medical Emergency Response Team (MERT). Essentially, A Squadron will have the fittest most capable CMTs and B Squadron the remainder as they do not have to leave the bases (aside from the MERT). The Medical Regiments have the ability to generate Mobile Surgical Groups but in Afghanistan the personnel that would form these are instead cross posted to the Hospital Squadron or MERT as there is no longer any part of the TFH AO that is outside MERT range.
To help crystallise a very complicated picture I shall use a snapshot of the JF MED GP organisation in October 2010.
16 Medical Regiment provided the core of the JF MED GP with its regimental HQ providing the command element of the group. 16 Medical Regiment in peacetime comprises 19, 23, 181 and Support Squadrons but as mentioned prior to deployment the regiment reorganised into A Close Support Squadron, B General Support Squadron and Support Squadron.
The regiment was uplifted by 30 odd TA CMTs and other specialists prior to deployment and these were posted throughout the three squadrons and the GP HQ. A Squadron saw approximately 90 CMTs deployed to the five battle groups with the local organisation varying greatly throughout the AO. Bolted onto this organisation of 3 squadrons was the Hospital Squadron which has evolved from forming the Hospital in Bastion to now being the British contribution to the Hospital in Bastion since it has grown massively since the American surge as it deals with US casualties from TF Leatherneck.
In October the Hospital Squadron was provided by 207 (V) Field Hospital, a TA unit serving for 3 months, replaced by 212 (V) Field Hospital in January 2011.
Overarching all this of course is the MERT, plenty of information is available about the MERT as it is sexy and cool and so I will not cover it in depth here.
The backbone of this entire organisation is the humble Combat Medical Technician, occupying a no man’s land between civilian nurse practitioner, paramedic and environmental health officers.
The job of the CMT is to provide trauma care on the front line from the point of wounding and in the Role One facilities. He or she also has to provide Primary Health Care to the Population at Risk (PHC involves the more mundane and every day medical care, skin rashes, headaches, pains, sprains, STDs etc) and also environmental health advice to their units.
If a lone medic they might have to provide the whole spectrum, in other areas the CMT might have a Doctor as his boss who can deal with much of the PHC aspect and lead on trauma that makes it through the doors of the FOB to the Medical Treatment Facility (MTF). To train as a CMT involves a 6 month course at the Defence Medical Services Training Centre in Keogh near Aldershot.
After completion of this course one passes out as a CMT Class 2, able to operate under supervision of a CMT Class 1 or a healthcare professional.
Skills are then developed in a Medical Regiment over 12-18 months before the Class 2 is sent back to the DMSTC to complete a 7 week Class 1 course from which they emerge able to officially operate independently as patrol medics. Prior to deployment the CMT will be worked up in pre-deployment training both within the regiment and by being attached to other units during their exercises either as actual medical support or acting as exercise troops, more often they will do both. They must also attend a Battlefield Advanced Trauma Life Support Course (BATLS – see what they did there?) a world leading course based on the civilian ATLS but obviously with a battlefield emphasis.
All medical personnel attend this course and it is almost identical for everyone from CMT to Consultant Surgeons. It emphasises the treatment of battlefield casualties and trains the personnel in the drills and kit needed to maintain life after an IED strike or gunshot wound etc. The instructors are all extremely experienced and due to the short tours of doctors and TA medical professionals they will have bang up to date theatre practises and realities to pass on.
This course is world renown and several other countries subscribe to it – singly the most important course that a medic on the ground can attend.
The TA CMTs attend three two week courses, a Class 3, a Class 2 and a Class 1 volunteer course. Recently a new deployment pathway has been developed for the TA CMT with the result that now all TA CMTs will attend the regular CMT Class 1 course whether they have done the TA one or not. Again they attend the BATLs course. General Duties Medical Officers are usually baby doctors on their first Army posting and will obviously have Army trauma training on top of their doctors training – however, in a trauma situation on the ground there is little difference in the skill set of the GDMO and the BATLs trained CMT.
There is only so much you can do in a Care Under Fire situation.
Next level down is the Team Medic. These are normal members of a unit given extra medical training, some of which is found in the BATLs drills and skill sets. In theory each combat support unit will have 1 in 8 of its men trained as TMs and combat units 1 in four. In practise however units will tend to cram as many as possible on the course prior to deployment now that there is sufficient critical mass of TM instructors available. They are an extremely valuable asset even if the patrol or sub unit has an embedded CMT on the ground since they are capable of assisting the CMT as well as operating independently. This initiative is relatively new to the British Army but is proving its worth every week in Afghan.
Now that we have explored the organisation and training of battlefield medicine on the ground in Afghanistan we shall move onto some of the kit of the patrol medic.
Dismounted Patrol Medical Bergan (Module 584)
In the Defence Medical Services all equipment is organised into modules depending on its purpose.
So, a Primary Healthcare Facility will have a 501 Module in which there are the drugs and kit to support x number of personnel.
Likewise the CMT on the ground has his own medical module and it is known as the 584 Module, the Dismounted Patrol Medic Bergan. The concept of this bergan is to provide the CMT with enough medical kit to treat one catastrophically injured casualty and a severely injured casualty as well as provide a range of Primary Healthcare products to help maintain the health of a section/platoon of men independently.
Complete, it all fits inside a Blackhawk Medical Bergan although it is extremely heavy.
In practise, whilst the module is issued complete, CMTs will customise it. If the medic is deployed to a FOB then there will be Primary Healthcare products available there, so there is no need to patrol with that part of the module, it can be left in Sqn stories in Bastion.
If deployed as a lone medic to a newly constructed Check Point then the Primary Healthcare kit will be taken but left in the CP whilst out on Patrol.
Essentially every CMT will strip down their bergans to enough kit to support two severely injured casualties. The Primary Healthcare kit mostly comprises drugs for common ailments; it comprises various painkillers, anti diarrhoea tablets, allergy tablets, a range of antibiotics, dressings, antiseptics, dioralyte, bandages, needles, syringes and so forth.
The trauma kit I will discuss further below.
CAT (Combat Application Tourniquet)
Probably the most cost effective, life saving bit of kit ever purchased by the army in any period in history.
This bit of kit has saved innumerable lives.
Prior to 2004 the Army did not recognise the vital role played by the tourniquet in trauma treatment thus the only one in the medical inventory was a medieval thing that was never intended for use outside of the surgical facility.
This is not necessarily the fault of the army since the civilian health services are only now just coming around to its utility and only very slowly.[browser-shot width=”600″ url=”http://combattourniquet.com/”]
Every soldier is issued two of these and TMs are issued additional supplies. The 584 module contains 5 CAT‘s but many medics will carry extra, there are boxes and boxes of these things in theatre. From 2004 onwards it was recognised that the leading cause of preventable death on the battlefield was bleeding out from the limbs.
BATLs recognised this and emphasises dealing with this bleeding before anything else.
The CAT is able to stop bleeding in almost every case of a traumatic amputation of a limb or serious injury to it. It can be applied by the casualty himself one handed. Two are usually needed per amputated leg, one per amputated arm – incredible bits of kit and if looked after, extremely strong.
In line with the need to control serious bleeding there comes a suite of other kit, the most basic but still extremely important is the Emergency Bandage from First Care Products[browser-shot width=”600″ url=”http://firstcareproducts.com/”]
Previous field dressings were hard to apply and simply soaked up large amounts of blood.
The Emergency Bandage is not designed to soak blood but instead comprises a sterile pad mounted on elastic bandage that is easily applied and applies direct pressure to the wound. It is simple and versatile and actually accomplishes bleeding control unlike the older dressings.
There are two main sizes, the normal dressing and the abdomen dressing, a much larger dressing which is very useful to control bleeding from the groin area if the casualty has been caused by an IED strike and there is trauma between his or her legs.
Another weapon in the fight against bleeding is CELOXgauze, a haemostatic in that it causes blood to clot and thus can prevent bleeding.[browser-shot width=”600″ url=”http://www.celoxmedical.com/int/”]
It comes in bandage form and can be literally stuffed into the wound to pack it out and clot the blood vessels.
The CAT, whilst extremely effective is not suitable for wounds to the torso, head or neck for obvious reasons, and the Emergency Bandage itself might not control bleeding entirely. Therefore the medic can stuff the wound with CELOX for great effect and then wrap the wound with an Emergency Bandage.
The final weapon in this article to control bleeding is the SAM SLING.
When a soldier detonates an IED the trauma can literally break his pelvis in half with the trouble that the pelvis is a large space that can absorb your entire blood volume – you can bleed out into your pelvis and this being internal bleeding there is no way combat this using CATs or dressings. The solution is the SAM SLING which effectively pulls the shattered pelvis back into shape, reduces the space for the blood to go into and thereby reduce the chances of bleeding out.
On a double or triple amputee it is usually necessary to use the entire suite of products mentioned above, two CATs per leg, CELOX and dressings to pack out groin wounds, dressings for the stumps and the SAM SLING for the pelvis.
After stopping the bleeding the other main problem on the battlefield is being able to replace any lost fluid since without at least a minimal fluid volume the casualty will suffer a cardiac arrest and die.
The severe trauma and shock suffered by a casualty may mean that their veins literally shut down and it becomes impossible to get intravenous access. There are two tools available to the CMT to administer fluid in this scenario, both of these involve administering fluid through the bones, this is called intraosseous rather than intravenous.
The first IO device is called the FAST 1 and is a mean looking tool designed to fire a needle into the breastbone through which fluid can be squeezed. The device is pressed against the chest and when there is equal pressure on all spikes the gun is level and will automatically fire the needle into the chest.
It is an effective method of fluid infusion on the battlefield although it can fail 50% of the time.
The second device works exactly the same although it is not used on the chest but usually in the legs, pelvis and sometimes the shoulder.
The EZ IO from Vidacare
It is a brutal manual device and simply requires the medic to locate where the needle shall go and then literally push the needle into the bone using brute force. An unpleasant method, but vital if venous access is not possible.
A Quick Scenario
Now a quick scenario to show how the medical process works in Afghanistan:-
An ISAF patrol is moving through a tree-line, it is 15 men in strength and contains 2 Team Medics and an embedded CMT Class 1 from the Medical Regiments A Squadron.
The leading man strikes an IED, is blown into the air and losses both legs and an arm.
Immediately the closest man can apply the CAT to his wounds since all soldiers are trained to apply it.
The Team Medic can move forward as well as the CMT. The patrol commander will be organising his defence and will notify his Ops Room that there is a man down.
The Ops Room will then immediately send the first lines of a 9 Liner casualty evacuation request. The CMT will check the CATs, secure the airway and organise the casualty to be moved to a safer area to avoid further casualties. There the CMT will use whatever TMs are spared to help him administer a higher level of care than he can give on his own in the open.
The patrol commander will ask for a MIST which is a statement of the casualties severity, injuries and vital signs, this will be passed to Ops Room who will pass it on – this information will pass to a medical liaison cell in Joint Force Helicopter Group and the appropriate airframe will be allocated based on the information in the MIST making it a vital piece of information – in this case the casualty is an ISAF triple amputee, the highest priority, known as a CAT A – this will see the MERT scrambled.
The MERT will then start spinning and get wheels up in minutes few.
Meanwhile the CMT will keep the MIST updated and continue to treat the casualty. The first sign of the MERT will be the Apache hovering overhead, laying down covering fire if necessary.
The MERT is incredibly fast, 20-25 mins max which means that the CMT might not even have time to complete his treatment before the next level of care arrives. Once the MERT lands the force protection section will run out and take-up position and the Paramedic on the MERT will come out and meet the CMT and take a casualty handover whilst the others get the casualty onto the MERT. Onboard the MERT will be a Consultant Trauma Doctor, an Anaesthetist and a Nurse. The MERT carries blood and blood products and so the MERT can put the casualty to sleep, secure his airway by intubation and then replacing the lost blood with actual blood rather than the fluids available to the medic on the ground.
The MERT will re-evaluate the casualty and complete and refine the treatments needed.
The MERT will then land back in Bastion and meet an ambulance from the Medical Regiments Ambulance Troop, part of B Squadron. The ambulance takes the casualty from the landing site to the hospital. In the Emergency Department there will be a trauma bay ready to receive the casualty with extra blood, instant x-rays, and a surgeon to evaluate the patient for surgery.
In the most severely injured, the casualty can go right past the trauma bay and straight into the surgical bay or into the MRI scanner.
As you can see, the treatment regime in the Role Three is very aggressive and very quick. From there, the casualty can be moved by an RAF Critical Care Air Support Team on a C17 back to the UK in 12 hours.
So in Afghanistan today you are looking at around 12-24 hours to go from the point you detonate the IED to being back in the UK receiving world class trauma care from the start to end. Previously under AMS doctrine you’d have been lucky to see an unenhanced Field Hospital within 24 hours.
Thus as you can see the provision of medical resources on operations in Afghanistan is a seriously complicated undertaking but which nonetheless is well exercised, aggressive, efficient, swift and well trained and equipped. Soldiers are surviving with wounds that just 5 years ago would have seen them classed as “unsalvageable” in that pleasant jargon of medical professionals. As ever, war and operations has once again bought the medical services to the fore and seen them properly resourced and enhanced from the poor state that they were allowed to fall.
The Defence Medical Services are light years from where they stood in 2001.