U.S. Army and Navy surgeons collaborate to offer ATLS demonstration course in Afghanistan

The U.S. Army and Navy recently joined forces to present an Advanced Trauma Life Support^® (ATLS^®) demonstration course in Kandahar, Afghanistan. A total of 25 students, including combat medics, nurses, and surgeons, were in attendance for the course led by Fellows of the American College of Surgeons (ACS).

Background

The course was offered to provide guidance to the surgical teams that provide care to the more than 13,000 U.S. North Atlantic Treaty Organization (NATO) troops deployed in Afghanistan in support of Operation Freedom’s Sentinel and the Resolute Support Mission. Kandahar Airfield is the hub of U.S. and NATO forces in southern Afghanistan, and two surgical teams are stationed at Kandahar Airfield to care for wounded military forces. One team is a U.S. Army expeditionary Forward Surgical Team (FST), and the other is composed of the U.S. Navy surgeons and health care providers at the NATO Role 3 Multinational Medical Unit (MMU). The FST deploys with the warfighter forward to perform damage control resuscitation and surgery for wounded soldiers.¹ Department of Defense doctrine now states that warfighters engaged in combat missions must be within proximity of a resuscitative surgical team.

FSTs are the foundation for “golden hour” trauma resuscitation on the battlefield. The NATO Role 3 MMU receives medical evacuation (medevac) soldiers either directly from the battlefield or from the FST and performs further resuscitative surgery as needed. The NATO Role 3 MMU serves as the best-resourced trauma center in-theater. Surgical subspecialists, radiology, laboratory, and blood banking are all present at the Role 3 hospital. Both the FST and the NATO Role 3 MMU must be prepared to effectively manage mass casualty events.

The two formidable challenges for both of these trauma teams are turnover of surgical teams and allied medical providers at the end of service tours and the variability of pre-deployment trauma experience within the team. Therefore, to sustain medical readiness both the FST and the Role 3 MMU perform training exercises.

Course design

Consistent with this intense training, the Army FST and NATO Role 3 MMU collaborated to perform the ATLS demonstration course November 1−2, 2017, at the NATO Role 3 MMU at Kandahar Airfield. There is a long history of such collaboration at the Defense Medical Readiness Training Institute in San Antonio, TX, where officers of the U.S. Army, Navy, and Air Force teach the ATLS-OE [Operational Emphasis] Course. However, this collaborative in-theater educational effort, which included both conventional and unconventional forces, was unique.

The 25 students from the 1st FST, 82nd Airborne, and 10th Special Forces Group who attended the demonstration course praised both the lectures and the interactive skills stations that took place in the simulation center of the NATO Role 3 MMU. The NATO Role 3 simulation center is a modern learning environment within the hospital and had the capacity to facilitate the ATLS skills stations and small group radiology imaging review. Learning tools such as TraumaMan Surgical Simulator, intubating mannequins, portable video laryngoscopes, and junctional tourniquets were all incorporated into the demonstration course.

Clinical scenarios specific to the Afghanistan Theater were discussed in conjunction with both lectures and skills stations. Management of injuries from improvised explosive devices (IEDs) and vehicle-borne IEDs were reviewed and heavily discussed. Additional content discussed during the course included the Joint Trauma System Clinical Practice Guidelines for the care of injured soldiers, tourniquet application and management, 9-Line medevac, and medical rules of engagement and ethics of caring for enemy combatants. It was the first official ATLS demonstration course taught in Kandahar.

ATLS is the most influential trauma educational course in the world and a valuable tool for the military trauma team. More than 1 million students in 86 nations have enhanced their trauma skills through the ATLS course (see related stories). The ATLS course is an effective tool for team building and developing a common language in caring for trauma patients.

Value of the course

Demonstration courses help military trauma care providers to enhance their overall trauma knowledge and the technical skills required for lifesaving battlefield resuscitative procedures. Discussion of specific battlefield scenarios allowed students to understand the abbreviated damage control approach to combat injuries in a forward environment, which is vital for expeditionary FSTs because of their intentional limited capacity to provide extended postoperative care to critically injured soldiers.^2,3 Triage skills are crucial to ensure appropriate resource utilization.

Furthermore, appropriately preparing patients to quickly transition from the FST to the rotary wing or fix-winged medevac platform is important. The small group of trauma providers who comprise the FST are all cross-trained and have multiple skills to facilitate both the resuscitation and rapid transport of injured soldiers to the Role 3 hospital. It is for these reasons FSTs have been dubbed the Army’s most powerful tool for conserving the fighting force on the battlefield. They were first deployed in Iraq and now provide the primary component of the trauma care in Afghanistan.^2-4

Key personnel

Permission to present the Kandahar course was granted by the ACS Committee on Trauma (COT) ATLS Committee. The course was co-directed by co-authors of this article—Colonel Mallory Williams, MD, MPH, FACS, Co-Commander of the 1st FST, and Commander Matthew E. Tadlock, MD, FACS, Chief of Trauma, NATO Role 3 MMU. Howard University College of Medicine, Washington, DC, served as the host institution in the U.S. for both the coordination of the demonstration course and the Continuing Medical Education (CME) program on damage control resuscitation and surgery for the FST. Through this unique university-based partnership, soldiers in the FST were able to be educated on mission-essential trauma-related material, as well as receive CME and continuing education unit credits to maintain their professional licenses, a common challenge for deployed soldiers.

Kenyatta Hazelwood, RN, BSN, MPH, trauma program manager, Howard University Level I Trauma Center, and Lieutenant Commander David M. Lim, DO, staff emergency medicine physician at the NATO Role 3 MMU, worked to coordinate the course. In addition to Dr. Williams and Dr. Tadlock, course instructors included Dr. Lim; Colonel James B. Smith, MD, FACS, Commander 1st FST, a co-author of this article; and Captain Robert Strange, MD, FACS, cardiothoracic surgeon, NATO Role 3 MMU.

Acknowledgments

The authors extend their gratitude to Sharon Henry, MD, FACS, Chair of the COT ATLS Subcommittee; Freddie Scruggs, ATLS Regional Program Coordinator; and the COT ATLS Subcommittee members for making this demonstration course a reality. The authors recognize the sailors who organized the NATO Role 3 MMU Simulation Laboratory that made this collaborative effort possible and serves as a significant resource to the overall trauma readiness of the warfighter in Kandahar. We also express our gratitude to Margaret Boyer, PhD, director of CME at Howard University College of Medicine for her outstanding contributions to the FST CME program. Finally, we acknowledge the eternal investment of the more than 2,000 U.S. soldiers who have given their lives in the war effort in Afghanistan.

Disclaimer

The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the Department of Defense, or the U.S. government.

References

1. S. Department of the Army. Field Manual 8-10-25 Employment of Forward Surgical Teams. Washington, DC: U.S. Government Printing Office; 1997.
2. Counihan TC, Danielson PD. The 912th forward surgical team in Operation New Dawn: Employment of the forward surgical team during troop withdrawal under combat conditions. Mil Med. 2012;177(11):1267-1271.
3. Place RJ, Rush RM, Arrington ED. Forward surgical team (FST) workload in a special operations environment: The 250th FST in Operation Enduring Freedom. J Surg Educ. 2003;60(4):418-422.
4. Ling GS, Rhee P, Ecklund JM. Surgical innovations arising from the Iraq and Afghanistan wars. Annu Rev Med. 2010;61:457-468.