Professional Note: Forward Resuscitative Surgery in Operation Iraqi Freedom

On 21 March 2003, U.S. Marines assigned to Operation Iraqi Freedom (OIF) streaked north toward Baghdad in the Corps' largest and most rapid overland combat operation. Within three weeks, forward elements of I Marine Expeditionary Force (I MEF) had fought their way to Tikrit, 600 miles from the sea and the nearest casualty treatment ship-and naval medical support was prepared for the task.

Historically, 20% of modern war casualties are killed in action (KIA); i.e., they die before reaching a medical officer. Many of them suffer injuries so grievous they cannot survive, even with immediate surgical care. Half of the KIAs die 10-60 minutes after being wounded (at least 50% of them from hemorrhaging). They represent a potentially saveable group that should be treated as quickly as possible.¹

In the past, surgical companies of the medical battalions and the fleet surgical teams-the latter operating on LHA- and LHD-class amphibious assault ships-provided most of the forward surgical capabilities to Marine forces. In Operation Enduring Freedom (OEF) in Afghanistan and OIF, Marine combat units operated 300-600 miles from the nearest casualty receiving and treatment ship. During OEF, when the forward resuscitative surgical system (FRSS) was still in the prototype stage, a task-organized element of the surgical company was deployed. The logistical support needed for this unit was heavy and bulky. Prioritization of the logistical flow into Camp Rhino was such that medical equipment arrived five days after the medical personnel and just hours prior to a mass casualty event.²

Marine Corps doctrine focuses on expeditionary maneuver warfare, which provides the commander a task-organized force and emphasizes maximum mobility of combat and combat service support elements. Emphasis on maneuverability and speed, however, imposes problems on medical personnel. As time and distance from injury to surgical intervention increases, so does morbidity and mortality.^₃ The FRSS was developed to meet the need for mobile emergency surgical care in proximity to the point of injury, and accomplish it with a minimal footprint.

FRSS Capabilities and Missions

The FRSS is "a highly mobile, rapidly deployable, trauma surgical unit that will provide emergency surgical interventions required to stabilize casualties who might otherwise die or lose limbs before reaching treatment."⁴ It cares for as many as 18 surgical casualties in a 48-hour period without resupply or relief of personnel. The medical material includes:

* Draw-over anesthesia vaporizer

* Portable oxygen generating system

* Surgical instruments

* Monitors and noninvasive imaging

* Blood storage

* Laboratory diagnostic equipment

Consumable medical supplies consist of intravenous fluid, medications, sutures, and other supplies. These supplies and equipment, including shelters and electrical generators, weigh 5,900 pounds (dry)-or 6,700 pounds, including water and fuel-and occupy 400 square feet. Under ideal circumstances, the system can be established by eight medical personnel and be ready to receive casualties in one hour; after evacuation of casualties, it can be disassembled and embarked for transport in one hour. The FRSS can be carried by rotaryand fixed-wing aircraft, naval surface vessels, or by two high-mobility multipurpose wheeled vehicles with trailers.

The doctrinal concept of operations calls for the FRSS to augment the shock trauma platoon (STP) that deploys with the combat service support element (CSSE). It also can augment a battalion or regimental aid station, with or without an STP. The augmented STP or aid station provides initial triage and assists in pre- and postoperative patient care.

The FRSS is employed when the tactical situation precludes use of a surgical company or when rapid transport of casualties to a higher echelon of medical care is not possible. It may be used in support of humanitarian assistance and disaster relief operations when rapid response is needed for a short-term mission. Further, it can support a brigade service support group mission during low-intensity conflicts—for example, with the Marine expeditionary brigade that provided security in Iraq after the initial combat phase. Other possible tasks include surgical support for split amphibious readiness group operations, afloat and shore. Finally, the FRSS could provide surge augmentation of existing facilities or en route surgical capability during transport on a high-speed vessel.

FRSS and STP Organizations

The table of organization for the FRSS includes 2 general surgeons, 1 anesthesiologist, 1 critical care nurse, 1 independent duty hospital corpsman, 2 operating room technicians, and 1 field medical technician. For OIF, an en route care nurse with critical care experience was added to each team to move stabilizing patients requiring critical care to definitive treatment facilities farther in the rear. In addition, half the FRSS teams had an orthopedic surgeon in place of a general surgeon to expedite treatment of limbthreatening injuries.

The STP is designed as a mobile emergency room staffed by 2 emergency medicine physicians, 1 physician's assistant, 1 emergency room nurse, 14 Navy hospital corpsmen, and 7 Marines. The STP was designed originally to reinforce a battalion or regimental aid station or to establish a helicopter or beach evacuation station. When augmented with an FRSS, it can triage, resuscitate, and stabilize casualties. In this configuration, STP personnel also provide pre- and postoperative care to surgical patients that frees surgeons and anesthesiologists for operations.

Operation Iraqi Freedom

For Iraqi Freedom, six FRSS authorized medical allowance list blocks (AMAL 645) were available in theater. Because only two FRSS teams had been trained prior to deployment, an additional four teams-composed of personnel from active and reserve surgical companies-were trained intensively in Kuwait four weeks before the beginning of the war. (Ten STP teams deployed during OIF, three of which were paired with FRSSs.)

The FRSS had two distinct missions during OIF. One was to act as the initial surgical capability for a surgical company. The FRSS-STP and ward section of the surgical company moved quickly to the surgical company's site and provided nearly immediate casualty care until the remainder of the company was operational (which usually took two to three days). They would then meld into the surgical company until ordered to a new location. The second mission was to function as a forward FRSS in close support of 1st Marine Division elements. The forward teams were assigned to CSSEs that were in direct support of regimental combat teams.

Combat operations started 21 March and lasted until cessation of offensive operations was announced on 1 May. During most of the conflict, three teams served as forward FRSSs; the other three served as jump FRSSs. Two teams served in both capacities at different times. When one team lost half its medical equipment because of vehicle breakdown during a sandstorm early in the campaign, FRSS Team 1 and FRSS Team 6 operated together for the remainder of GIF as a forward FRSS (reinforced).

The FRSS is designed specifically to perform resuscitative surgery, with the objectives of decreasing mortality in the potentially saveable group of casualties and decreasing morbidity by rapid restoration of normal physiology and control of contamination. Thus, nearly all patients operated on at an FRSS during OIF required definitive surgery at a higher echelon of care. Data used here is for patients evaluated and treated by FRSS teams during the time period noted above; for jump teams, it includes only patients treated at the FRSS prior to establishment of the surgical company. Ninety-six casualties (34 Marines and 62 Iraqis) were treated by FRSS teams.

The types of injuries seen were typical of conventional warfare. In comparison to previous conflicts, the incidence of gunshot wounds was slightly higher than to be expected and was related to the severity of injuries to patients treated at the FRSS. (See Figure 1.) The Marines' Kevlar helmets and body armor helped protect them against head, chest, and abdominal injuries.

Because of weather conditions and distance, wounded Marines taken to a forward FRSS arrived within an hour of injury; those taken to a jump team arrived much later. As a rule, forward teams were less than 15 kilometers from engagements and jump teams were more than 50 kilometers away in general combat service support areas. Consequently, surgical procedures performed by forward teams tended to be the most urgent. Of five physiologically unstable casualties, four went to forward teams and one to a jump team.

Only three Marines died of wounds early in the war (at one of the surgical companies). All Marine casualties treated at an FRSS during OIF have survived to date. Note that, of total Marine casualties during the combat phase, the died-of-wounds (DOW) rate was 1%—lower than that of previous conflicts, when it ranged from 2.1% to 8%.⁵

Evacuation Considerations

Tactical casualty evacuation (CasEvac) refers to the evacuation of casualties from the point of injury, or from an aid station, to the first surgical care. Medical evacuation (medevac) refers to the evacuation of patients from the first point of surgical care rearward to a more capable medical facility.⁶ During OIF, CasEvacs and medevacs generally used dedicated helicopters. Four dedicated Marine CH-46s at the 1st Marine Division headquarters provided casevacs, contrary to the previous practice of using lifts of opportunity only. The Army assigned a company (12 UH-60s) to I MEF for medevac of patients from the FRSS-STP or surgical company to medical facilities in the rear. The patient evacuation team at the direct air support center directed movement of injured patients to the nearest FRSS or surgical company, and from there to the rear.

Postoperative care and evacuation become critical when Marines and civilians are operated on in a combat environment. The FRSS only has a limited ability to care for postoperative patients who require extensive resources-for example, mechanical ventilation, intravenous medications, fluid resuscitation, and blood transfusions to stabilize blood pressure. These requirements demand rapid medevac after stabilization surgery. Sixteen of the 96 casualties (17%) treated by an FRSS team required en route care. Those acutely ill patients were moved rearward with the equipment, medication, and nurses needed to continue treatment on the way to the rear. The longest of these moves entailed use of helicopters, fixed-wing aircraft, and ground transport from outside Baghdad to the Army 47th Combat Support Hospital in Kuwait City, a distance of 350 miles.

Lessons Learned

A concerted effort must be made by naval medical and Marine commanders to meet the challenges of this new capability. The future success of the FRSS depends on identifying and training a cohesive group of individuals with certain clinical skills, operational medical skills, and experience. Dedicated CasEvac assets and nurses trained to care for critical patients during aircraft transport legs are necessary to maximize the effectiveness of FRSS-STP teams.

Force service support group commanders determined that the active and reserve medical battalions need to be reorganized. Surgical companies are too large to keep up with maneuver warfare. The FRSS-STP teams add significant value only if they are far forward, near the action. In addition, medical communications must be improved-satellite telephone and e-mail were the only reliable forms of communication during OIF.

The FRSS concept faces three major challenges:

* Personnel assigned to FRSSs and STPs must be identified specifically. This is essential for team training and continuity and rapid deployment. The current component unit identification code/mobilization augmentation platform system does not provide the requisite specificity. Establishment of dedicated Marine Corps naval medical personnel (FAC-U) billets for the clinicians who will compose the FRSS is a "win-win" situation for both the Bureau of Medicine and Surgery and the Marine Corps. These officers and enlisted persons would be assigned to full-time billets in the Corps' medical battalions. Their primary duty would be to support operational units, and they would be accountable to the operational commanders. When not committed to duties with their operational units, they could support healthcare tasks at naval hospitals.

* Planners must recognize the peacetime healthcare mission does not adequately support and train Navy clinicians for wartime needs. The Medical Corps reserve component has most of the current trauma experience. The Navy recently opened a trauma training center at the Los Angeles County Medical Center and now can rotate active-duty FRSS and fleet surgical teams through its program. This effort should be a fundamental focus of FRSS and STP training.⁷

* Exposure to, and experience in, the operational setting is essential. Marine commanders must expect supporting medical units to train with their combat units, and they should regularly conduct casualty care and evacuation exercises in concert with field and command post exercises. Wartime is not the time for a CSSE commander to learn how to support a mobile surgical unit, or for the surgical unit to learn convoy tactics, communications, and security procedures.

Conclusions

Operation Iraqi Freedom demonstrated that the FRSS-STP team-when appropriately deployed close to the battlefield, provided with adequate communications, and supported with adequate CasEvac, medevac, and en route care assets-can be highly effective in saving life and limb. Regular and reserve medical components must adjust their organizations and training to take advantage of the lessons learned.

Marine commanders must be more attentive to medical readiness and support issues, and incorporate realistic medical training—including patient evacuation—into exercises. Only those measures will ensure that skilled medical personnel will be ready to respond when naval forces are required to operate from over the horizon and far from the sea.