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Military Medical Assets Deployed to the Iraq and Afghanistan Wars

The United States and coalition partners sent thousands of nurses, physicians, and support medical personnel to Operation Desert Shield/Operation Desert Storm in 1991. Because of the ground war’s limitation of 4 days of combat, the coalition medical resources cared for a very limited number of casualties. At the end of the first Gulf War on February 28, 1991, 2,215 Army Nurse Corps officers were deployed to the Gulf region (Sarnecky, 2010.) The U.S. Army, Navy, and Air Force deployment of medical personnel in support of Operation Desert Shield and Operation Desert Storm was massive, expensive, multifaceted, and very challenging.

In the early 1990s, the Army Medical Service was in the process of converting from its Vietnam-era Medical Unit Self-Contained Transportable (MUST) hospital structure to a more current and mobile deployable system of medical equipment and modern environmentally controlled tentage. A significant number of medical units deployed to the Gulf were deployed with the older MUST equipment and tentage. The deployed medical personnel found the desert environment very tough on their outdated MUST systems. As a result, the Army Medical Department was compelled to rapidly replace the old MUST systems with the much newer deployable systems (Sarnecky, 2010). In addition, the beginning of Operation Iraqi Freedom marked the last wartime use of an active Mobile Army Surgical Hospital (MASH). During this operation, the army officially replaced its last active MASH with the new combat surgical hospital and fast-forward surgical teams (e.g., King & Jatoi, 2005).

In addition to modernizing deployable medical facilities, the Army Medical Service also implemented a new doctrine and concept of operations, called “Medical Force 2000.” The two most significant changes in doctrine included employing far forward surgical assets and an increased breadth and depth of psychiatric support (Sarnecky, 2010). To understand how care was delivered by U.S. military personnel in a war zone, one has to appreciate the structure of military medical care. Military medical doctrine supports a system of triage, treatment, evacuation, and then return of military troops to duty in the most efficient and effective manner. Troops not fit for duty are returned for further evaluation, treatment, and rehabilitation in the United States. This current paradigm dictates an “evacuate and replace” philosophy, which places considerable demand on the transport and en route care abilities of all the military services (Joint Publication 4–02, 2012, p. I-6).

The wars in Iraq and Afghanistan commenced the extensive use of the U.S. Army’s forward surgical teams (FSTs) to support military operations in Operation Enduring Freedom and Operation Iraqi Freedom (Counihan & Danielson, 2012). For example, the army’s 102nd FST was deployed to Kandahar, Afghanistan, to provide trauma and surgical services in support of the army’s 101st and 82nd Airborne Divisions during the beginning of Operation Enduring Freedom. Later, the unit’s medical tasking was expanded to include local humanitarian assistance (Beekley & Watts, 2004).

The U.S. Air Force was considerably downsized after the end of the Cold War and the first Persian Gulf War. The Base Realignment and Closure (BRAC) commission proceedings resulted in the closure of several stateside and overseas air bases. With the closure of overseas bases and potential involvement in areas with little, if any, U.S. military facilities, it became crucial to reexamine, update, and alter U.S. air power doctrine to deal with future threats (Looney, 1996). In addition, to enforce the no-fly zone over Iraq in the mid-1990s, Operation Northern Watch and Operation Southern Watch placed additional burdens on airframe, logistical, and personnel assets (Air Force Doctrine Document 2, 2007).

Air force leadership crafted a new doctrine to demonstrate how it planned to meet its future global commitments. The Air Expeditionary Force (AEF) concept was designed, developed, and implemented to meet these worldwide demands. Under this concept of operations, the air force leadership mixed active duty; reserve forces; and Air National Guard airframe, logistical, equipment, medical, and other assets into a combined force (Nowak, 1999). Instead of deploying an entire active duty unit, such as a fighter aircraft squadron or a deployable hospital unit with all of its equipment and personnel for a year or longer, now specially sized “aviation packages,” “logistical packages,” or “medical packages” from several active duty, reserve, and Air National Guard wings would deploy together as a single AEF to carry out the deployment mission. These package sizes are flexible and tailored to meet specific mission requirements and capabilities (Nowak, 1999). Usually after a 4- to 6-month deployment, another AEF package would replace them in the operational theater. The air force “relies on the AEF as a force management tool to establish a predictable, standardized battle rhythm ensuring rotational forces are properly organized, trained, equipped and ready to sustain capabilities while rapidly responding to emerging crises” (Air Force Pamphlet 36–2241, 2013, p. 82).

Recent history has demonstrated that, over time, the U.S. experience in war increasingly demands cooperation, coordination, and integration of all U.S. military services. Today, joint operations are routine. It is not uncommon for air force personnel to augment army soldiers on convoy operations, or for army and navy medics to be assigned to an Air Force Theater Hospital in the Iraq and Afghanistan wars (Air Force Doctrine Document 2, 2007). On the battlefield, effectively integrated joint forces are able to rapidly and efficiently identify and engage enemy vulnerabilities, without exposing their own weaknesses to ensure mission accomplishment. In today’s combat environment, U.S. armed forces must always be ready to operate in smoothly functioning joint teams (Air Force Pamphlet 36–2241, 2013).

In summary, the air force has taken its combat and mobility wings (active duty, reserve, and Air National Guard), and assigned them to one of 10 AEFs. Several of these 10 wings have contributed to the force mix in the Iraq and Afghanistan wars. The AEF is one that can conduct military missions on short notice in response to operational requirements or sudden crises with specific force packages tailored to achieve limited and clearly stated objectives. Several AEF organizations are defined as provisional in nature, organized to meet a specific mission or national commitment. As such, they are activated and inactivated as necessary (Air Force Doctrine Document 2, 2007).

In terms of AEF medical assets, they are a total force endeavor with staffing coming from the active duty, air reserve, and Air National Guard components. At times when medical specialists, such as neurosurgeons or otolaryngologists, are needed, it is not uncommon to have a few U.S. Army and/or U.S. Navy medical personnel attached to a predominantly air force unit. The USCENTCOM (United States Central Command) area of responsibility (AOR) covers the “central” area of the globe and consists of 20 countries: Afghanistan, Bahrain, Egypt, Iran, Iraq, Jordan, Kazakhstan, Kuwait, Kyrgyzstan, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Syria, Tajikistan, Turkmenistan, United Arab Emirates, Uzbekistan, and Yemen (U.S. Centcom, 2015).

The U.S. Navy had historically relied on fleet surgical teams to provide surgical and critical care onboard large deck ships and hospital ships, both having helicopter landing pads to receive casualties. However, because of the geographical distances involved in the Afghan and Iraqi war theaters, this aforementioned strategy was deemed impractical. As a result, the U.S. Navy designed, developed, and implemented a new type of surgical unit, the Forward Resuscitative Surgery System (FRSS) to provide a light weight, mobile, forward surgical and stabilization capability (Bohman, Stevens, Baker, & Chambers, 2005).

The goal of the FRSS is to “save life and limb” of those casualties who would die, mostly from blood loss, caused by delayed access to surgical and resuscitative care by minimizing transport time between point of injury and surgical intervention. In order to meet this goal, the FRSS staff perform what they call “damage control” surgery. The aim of this surgery is to restore normal life-saving physiology rather than providing anatomical repair. Anatomical repair would be accomplished later at a higher echelon of surgical care. An FRSS is usually staffed by one or two general surgeons, an orthopedic surgeon, a critical care nurse, an anesthesia provider, two operating room (OR) technicians, two hospital corpsmen, and a transport nurse. During Operation Iraqi Freedom, each deployed FRSS was matched with a navy shock–trauma platoon (STP). The STP is a mobile expanded emergency care facility staffed by two emergency room (ER) physicians, a physician’s assistant (PA), an ER nurse, 14 corpsmen, and seven marines. When matched with an FRSS, the STP provides care to patients not needing FRSS services, but also supplements the preoperative and postoperative care provided by the FRSS (Bohman et al., 2005).

More than 2.5 million military veterans have been deployed for service in Iraq and Afghanistan since 2003 (Conard, Allen, & Armstrong, 2015). The austerity and danger of the war zone intensifies the complexity of providing critical care in the airborne and ground environments. Medical facilities and medevac aircraft have to operate with limited resources, medical and nursing personnel may be asked to assume unexpected roles out of necessity, and combat injuries can involve multiple areas of the body and organ systems (Venticinque & Grathwohl, 2008).

Current military medical doctrine directs five echelons of care. The first echelon commences in the combat zone when a military member is injured. Immediate first aid is delivered by the injured soldier (self-aid), by a fellow soldier (buddy-care), or by a military medic. First echelon care includes such activities as assessing the patency of the airway, breathing, circulation, controlling bleeding, and requesting evacuation to a FST facility or combat support hospital (CSH). FSTs and CSHs have been developed and used extensively only during the wars in Afghanistan and Iraq (Schoenfeld, 2012).

The second echelon of care is the FST, sometimes called the “Army Battalion Aid Station,” which is located in the wider combat zone. Staffing for FSTs or aid stations usually includes physicians’ assistants or nurse practitioners, one or two nurse anesthetists, and two or three physicians (one usually being a general surgeon). Third echelon care takes place once the injured soldier is evacuated by ground or air to the CSH. Here, more definitive surgery and care is provided by surgeons and other specialists (Joint Publication 4–02, 2012; Schoenfeld, 2012).

The CSH has larger inpatient medical–surgical care units as well as an intensive care unit (ICU) and several ORs. Most CSHs usually operate at 44 to 50 beds, but can be expanded. CSHs need to be located close to an airbase with runways capable of handling the air force’s large aeromedical transport aircraft, the C-17 Globemaster III, C-130 Hercules, and the C-135 Stratolifter. The fourth echelon of care is provided at a large medical center that has specialty care capabilities such as a burn care unit, neurosurgery, special hand surgery, and cardiac surgery outside the combat zone. The Joint Services Military Medical Center (formerly the 2nd Army Regional Medical Center) in Landsthul, Germany, next to Ramstein Air Base, is an example of a fourth echelon medical facility. Fifth echelon care is provided in large medical centers in the United States, such as Walter Reed National Military Medical Center in Bethesda, Maryland (Kenny & Hull, 2008; Korzeniewski & Bochniak, 2011). The war in Afghanistan and the second Iraq war became a long-term test of current military medical doctrine.

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