R3 MMU - KAF: Surgical Care in Kandahar 

LCol Robert E. Stiegelmar, M.D. FRCSC
Edmonton, AB 

As of as of early February 2006, Canada has become the lead nation at the Role 3 Multinational Medical Unit (R3 MMU) Kandahar Air Field (KAF). In civilian terminology, Role 1 is "buddy care" or a first aid provider in the field. In the past, Role 1 care was provided only by medical technicians or "medics"; however, new training encompassing the Tactical Combat Casualty Care (TCCC) has the goal of providing all soldiers with tactically relevant first aid training. Role 2 has been traditionally defined as the "Unit Medical Station" or the UMS, which has been the site where a patient first meets a physician in the chain of evacuation. Role 3 has surgical capabilities but limited holding capacity. Role 4 is back to a hospital in the home country and Role 5 sites are rehabilitation facilities.

 

The R3 MMU in KAF is a combat casualty trauma centre as well as a referral centre for all Role 1 and 2 facilities in Southern Afghanistan. This multinational unit has a staff of 180 made up of approximately 120 Canadians. Other countries providing medical personal to the Role 3 MMU include: Australia, Denmark, Holland, United Kingdom, and the United States.

Staffing consists of two surgical teams who alternate call. The surgical staff consists of a total of two general surgeons, one or two orthopaedic surgeons, one oral maxillary facial surgeon, and occasionally, a neurosurgeon. The OR staff is completed with two anesthesiologists, five OR nurses/ techs and two or more CSR techs. At times, the Europeans send in a "Trauma Surgeon". These are general surgeons who fix fractures, do thoracotomies and sometimes craniotomies for trauma. Other medical specialties include an internist and, on a variable basis, a radiologist. We try to ensure that one physician in the group has Intensive Care skills.

There are approximately six general practitioners and fortunately some have experience and emergency medicine training. Other support staff include: 20 nurses (4-12 with critical care experience), approximately eight med techs, lab and X-ray techs, and interpreters. In the hospital there are also administrative and support staff which includes an air Medevac cell.

There are two operating rooms. The ortho OR is the "cleaner" theatre and the one that the C-arm fluoroscopy unit can just barely fit. There are 20 to 40 beds and four to six ICU beds.

The laboratory has capability for hematology and chemistry panels. Microbiology is limited to Gram stain and cell counts with no ability to culture. Blood banking is via the Dutch system with limited blood bank, PRBC, plasma, and frozen platelets which may or may not have hemostatic function. The Americans prefer a "walking" blood bank over the Dutch bank.ank.

There is a digital radiography suite with the ability to send radiographs digitally to Canada. When a report is needed, we can call and have a report sent back to us from the radiologist in Halifax if there is no onsite radiologist in KAF. However, we rarely require a radiologist's report because most of us can read our own X-rays and CT Scans. Our two-slice CT scanner has been replaced by a 16-slice scanner which is usually functional. We also have ultrasound, FAST U/S and the C-arm has the ability to do digital subtraction angiography (DSA). The FAST U/S has saved lives by being able to diagnose urgent conditions such as cardiac tamponade.

The environment is harsh with KAF situated in the high desert in southern Afghanistan. Summer daytime temperatures are often greater than 50 degrees Celsius. The sand is fine and dusty (like flour) that permeates everything. Nighttime summer temperatures cool to the mid 30's. There is no appreciable precipitation in the summer. In the winter, however, it is cold and wet, sometimes snowy. In the winter the dry dust of summer turns into muck. I prefer the dry heat over the wet cold.

Flow of Casualties
Information on incoming casualties is received both by radio and secure intranet. Information from multiple casualties is tracked on a wipe off board (known as "The Board") so that all staff can see it and prepare accordingly.

Pre-hospital care includes battlefield care by unit medics and most patients have hemostatic dressings such as Quikclot © or HemoCon ©. Almost everyone has a tourniquet but not everyone has an IV or spine protection. Sometimes trying to start an IV in the field wastes precious time in getting a bleeding soldier to the OR and most patients with GSW (gunshot wounds) or other projectile injuries do not benefit from spine immobilization. When data from this conflict are further analyzed, we will have more information to support this view. Many casualties are received directly from the battlefield, usually airlifted to R3 MMU using US Blackhawk teams, Chinooks, or by ground if very close by.

There is a low threshold for activation of the "Trauma Team" due to the high acuity and severity of injuries. Pre-hospital communication is variable so we expect and plan for the worst and don't complain, but rather are grateful when the Trauma Team gets sent home because we are not needed. The limited holding capacity and frequent unexpected mass casualty scenarios require rapid triage, assessment, treatment and transfer of patients down line to make the system work.

Statistics
Most of the data is still being analyzed and some of the information is privileged for security reasons, but on average, there are two casualties each day and most go to the OR for a debridement of one or more extremity wounds. For periods of more intense military campaigns or more importantly, increased insurgent activity, the casualty rate can double and frequently there are true mass casualty events where injuries can overrun the system. Most patients (60% to 80%) are local nationals from the Afghan National Army (ANA), Afghan National Police (ANP), or Afghan Border Patrol (ABP). Coalition soldiers receive "damage control surgery". Typically this treatment includes debridement of wounds, fasciotomies, application of external fixators, revision amputations without closure and vascular repair. Typically, patients are Air Medevac'd in 12 to 36 hours - as soon as the patient is stable for transport via CCAT (Critical Care Air Transport), which is a flying ICU. Most Canadians and American casualties are sent and re-assessed at LARMC (Landstuhl Army Medical Centre). Our wounded Canadians are (in theory) to spend five days at LARMC, but typically it is more than a week before they can be repatriated back to Canada. In the US, most of the injured are first sent to Walter Reed Medical Centre, but in Canada, casualties are dispersed depending on their military base of origin. This dispersion raises some issues because many of our military bases are not close to major trauma or rehab centres. LARMC is not a trauma centre and usually does not complete definitive surgery. Almost all repatriated patients dispersed to my facility from LARMC require several debridement and closure and half of the lower extremity fractures require revision surgery.

Afghan forces and local nationals have poor local resources and receive definitive care at the R3 MMU. Long bone fractures get treated with IM nails if indicated. ANA soldiers are able to rehab at ANA hospital but rehab facilities are not structured for ANP or ABP. Civilians are not treated in KAF unless they are casualties of war as a result of coalition interaction, or "Hearts and Minds" cases which require "high level" approval. Most of the senior medical specialists in the military are concerned with doing humanitarian work because of the favoritism it may show for the person or group who "wins the lottery" and the ill feelings that occur when things go bad. Many of these cases are children and our military medical staff have a limited paediatric comfort zone.

Injury patterns have changed during the conflict as the combatants have adjusted their tactics. Originally there were high velocity GSW wounds and later fragment injuries form RPGs and other types of fragmentation projectiles. Currently most of the injuries are from road side Improvised Explosive Devices (IED's) which explode outside an armoured vehicle and result in fewer penetrating injuries but with mangled extremities, spinal compression injuries, and barotrauma.

After looking at the silhouette of a soldier, one can see that 70% of the shadow is extremity; therefore even without body armour, 70% of the injuries are extremity injuries. Ninety percent have musculoskeletal/extremity plus other injury. Seventy percent MSK/extremity alone and 30% have fractures. Ten percent of these extremity injuries are associated with a vascular injury, and ten percent have a nerve injury. For nerve injuries, we wait if the injury was from a GSW because it is usually contused. Early exploration and repair are performed if it is a fragment (low velocity) wound because the nerve is usually lacerated with a smaller zone of injury. In 60 days I personally saw median, radial, ulnar, peroneal, femoral and sciatic nerve injuries.

The Canadian Forces numbers estimate that more than 35 000 have served in the area of operations (Afghanistan and at times Pakistan) from 2001 to 2009. We have 600 WIA (Wounded in Action) and approximately 700 NBI (Non Battle Injuries). A total of 118 members of the Forces have died in Afghanistan or in support of the Afghan operation between February 2002 and April, 24 2009. We have about 25 amputees in the CF - half from battle injuries and half from civilian trauma.

US Global War on Terror (GWOT) data from 2006 (2009 estimate) numbered 3400 (5200) deaths, 40,000 injured (60,000), with 20,000 (30,000) minor and returning to duty. Regarding amputations; 560 (800), however 20% are multiple amputees and 18% have Traumatic Brain Injury (TBI). In 2006, sixty amputees had returned to duty with eight (9?) returning to Iraq. Two are "Iron Men". One is a Special Forces Medic and starts an IV with his prosthetic hand, and also punches his prosthetic hand through walls. Perhaps the full year that amputees spend at Walter Reed for advanced skills rehab allows this high level of function.

In Canada, we have the "Soldier On" program, which treats amputees like athletes and has a Peer Support Program and a link to Para-olympians. We are hoping to facilitate centres of excellence.

It is difficult to tell if we are better at treating war injuries than in the past. It is the intensity of battle and the size of the bombs that have a bigger effect than does the type of dressing or resuscitation. The Taliban often determine the level of conflict. However, 97 - 99% injured in battle survive if they make it to hospital. If the patient makes it to the hospital alive, there is 1 - 3% mortality in hospital. Those are good numbers compared to previous conflicts but most soldiers still die on the battle field.

Lesson We Are Learning: ABC'S of the ATLS © Save Lives

  • Airway management with intubation. Often a surgical airway is needed for GSW to the face.
  • Breathing: chest tubes save lives.
  • Circulation: Ten per cent of the wounded die from bleeding that could be controlled with a tourniquet - not with an IV. If a laparotomy is needed, get the patient to the OR fast. Hypo-tensive resuscitation, if used appropriately, can help prevent the lethal triad of hypothermia, acidosis and coagulopathy.
    • High energy wounds need surgical debridement. HemCon © is better than QuikClot ©. Whole blood is better than Factor VII and a cold patient's blood does not clot.

Afghans are a hardy people and do not seem to get infections easily or do not demonstrate a dramatic inflammatory response. They all have parasites and are malnourished. Their femurs are externally rotated and have an INR = 1.5 or more (I thought that INR was international and normalized?).

I have been asked how I personally feel about my experience in Afghanistan. This is best described by comparing my work there with my job here in Canada. When a trauma patient arrives in KAF, he is greeted by a four member experienced team who spend the next 45 minutes sorting him out. If he needs surgery, he goes there next and then gets admitted to ICU if needed. In Edmonton, patients wait for hours on stretchers in the ER, then we need to find a bed for admission and they wait days to get their surgery. My team in KAF all know the patient and are experienced medical staff. In Edmonton, staff are often in-experienced and do not perform as team members whose goal is care of the patient. In Canada, there appears to be a series of empires we have to navigate through to get our cases done. In KAF, it is the patient who needs the operation, not the surgeon. I feel far less stress in KAF dealing with a mass casualty scenario than being on call at the University of Alberta on a summer long weekend when the trauma/emergency list has 14 patients on the list. In KAF, we will get the cases done - in Edmonton half of my cases will get cancelled. In KAF, we get thanked every day, in Canada, we get complaints every day about wait times.

I cannot explain how it feels to have a soldier, in better shape than a NHL hockey player, brought into the trauma bay by his best friends, vital signs absent with his legs blown off. The next day, he is eating breakfast; all his medical parameters are stable, and he thanks you for amputating his legs and saving his life. Does the wounded soldier feel important? Do health care consumers in Canada feel important? Which one feels like they have received appropriate care?

Are we making a difference? In Taliban times less than 30% were able to read. There was no legal schooling for girls. There was no real health care for women because women could not be educated and male physician could not exam women. Afghanistan has the highest fetal and maternal fatality rate. If a baby is breach, typically both the mother and baby will die. Before, less than one million (600,000?) were in school, now there are more than six million. Some say that if we leave, the first thing they will do is kill the teachers, then the students.

References
  1. CRS Report for Congress; Order Code RS22452, United States Military Casualty Statistics: Operation Iraqi Freedom and Operation Enduring Freedom. Fischer, Hannah. Updated September 9, 2008.
  2. Franklin, MCpl. P. CAS SUPPORT BRIEFING NOTE V2: Actual Casualty Rates for Task Force 1-08. 26 August, 2008, Internal CF BN.
  3. Armed Forces Amputee Patient Care Database, Walter Reed Army Medical Centre, Washington DC. April 2006.
  4. Emergency War Surgery: Third Unites States Revision. Washington DC: United States Government Printing Office, 2004.
  5. Butler Capt F., Hagmann LTC J., Butler ENS G., Tactical Combat Casualty Care in Special Operations, Military Medicine, 161, Suppl:3, 1996.
  6. American War and Military Casualties: List and Statistics. Updated 14 May 2008 http://www.fas.org/sgp/crs/natsec/RL32492.pdf.
  7. Bringing Our Wounded Home Safely. Report of the Standing Senate Committee on National Security and Defense. http://www.fas.org/sgp/crs/natsec/RL32492.pdf.
  8. General Statistics - Veterans Affairs Canada J:\afghan talk\General Statistics - Veterans Affairs Canada.
  9. Iraq War Facts, Results and Statistics as of June 09. J:\afghan talk\ Iraq War Facts, Results and Statistics.

 

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