U.S. Navy surgeons and hospital corpsman assigned to a surgical/shock trauma platoon at Camp Taqaddum, Iraq, operate on a Marine injured by an improvised explosive device. U.S. Marine Corps photo by Staff Sgt. Jim Goodwin.

attlefield surgery in Iraq has moved forward light years in comparison to previous conflicts. Despite the fact that explosive devices are being used in greater numbers than in previous conflicts, the survival percentages of our troops have never been higher. A great part of this success is due to improved protective equipment — our troops are driving around in armored humvees and other vehicles, wearing flak protection and Kevlar individual armor and protecting their eyes and ears with ballistic glasses and ear plugs. As a result, we are now finding that the vast majority of injuries sustained are to the extremities, and therefore more of our troops are surviving to reach the medical and/or surgical help they need to continue to survive. In treating these injuries, military medicine organized the delivery of care into five levels based on location and capability.

Level 1
Level I care is provided from the point of injury until the injured soldier arrives at the battalion aid station. This includes anything from self aid and buddy aid to aid by a corpsman or medic (I.V., morphine, antibiotic) to a mobile emergency room setup like the Navy Shock Trauma Platoon (STP). Care at the STP level is delivered by general medical officers or by specialists, depending upon the setup, and is mostly advanced trauma life support, with some exceptions. Diagnostic equipment can range from virtually nothing except a portable Propaq to laboratory and X-ray support, ultrasound, etc. Care is modified in the face of tactical or battlefield circumstances, and hypotensive resuscitative techniques target permissive hypotension to reduce blood loss. The goal is to limit fluid resuscitation to maintain a blood pressure in the 80-90s range, with early surgical intervention being of paramount importance.

A forward surgical casualty triage tent. Photo by Capt. H.R. Bohman, M.D.

Level 2
Level II is the first level where surgical intervention is performed. In the Navy, the units may consist of the Forward Resuscitative Surgical System, or FRSS, with one or two such units usually paired with an STP to form a Surgical Shock Trauma Platoon (SSTP). In the Army, they are called Forward Surgical Teams; and in the Air Force, they have the Mobile Forward Air Surgical Team, or MFAST, and “SPEAR” teams. In each case, the teams are made up of general and/or orthopedic surgeons, anesthesia providers, critical care specialists and technicians to deliver forward surgical care near the forward edge of the battlefield. These units were designed for expeditionary warfare, and the teams can set up to be ready to take care of casualties in an hour or so. There are usually one, two or three surgical operating rooms (O.R.s) present. Such care is known as tactical surgical intervention because it is modified by the physiologic status of the patient in addition to the tactical situations occurring in the battlefield, by numbers of patients expected and types of wound expected, and by limited amounts of supplies in the field. Life-and-limb salvage surgery is the norm at such sites, mainly those patients who would otherwise not survive transport to surgical sites farther away from the battlefield. While somewhat limited in the amount of supplies and diagnostic equipment available, such units can do basic labs, including complete blood cell count and arterial blood gas, basic X-ray, abdominal ultrasound examinations, invasive monitoring and mechanical ventilation of patients. In a stationary “battlefield” such as Iraq, there are a number of small surgical units like this spread over the country, with several larger Level III hospitals in more central areas.

Level 3
Level III surgical hospitals are designed to be mobile, too, but take much more time and energy to move. They have six or more O.R.s and have many different surgical specialties represented, including general, orthopedics, neurosurgery, ENT, maxillofacial, ophthalmology and other specialists. In an expeditionary battlefield, but also in general in the stationary battlefield that is Iraq, patients will transfer through each level before leaving the country. Most of the flights leaving Iraq with patients leave from the level III centers. In addition to surgical procedures, many of the patients leaving these centers have either continuous nerve block infusions or patient-controlled anesthesia (PCA) devices with them to make the flight out of Iraq more comfortable. This is a relatively new addition to the standards of care able to be given to patients recovering from their wartime wounds and can improve overall patient care tremendously.

Level 4
Such patients are usually flown to a Level IV out-of-continental U.S., or OCONUS, hospital such as Landstuhl, Germany. The patients are further evaluated and, depending upon urgency, flight availability, etc., may have further surgery there or may be sent on to the United States. Usually the continuous block or PCA techniques are continued throughout this stage and back to the stateside hospitals.

Dr. Baker, left, in a forward surgical unit. Photo by Capt. H.R. Bohman, M.D.

Level 5
Currently most of these patients are flown into the Bethesda/Walter Reed Hospital Consortium near Washington, D.C., two of a number of Level V continental U.S., or CONUS, hospitals where further evaluation and definitive treatment is rendered. In some cases, the patients are reaching the D.C. areas as early as 24-48 hours after being wounded. They may stay only for a short period of time or may stay for weeks before returning to a hospital such as the Naval Hospital Camp Pendleton in California, where the patient was stationed prior to going to Iraq. Depending on the complexity of the injury, the completion of their initial care and follow-up as needed also may occur at these smaller centers or through the Veterans Administration system, in accordance with the patient’s duty status and disability. Routine screening for post-traumatic stress disorder and chronic pain occurs at most of these sites.

Given this structure of medical care across thousands of miles, it is imperative to have an understanding of the role and capability of those in front of and behind us. We previously reported on the capability and limitations of delivering forward surgical care in the December 2005 edition of the NEWSLETTER. In this issue, we provide more detailed information on the transportation of injured soldiers and the care delivered at some of the other levels.

Disclaimer: I am a military service member (or employee of the U.S. Government). This work was prepared as part of my official duties. Title 17, USC, § 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17, USC, § 101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties.
 
The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.

Bruce C. Baker, M.D., Capt., Medical Corps, U.S. Navy, is Staff Anesthesiologist, Naval Hospital Camp Pendleton, California.