Combat Casualty Care: The Alpha Surgical Company Experience during Operation Iraqi Freedom

Military Medicine, Jun 2005 by Marshall, Thomas J Jr

Background: Operation Iraqi Freedom was the first large-scale combat operation involving the U.S. Marine Corps since the Persian Gulf War in 1991. Data from a combat surgical company are presented. Methods: Records of all U.S. and Iraqi combat casualties admitted to the surgical company were reviewed. Results: Fifty-three (57%) of 93 patients suffered penetrating injuries. Most wounds were produced by high-explosive munitions (mines, hand grenades, and rocket-propelled grenades), and the majority (51%) of wounds were to the extremities. The time to surgical care averaged 4.7 hours (range, 1.5-48 hours), and 98% of the patients seen at our facility survived. Conclusions: The time from injury to surgical care was considered long by civilian standards; however, this did not appear to affect outcomes substantially. A small percentage (5.2%) of injuries were to the torso. Hypothermia was commonly present. Because of the nature of their wounds, all patients required additional surgery after evacuation to rear area facilities. The outcomes of individual patients are not known, although it is known that only one Marine died after reaching medical care and, to date, no Marines have subsequently died of their wounds.

Introduction

Alpha Surgical Company (Alpha Company), a U.S. Navy field surgical facility deployed with the 1st Marine Expeditionary Force to Camp Coyote, Kuwait, during Operation Iraqi Freedom, was a component of the Health Services Battalion of the 1st Force Service and Support Group. It was the first inpatient-capable Level II surgical unit set up in Kuwait, approximately 20 miles from the Iraqi border, and functioned as the only Marine Corps Level II surgical facility from February 10 to March 24, 2003, when Forward Resuscitative Surgical System (FRSS) 4 began receiving patients at Camp Viper, Iraq.

For those unfamiliar with the U.S. Navy/Marine Corps classification of combat casualty care facilities, a Level I facility is staffed with a physician who is not a surgeon and is capable of resuscitative care and minimal lifesaving interventions, such as intubation and chest tube placement (e.g., a battalion aid station). A Level II facility is staffed with surgeons and is capable of definitive surgical care and inpatient care (e.g., a surgical company or FRSS). A Level III facility is capable of surgical subspecialty care (e.g., neurosurgery or cardiothoracic surgery and advanced diagnostic evaluations such as computed tomography and angiography) (e.g., a Navy fleet hospital or hospital ship). A Level IV facility is a fixed hospital facility capable of all inpatient and surgical modalities, usually located in the United States or Europe. Level I to III facilities are usually housed in tents and have varying degrees of mobility, depending on their size and equipment load.

Alpha Company was a well-staffed forward surgical facility with 286 medical personnel, of whom 26 were physicians. Seven of the 26 were surgeons, including four general surgeons, three of whom had subspecialty training (trauma, vascular surgery, and surgical oncology); two general orthopedic surgeons; and a gynecologist. Our operative staff also included an oral/maxillofacial surgeon and a podiatrist. The remainder of the physician staff included emergency medicine physicians, family practice physicians, pediatricians, and a medical oncologist.

The company was organized into a shock stabilization and triage area, capable of six simultaneous resuscitations, three operating rooms (each containing two operating room tables), and a 10-bed intensive care unit and three 30-bed wards. In addition, the company had portable X-ray capability; a rudimentary laboratory capable of blood typing complete blood count measurements and measurements of electrolytes; and an attached dental platoon and combat stress unit. All of these were housed in 18 Base-X and general-purpose medium tents spread over a 10-acre area of desert. There were an additional 20 general-purpose medium tents in the compound that were used for administrative, supply, and berthing purposes (Figs. 1 and 2).

Methods

A retrospective review was performed of the records of all U.S. and Iraqi patients admitted to Alpha Company during the combat period of March 19 through April 17, 2003. The following variables were assessed: total number of patients admitted, number of combat casualties, time from injury to admission to Alpha Company, types of wounds sustained, wounding agent, body part wounded, blood use, operations performed, and time to evacuation. The ultimate morbidity and mortality rates of these patients could be assessed from the records only indirectly because I was unable to track the majority of patients to their ultimate outcomes from the records available at Alpha Surgical Company.

Results

In the course of combat operations. Alpha Company admitted 338 patients, of whom 93 were combat casualties. On our busiest day, we admitted 39 patients. We performed 20 operative procedures during the 4-week wartime period. The greatest number of procedures performed in a 24-hour period was six, two of which were performed during a Scud missile attack.