Emergency War Surgery NATO Handbook: Chapter I: General Considerations of Forward Surgery

General Considerations of Forward Surgery

United States Department of Defense

Echelons of Medical Care
Echelons of Combat Medical Care

Military surgery, a subset within the art and science of surgery, is designed to carry out a specialized and highly significant mission under the adverse conditions of war. The mission of military surgery differs from civil sector surgery in that it is limited to emergency surgery that is performed on a mass production basis in what may amount to severely limiting circumstances. Stated another way, the military medical officer does what must be done rather than what could be done to the casualty before either returning him to his unit or rendering him transportable to the next higher echelon of medical care. To achieve these objectives, the military surgical care system depends upon an organized pre-hospital treatment and medical evacuation system and utilizes somewhat different and successively staged techniques to treat the penetrating perforating, and blast injuries of the battlefield. These wounds and their method, of management differ from those of a community practice in which the preponderance of surgery is elective and the majority of trauma is blunt. The additional necessity of haste in caring for the continuous flow of battle casualties does not mean that military surgery is carried out in an atmosphere of confusion and disorder or that standard principles of treatment are abandoned. On the contrary, as all past military history shows, intelligent planning and appropriate training in anticipation of the needs of the battlefield have resulted in enviable and ever-improving military medical results.

The currently employed, phased concept of wound management was developed, to a large extent, by Colonel Edward Churchill during World War II. Initial surgery, if necessary, rendered the casualty transportable via rapid evacuation to a rear hospital for reparative surgery. The initial surgical effort at the forward facility, by definition, was not complete surgery, but rather "that initial effort required to save life and limb, prevent infection and render the casualty transportable.... Surgical procedures not essential to wound management at that time may make a transportable patient non-transportable and are to be avoided" This concept of wound management allowed forward hospitals to be more mobile and concentrated more resource intensive casualty care far to the rear in secure base areas where evacuation hospitals were not required to move with changing tactical situations. This phased approach to the management of war wounds has withstood the test of time. However, the newer technologies of warfare will inevitably increase the depth and breadth of the modern battlefield. Fundamental changes in the nature of warfare will dictate certain alterations in the way medical assets accomplish their missions.

What are the missions of the combat commander's medical assets? And what are the relative priorities of those medical missions? The conservation of the army's fighting strength is clearly the primary goal. This goal is achieved by accomplishing several interwoven goals, listed not necessarily in rank order of importance: the maintenance of the health of the command, the prevention of very positive contribution to high morale and promotion of the individual soldier's willingness to fight by establishing a visibly creditable medical system. the provision of timely and efficient evacuation of casualties from the battlefield, and the preservation of life and limb.

How one structures his combat medical care delivery system will depend in large measure upon the nature of the war, the quantitative and qualitative aspects of the casualty load and the medical personnel, logistical and physical plant capabilities. If the nature of the war allows, sophisticated medical facilities can be positioned very near the wounded soldier. If not, the soldier must be moved considerable distances to the well-equipped, relatively immobile "state-of-the-art" surgical hospital. As a general rule, as the medics increase their technical capabilities, they do so at the price of increased requirements for complex equipment, which in turn requires increased lift. These increased cube and gross weight medical airlift requirements compete with combat arms lift requirements. Combat hospitals are already large, bulky, and difficult to move. Highly sophisticated hospitals in the battle zone could encumber the combat commander, restrict his freedom of movement, and at times become a liability rather than an asset. A battlefield medical system must be a compromise between what is best for the soldier and what is best for the conduct of the battle. The basic objective is the realistic minimization of the loss of life and limb.

Examples of two different approaches to combat casualty care can be drawn from World War II. The medical system of the German Army in Russia in 1941 was designed to evacuate the seriously wounded well to the rear and to care for the lightly wounded at the divisional level. This approach required only half as many medical personnel and achieved higher return to duty rates than did the U.S. Army's system in France in 1944, because the German system was intentionally designed for return to duty. The American system, on the other hand, returned proportionately fewer casualties to their combat units, but salvaged many more lives because of the capability to perform lifesaving surgery further forward. The ideal system for the modern battlefield must be optimized to maximize return to duty without sacrificing life or limb.

In the event of a sudden, so called "come-as-you-are" war, medical channels that return soldiers to duty may be the only functional personnel replacement system during the first few weeks of a lightning war. In this sort of scenario, it is of critical importance to the war effort that lightly wounded soldiers who do not require hospitalization be treated at or returned to their divisional areas if they can be held there without encumbering their combat commanders. We refer here to soldiers who are mobile and quite capable of defending themselves, but not yet ready to return to the fire fight. These valuable personnel assets are already trained, are battle-hardened, and are quickly available as opposed to untried replacements who must be transported from a distant homeland. The combat medical system of the short, lightning war must not be allowed to become a giant evacuation conduit through which trained, blooded soldiers pour out of the theater. The medical officer must "fix forward," for as has been said, "The farther a wounded soldier is evacuated from the combat zone, the greater will be his number of noneffective man-days and the less will be his motivation to return to combat duty." In the near chaos of the mass casualty situation, medical officers must be ever vigilant in their search for the lightly wounded, but heavily bandaged, casualty who can be returned to his unit rather than further retrograded through medical evacuation channels.

As alluded to earlier, advances in technology are changing the nature of modern warfare. The battlefield of the future will be broader, deeper, more fluid, more destructive, and more resource hungry. The concepts of phased wound management and initial and reparative surgery will certainly persist but the distances between echelons may be significantly increased. Resource-intensive facilities that are staffed to perform reparative surgery will, of tactical necessity, be deployed considerably further to the rear. The same could pertain, although to a lesser extent, to facilities that perform initial wound surgery. The same technology that increases the depth of the battlefield and of necessity forces fixed surgical capabilities further to the rear may also provide practical solutions. A new tiltrotor aircraft, with the vertical take-off and landing capabilities of a conventional helicopter is currently undergoing flight testing. This twin-engined craft, in the air ambulance configuration, is capable of picking up and moving twelve litter cases plus three medical attendants at speeds of up to 300 nautical miles/hour with a range of 1,000 nautical miles.

It is not inconceivable that on a highly mobile battlefield, initial wound surgery may have to be performed very far forward under extremely austere, even primitive, conditions within enveloped enclaves. Surgical teams carrying their equipment in rucksacks on their backs may be tasked to perform only that emergency life-saving surgery required to make the casualty transportable. Surgical teams of this sort would be assigned to airborne or air assault units that habitually operate in isolation for short periods of time. Other surgical capabilities would be brought forward and deployed as the situation requires and permits.

Another aspect of the recently envisioned "fix forward" approach to combat casualty care is the two-track flow of casualties. This system would divide the casualty flow at the division-level medical facility (Figure 1).

Figure 1

Casualties who are not expected to return to duty within the time constraints of the theater evacuation policy are passed through a chain of evacuation hospitals and out of the theater as rapidly as their conditions will permit. Only that surgery which is necessary to permit transport to the next hospital in the chain - generally planned as six-hour bed-to-bed moves - would be performed. These hospitals would serve as trauma centers and be equipped and staffed to stabilize casualties for transport back to a secure base. If that secure base were in the continental United States, the last hospital in the theater evacuation chain would do whatever was necessary for a 24-hour bed-to-bed move. Current evacuation doctrine restricts combat zone hospital stays to seven days and communications zone hospital stays to thirty days. If it appears that the casualty will require more than seven days of hospitalization in a combat zone hospital, he will be evacuated as rapidly as is safely possible to a communications zone facility. If that casualty will not be ready for return to duty within 30 days at this level, he is expediently evacuated to the continental United States.

Casualties on the other track (those whose wounds would allow return to duty within the theater evacuation policy time constraints) would be moved to a hospital facility intended to encourage early return to duty. The expectation in this facility would be that each patient will return to his unit and the war. When these soldiers no longer require the daily attention of medical officers or nurses, they would be transferred to medical holding companies. These medical holding companies will be minimal self-care facilities with austere staffing and equipment.

This model allows the medical planner to better tailor the medical force that must be deployed. The number of resource-intensive hospital beds would more closely match the actual requirements. The evacuation policy timeframe could be increased with the only requirement being the addition of relatively inexpensive return-to-duty hospitals and medical holding companies to the theater. The critically injured (those requiring the greatest care) would continue to pass through the evacuation or general hospital chain and be air evacuated expeditiously. Those casualties retained in the theater under a new, longer evacuation policy would necessarily be the least seriously wounded or ill of the population formerly evacuated. Their wounds or illnesses would require a longer period of time to resolve than those retained under the old, shorter evacuation policy timeframe; however, they would not require the personnel- and equipment-intensive environment of evacuation type hospitals. They would be shunted to and treated in the return-to-duty (combat support) hospital and convalesce in medical holding companies.

The medical planner of the future may be faced with a battlefield of such great depth that casualties may have to be moved very great distances to reach secure base areas where reparative surgery can be performed. The feasibility of safely accomplishing prolonged moves of fresh casualties has been demonstrated several times in the recent past. In the 1973 Arab-Israeli War, more than 4,000 stable casualties were evacuated approximately 150 miles from the Sinai to central Israel for definitive care. Most arrived within 24 hours of being wounded. In the Falklands Campaign, the British evacuated more than 500 casualties to the United Kingdom by way of Uruguay and the Ascension Islands. This 8,000 mile trip required 20 hours. The majority of casualties arrived within 48-72 hours of wounding. Following the 1983 terrorist bombing of the U.S. Marine Barracks in Lebanon, 55 casualties were evacuated directly to USAF medical facilities in West Germany within hours of injury. Although there was some criticism of this move, an examination of patient outcomes suggest that the results would probably have been the same had they been taken to closer medical facilities.

Echelons of Medical Care

A basic characteristic of the organization of modern military medical services is the distribution of medical resources and medical capabilities to facilities at various levels of location and function, which are referred to in formal military parlance as "echelons". Echelonment is a matter of principle, practice, and organizational pattern, not a matter of rigid prescription. Scopes of function may be expanded or contracted on sound indication; one or more echelons may be bypassed on grounds of efficiency or expediency, and formal organizational structure will differ with time and among various armed forces. The following general pattern; however, is usually apparent.

Echelons of Combat Medical Care

1. At the first echelon (Level 1) a "buddy" (or the trained medical aidman) provides first aid and conveys or directs the casualty to the battalion aid station. The U.S. Army, in an effort to upgrade "buddy aid", provides all basic trainees with 16 hours of first aid training. A more recent initiative identifies one member of each crew-served weapon system (air crew, tank crew, mortar crew, weapons team, etc.) with 40 additional hours of first aid training. Because of the proximity of the aid station to the battlefield, its mission is simply to provide essential emergency care allowing the return of the soldier to duty or the preparation of the casualty for evacuation to the rear. In the former case, this care would be minimal, whereas in the latter case care might include the establishment of an airway, the control of hemorrhage, the application of field dressings, the administration of an analgesic, or the initiation of intravenous fluid administration.

2. Second echelon care (Level 2), depending on the circumstances, is rendered at an assembly point, a clearing station, or the brigade medical company. Here the casualty is examined, and his wounds and general status are evaluated to determine his priority, as a single casualty among other casualties, for return to duty or continued evacuation to the rear. Emergency care, including beginning resuscitation, is continued and, if necessary, additional emergency measures are instituted, but they do not go beyond the measures dictated by the immediate necessities. This function is performed typically by company-size medical units organic to the brigade or division. These units have the capability to hold and treat the most lightly wounded.

3. At the third echelon of care (Level 3), the casualty is treated in a medical installation staffed and equipped to provide resuscitation, initial wound surgery, and postoperative treatment. Casualties whose wounds make them nontransportable receive surgical care in a hospital close to the clearing station. Those whose injuries permit additional transportation without detriment receive surgical care in a hospital farther to the rear.

4. In the fourth echelon (Level 4) of medical care, the casualty is treated in a general hospital staffed and equipped for definitive care. General hospitals are located in the communications zone, which is the support area to the combat zone or army area. The mission of these hospitals is the rehabilitation of casualties to duty status. If rehabilitation cannot be accomplished within a predetermined holding period, these casualties are evacuated to the Zone of Interior (Level 5) for reconstructive surgery and rehabilitation.

It is important to remember that there is a logistical problem in the care of all battle casualties. Military medical facilities must always be in a state of readiness to receive an influx of fresh battle casualties or to move according to the dictates of the tactical situation, though this necessity in no way lessens the responsibility of the medical service for providing for the medical care and disposition of casualties. Despite the exceedingly unfavorable circumstances of war, movement of casualties from echelon to echelon in the forward area is usually accomplished within a matter of hours. Distances, which are usually measured in terms of ground transportation or flight time, vary with the local tactical situation, but as a general rule, casualties are moved a distance of many miles between the battlefront and a hospital.

Because the individual who has been wounded in combat is cared for by multiple surgeons at different echelons of medical care and because hospitals at different echelons are usually separated by great distances, the consultant system has been developed. Certain individuals, selected as consultants because of their expertise in a given specialty field, have been utilized to evaluate and correlate end results noted in hospitals of the communication zone with initial surgical care provided in the combat zone. The responsibility for evaluating the effectiveness of combat surgery and for feedback to the individual surgeons in forward hospitals resides with these consultants. To augment the consultant system, professional meetings of practicing surgeons from both the combat and the communication zone hospitals have been utilized to evaluate the results and to exchange views on methods of surgical care. During the Vietnam conflict, annual War Surgery Conferences were held to bring American surgeons at all levels and from all branches of the armed services up to date on the latest information and results in the care of the wounded.

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Operational Medicine 2001

Health Care in Military Settings

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