Skill sets and competencies for the modern military surgeon: Lessons from UK military operations in Southern Afghanistan
Introduction
He who desires to practice surgery, must go to war. (Ambroise Paré 1510–1590).1
He who desires to go to war, must first learn war surgery. (2009)
In the past 5 years, UK military forces have been heavily committed on operations in Afghanistan and Iraq. Unlike previous peacekeeping missions in the Balkans, the recent operational tours have seen a significant increase in medium intensity combat operations. This has resulted in an attendant increase in battle injuries.17, 21 Political and humanitarian requirements to treat the local military, police and indigenous civilian population have meant that the Defence Medical Services and in particular, the main surgical specialties are now exceptionally busy on operational tours.
Operation HERRICK (UK military operations in Afghanistan) began in 2002, when Britain provided soldiers to the International Security Assistance Force (ISAF). Helmand Province became the area of responsibility for a much larger British force in May 2006. It remains the scene of continued heavy fighting.
Our UK deployment has been, and is currently medically supported by a dual-surgeon Field Surgical Team (1 consultant orthopaedic and 1 consultant general surgeon), as part of a 50-bedded medical treatment facility. This is standard UK practice. The hospital at Camp Bastion is the surgical resuscitation node for a helicopter based casualty retrieval system. It has clinical imaging (X-ray, ultrasound and multi-detector CT) and laboratory support. Its theatres, and ITU backup provide life and limb resuscitation and surgery. High volumes of penetrating and blast trauma are seen daily. Following initial surgery at the field hospital, UK casualties are aeromedically evacuated to the Royal Centre of Defence Medicine, Birmingham (in partnership with the University of Birmingham NHS Trust) where specialist units such as maxillo-facial surgery, neurosurgery and ophthalmology are available. This normally occurs within 24–72 h from the time of injury. For the most severely injured casualties, evacuation by the RAF Critical Care Air Support Team (CCAST) allows repatriation to the UK within 24 h from the time of injury. Where urgent neurosurgical, maxillo-facial or obstetric/gynaecological care is required, specialist coalition facilities within Afghanistan can be utilised.
In the UK, there is not a great deal of penetrating or blast trauma. Surgical training hours have been reduced by EU decree. If we do not accept that deploying surgeons may be on an initial learning curve (with a commensurate increase in preventable death rates) when they arrive in the conflict zone, we must then acknowledge that significant surgical team instruction needs to take place well before arrival in theatre.
Operation HERRICK is currently expected to be an ongoing military commitment for up to 10 years.5 We must therefore plan as such. We present the wide-ranging and challenging surgical workload at the surgical facility at Camp Bastion, Afghanistan over a 2-year period from 2006 to 2008. Using this data we have established the skill set required for the military surgeon deploying now, and used this to produce a training matrix and a course for those that will deploy in the future.
Section snippets
Method
A retrospective review of the theatre logbooks from the Medical Treatment Facility, Camp Bastion, Afghanistan was performed between 1st May 2006 and 1st May 2008. In addition, the personal surgical logbooks of 10 deployed surgeons were analysed to validate the results of the theatre log. Patient demographics collected included age, divided into children (under 16 years old) and adults, and military status which was subdivided into three categories; Civilian, Afghan Security Forces (ANSF) and
Results
During the study period 1668 cases required 2210 surgical procedures. Thirty-two per cent (540) were ISAF, 27% (450) were Afghan soldiers, police or enemy forces and 41% (678) were civilians. Paediatric cases accounted for 14.7% (245) of all casualties. The monthly variation of caseload is shown in Fig. 1, Fig. 2. There was a 1.95-fold increase in the surgical activity in the second 12 months of the deployment (1103 cases) compared with the first 12 months (565 cases) (Student's paired t-test, p
The country
The NATO mission to Afghanistan aims to create a secure environment that is conducive to development, poverty reduction and democracy.26 As part of this mission, it is committed to providing care to the local Afghan National Security Forces. This includes direct patient care through medical evacuation and treatment. This is considered essential for the maintenance of morale for Afghan soldiers and policemen.6 Our study highlights the high percentage of ANSF forces that are initially cared for
Conclusion
Advances in pre-hospital care, resuscitation and rapid aeromedical evacuation have seen the modern military surgeon faced with multiple casualties, in resource limited and environmentally austere locations. We must proactively prepare the deploying surgeon to face these challenges. The deployment of surgical trainees as part of their formal specialty training, and the introduction of the MOST course may go some way to further this aim.
Conflict of interest
None declared.
Acknowledgments
The authors are grateful for the assistance of Lt Col NR Tai RAMC, Lt Col P. Hill RAMC, and Lt Col A. Brooks RAMC(V).
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