Medevacs & Medics, Angels of Mercy
By Ed Marek, editor
March 17, 2012
Forward Surgical Team, the FST
The FST, was developed in the 1990s when it became apparent that Army forces would operate in smaller than division-sized units, often in unconventional warfare, but would still need a surgical capability with a small footprint nearby. Fundamentally, the FST is to serve the maneuver commander. We should underscore "maneuver," because today's warfare is fast moving, and quite often there are no battle lines.
The FST is relatively new, and is still evolving. The first Iraqi War saw the first major deployment and test for the Army's new Deployable Medical Systems. In that war, "Desert Storm," the Army quickly learned it was short on rapidly maneuverable surgical capabilities. The battlefield was becoming increasing fluid, with combatants rapidly moving from one location to another, but without a surgical capability that could do the same.
The wars in Afghanistan and then Iraq were the first real tests for the FST. The airborne medevac was a huge development for battlefield medicine during Korea and then Vietnam. The FST is just as huge a development.
Three DRASH tents that comprise the 250th FST. The apical tent on the far right is the ATLS/pre-op tent; the two to the left are the operating room and SICU/post-op tents. Presented by "College plays pivotal role in Operation Iraqi Freedom," by Lt. Col. Harry S. Stinger, MD.
The FST is rapidly deployable. It is meant to be an initial and immediate surgical operation only. The idea is to enable a critically wounded soldier to make it to an immediate surgical level of care. It is an austere operation. It brings its own equipment, people, and often forms its own convoys and provides its own security. It can set up in a building, in tents, or simply remain out in the open. The old saying, "Everyone is infantry," holds here. FST members have to know how to fight, and in some cases, they also have to know how to be paratroopers.
The inside of the 250th FST operating room fully set up and ready to receive casualties. Presented by "College plays pivotal role in Operation Iraqi Freedom," by Lt. Col. Harry S. Stinger, MD.
The FST can arrive at a location near a battle, stay for a while, conduct some surgeries and then high tail it to the next location. Its core is 20 people with two operating tables and the minimum essential levels of equipment to do what they have to do. There are few, if any, bells and whistles. The goal is to assign one FST to each brigade. It's best to be collocated with a medical company. That said, the FST can be split and sent to more than one location. We have seen reports of 5-person and 10-person FSTs being deployed out near a battle area, while the rest of the FST remains put, available to move if it has to.
Roughly speaking, a FST will have 10 officers and 10 enlisted people. All the doctors are operating surgeons, usually including four surgeons, three general and one orthopedic, trained in trauma. The FST also has two nurse anesthetists, three additional nurses (one emergency room nurse, one operating room nurse, one intensive care unit nurse), one operations officer, and enlisted operating room technicians, practical nurses, and combat medics. It is designed to handle initial surgical and continued post-operative care for up to 30 critically wounded or injured patients continuously over 72 hours, when fatigue and exhaustion normally set in and the FST starts to run out of supplies. While soldiers have to fight even when fatigued, it is very dangerous for medical people to do so, though we all know they do.
The realities of Afghanistan, especially in the early stages, confronted the FSTs with a great demands to be flexible. It's best if they area collocated with a medical company, which provides needed supplies and equipment. Sometimes they were with medical companies, sometimes not. When not with a medical company, they often would lack sufficient sterilization equipment, generator capacity, heaters, and tents. We saw an example when the 759th had trouble with its X-ray equipment. That was a frequent problem, among the biggest problems experienced early on. We have seen accounts that say X-ray machines were not even on the tables of equipment for FSTs. It was thought that the medical company would provide that. Same for automated ventilators.
FSTs often found themselves virtually on their own, with no clear lines of command and control. Early on, there also had not been enough time to train with maneuver units so everyone understood the other, and how they work.
Stinger and Rush emphasize this:
"To stay light and deployable, the FST ... contains only the personnel and equipment necessary to perform 30 lifesaving operations in 72 hours in support of a major offensive in a Brigade Support Area (BSA). Surgical operations consume a staggering amount of equipment, supplies, and human energy. After the initial period of 72 hours of continuous surgical operations, the FST is essentially non-mission capable due to exhausted equipment, supplies, and personnel. The team then needs to be reconstituted. The best way to do this is to physically move the team personnel and equipment back to the division rear combat support hospital where they can repack and re-sterilize their equipment, fix any broken equipment, and prepare to be repositioned in the BSA near the next major offensive where a high number of casualties may be encountered."
They also emphasize that surgeons represent a critical skill, and cannot be wasted, but instead must be positioned where there is going to be sufficient volume to justify their being there. In addition, support staff is critical, so the FST was not designed to hold patients, but instead is supposed to evacuate the patient within 6-8 hours. They are not always able to do that.
Pressures are always present to employ the FST in other less crucial roles. For example, FSTs have been used a lot to care for locals who might be sick or injured. And, there is always the unexpected.
We have seen some writing about providing more post-surgical support at the FST than previously envisioned. Some of the reasons for this include problems with evacuation to a hospital due to inclement weather, especially near mountainous areas, a tough environment for medevac helicopters. There is also competition for resources, especially since FSTs are so close to combat areas. Medevac helicopters can be eaten up picking up wounded troops from the front-lines rather than moving them out of the FST. There are also issues with whether armed helicopter escorts are available to accompany medevac helicopters out of the brigade support area. One result of these kinds of events can be that patients might have to stay at the FST longer than desired, perhaps even up to and sometimes exceeding 72 hours. In such cases, the FST has to deal with things like feeding a post-surgical trauma patient hours after the surgery and taking the next surgical and medical steps that should have been done at the next level.
Furthermore, as the battle landscape changes, FSTs often have to be split and moved, sometimes frequently. This eats up a lot of time and energy, and can be dangerous. We found an interesting article about the 247th FST, done by George E. Peoples, Tad Gerlinger, Robert Craig, and Brian Burlingame, entitled "The 274th Forward Surgical Team Experience during Operation Enduring Freedom," June 2005.
All of this is in a tremendous state of evolution, with lots of things to be worked out. The medical systems in place for the wars in Iraq and Afghanistan are terrific, far better than anything our forces have ever had before. They are simply going to get better. Throughout any evolution such as this, we will guarantee you of one thing: the people make it work.
We found some photos of FST people who make it work. We'll close by applauding them and giving the FST a human face.
947th FST, Bagram AFB, Afghanistan. An assistant grabs surgical instruments for the doctors during an appendectomy operation on a soldier. Photo credit: Staff Sgt. Jeremy T. Lock, USAF. Presented by Defend America
Forward Resuscitative Surgical Systems (FRSS), USN, stationed with a Marine aviation element. Served in Iraq, Ensign Kelly Bowman (right) says, "We did surgery and pulled a four-inch piece of metal out of his leg. We gave him blood and then evacuated him. We had to move him or he would die." "Critical care," presented by University of Texas Arlington Magazine.
250th FST (Airborne), "Blacksheep." Served in Iraq. Self-sustaining, rapidly deployable, everyone able to fight. Yes people, the 250th has paratrooper surgeons who jump out of perfectly good airplanes to save troopers on the ground. Presented by 250th FST (Abn) with a terrific photo gallery.
250th FST paratroopers: These are the guys that jumped out of perfectly good airplanes, parachuting into northern Iraq to open up the northern front. You might recall Turkey refused to allow the 4th Infantry Division to invade by land, so many of our forces had to go in by parachute. These guys went in with the 173rd Airborne Brigade. Standing from left to right: Brad West, CRNA; William Goldsworth, OR tech; Robert Novak, LPN; Abel Tavares, OR tech; Robert Burns, trauma medic; Luke Fullerton, trauma medic; Dr. Stinger; and Dr. Devine. Front: Glen Carlsson, CEN, trauma nurse. In the background are the C-17 Aircraft that they would soon board for Iraq. Presented by "College plays pivotal role in Operation Iraqi Freedom," by Lt. Col. Harry S. Stinger, MD.
1st FST, let's roll 'em out. 1st FST are the two CRNAs (left to right) Capt. John H. Mulreaney and 1Lt Jeffrey L. Allen. They stopped by the 67th Combat Support Hospital on their way to their final location in northern Iraq. The 1st FST convoyed into Iraq from Kuwait and stayed at the 67th CSH for two days to pick up extra supplies and get some additional schooling on the "PAC" draw-over anesthesia system. February 2004. Presented by the American Association of Nurse Anesthetists.
541st FST, Orgun-E, Afghanistan. Aid-station Soldiers run with a patient suffering from a gunshot wound to the leg. The aid-station staff is made up of two units: 1st Battalion, 503rd Infantry (Airborne) from Vicenza, Italy, and the 541st Forward Surgical Team from Fort Bragg, N.C. They function as one. The only thing separating them is the patches on their shoulders, said one medic. Photo credit: Staff Sgt. Daniel Bellis, USAF. Presented by Soldiers Angels.
934th FST. Served in Iraq. Lieutenant Colonel Robert Borrego operates on a wounded U. S. Army soldier near Baghdad, May 2003. Presented by Warshooter, a portal for photojournalists covering conflict, crisis and disaster.
909th FST. Meet Dr. (Col.) J.D. Wasser, working in Afghanistan on a soldier who has lost part of his right arm. "We all knew just what to do, but never knew what to expect." From "Making a difference in a war zone," by Dr. Wassner. Presented by University of Illinois Carver College of Medicine.
102nd FST. Served in northern Iraq. Presented by American Association of Nurse Anesthetists.
1982nd FST. Served in northern Iraq. Photo credit: Lt. Col. Michael Badellino. "We moved right out with the line units on convoy." "Forward Surgical Team takes life-saving show on the road," by Sgt. Robert L. Jones
Live RPG impaled in his abdomen, Army medical team saves his life