ABSTRACTTwo Air Assault Surgical Groups(AASGs) from 16 Close SupportMedical Regiment deployed toKuwait on Operation Telic inFebruary 2003. Each AASG wascomprised of a four-table resus-citation facility, a two table FST anda twin-bedded ITU facility. An A+EConsultant and nurse, an exper-ienced radiographer and laboratorytechnician with two further RGNsand CMTs provided resuscitationsupport. Each FST had anorthopaedic and a general surgeon,two anaesthetists and eightoperating department practitioners.Further equipment consisted of aPolymobil 111 X-ray unit, a Sonosite180 ultrasound scanner and anISTAT gas, haematocrit andelectrolyte analyser. 100 units ofmixed blood were carried by eachAASG.

Fifty-one surgical procedures wereperformed on thirty one patients.Twenty one of these patients wereIraqi prisoners of war or civilians.Seventeen wound debridements, fiveamputations, five laparotomies, fourinsertions of Denham pins withThomas splintage for femoralfracture, three external fixations andone axillary artery repair formedthe basis of the major casesundertaken. The first field use ofactivated factor VII by the BritishArmy was successful in theresuscitation of a patient withexsanguinating haemorrhage afteran open-book (APC-III) pelvicfracture and a ruptured intrapelvichaematoma.The other cases includ-ed eleven manipulations underanaesthetic/application of plasterand four finger terminalisations.

Forward military surgery has acontinued role to play on the modernfast moving battlefield. 16 CloseSupport Medical Regiment norm-ally supports 16 Air Assault Brigadewith its remit for expeditionaryoperations and SF support. Itsexperience on Op Telic shouldinfluence planning for futuredeployment.

Background16 Close Support Medical Regiment (16CSMR) is responsible for the provision offront-line medical support to the highlymobile 16 Air Assault Brigade and alsoUKSF. Its light surgical teams are designedto provide an extremely high level of medicaland surgical care in austere, arduous andremote environments. It has the ability todeploy by parachute and by rotary-wing orfixed wing insertion. On Operation Telic(The 2003 Gulf War), two Air AssaultSurgical Groups (AASGs) from 16 CloseSupport Medical Regiment deployed toKuwait in February 2003. During theconflict phase, these two AASGs leapfroggedeach other northwards supporting the rapidadvance of 16 Air Assault Brigade. Thispaper examines the cases performed and thelessons learnt during this period.

EquipmentEach AASG was comprised of a four-tableresuscitation facility, a two table FieldSurgical Team (FST) and a twin-beddedIntensive Care facility with two additionalHigh Dependency beds. An accident andemergency consultant and nurse, anexperienced radiographer and laboratorytechnician with two further RGNs andCombat Medical Technicians providedresuscitation support. Each FST had anorthopaedic and a general surgeon, twoanaesthetists and eight operating departmentpractitioners. Each AASG was independentlymobile on 13 light trucks. Furtherequipment consisted of a Polymobil 111 X-ray unit, a Sonosite 180 ultrasound scanner

Lt Col P J ParkerRAMC Email: paul.parker@stees.nhs.uk

Maj S A Adams RAMC

Maj D WilliamsRAMC(V)

Col A ShepherdL/RAMC

Parachute FieldSurgical Team, 16 CloseSupport MedicalRegiment, GoojeratBarracks, Colchester,Essex, CO2 7NZ

Forward Surgery On Operation Telic – Iraq 2003

PJ Parker, SA Adams, D Williams, A Shepherd

J R Army Med Corps 2005; 151: 186-191

“A great deal of claptrap has been written about the principles of war surgery…the surgeonat war is faced by certain problems not met with in civilian accident surgery. He has to dealwith casualties greater in number and severity,and more varied in type;his operating theatremust be mobile and adaptable to diverse conditions;and he must evacuate the wounded withall possible speed, both to clear the unit and restore its mobility…he must wherever possible,avoid procedures that will prevent the early evacuation of the patient” (1).

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PJ Parker, SA Adams, D Williams, A Shepherd 187

and an ISTAT gas, haematocrit andelectrolyte analyser. 100 units of mixed bloodwere carried by each AASG. Tentage in oraround buildings was the normal unitconfiguration (Figure 1).

Military BackgroundWhen the war began on March 20th 2003,23 Squadron was set up in the Brigadetactical assembly area just south of theKuwait/Iraq border. 19 Squadron wasmobile on wheels and ready to move at 15minutes notice. When 3 Para battle groupcrossed their start line into Iraq on 22ndMarch, 19 Squadron moved with them andset up 40 kilometres north of the border inthe southern Rumayliah oilfields. Once theywere set up and open, 23 Squadron collapsedand followed 1 Para into the oilfields. Duringthe course of the war, the two squadronsleapfrogged each other northwardssupporting 16 Air Assault Brigade as itcrossed the Hamar canal and the EuphratesRiver. By 14th April they reached what wereto be their final locations in Maysan provinceof south-central Iraq on the outskirts of thetown of Al-Amarah on the banks of the TigrisRiver.

Surgical Cases - SummaryFifty one surgical procedures wereperformed within Iraq on thirty one patients.Twenty one of these patients were IraqiPOWs or civilians. Seventeen wounddebridements (Figures 2a, 2b, 2c, 2d), five

Fig 1. The AASG set up inside a GOSP (Gas OilSeparation Platform).The COLPRO facility is to the left.

laparotomies, five amputations, fourinsertions of Denham pins with Thomassplintage for femoral fracture, three externalfixations (two tibial, one pelvic) and oneaxillary artery repair form the basis of themajor cases undertaken between 20th Marchand 25th April 2003. The other casesincluded eleven manipulations underanaesthetic/application of plaster and fourfinger terminalisations.

Fig 2a. High energy transfer injury to right thigh showingthe exit wound.

Fig 2b. Initial debridement of wound cavity showing extentof tissue damage.

Fig 2c. Blast injury to left hand, partly treated at a localIraqi factility.

Fig 2d. Simple cleaning using bottled mineral water thendebridement.

Major Surgical Cases – Details

Laparotomies1. An Iraqi Fedayeen in his late 30’ssustained a shrapnel injury to both sides ofhis chest. A left haemothorax and rightpneumothorax were noted on chest X-ray,500 ml blood drained on insertion of a leftchest drain. There was a shrapnel wound tothe left elbow. FAST (Focussed AbdominalSonography in Trauma) scan was (falsely)positive in the hepato-renal pouch. No intra-abdominal injuries were found atlaparotomy (Figure 3).

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188 Forward Surgery Op TELIC

Fig 4. Laparotomy Four: FAST scanning for a rupturedspleen in a patient with multiple long bone fractures.

5. A UK soldier age 26 was involved in rollover RTA and ejected. He sustained anAPC-III(2) injury to his pelvis. He washypotensive and tachycardic on admission.Initial FAST scan showed a contained intra-pelvic haematoma. A Hoffmann 2 pelvicexternal fixator was applied with sometransient stabilization of his condition,however he then continued to deteriorate.FAST scan showed accumulatingintraperitoneal free fluid from a rupturedretroperitoneal haematoma. His conditionbecame critical. No helicopters could flynorth because of sandstorms to the south.Laparotomy, pelvic packing, aortic crossclamping, selective iliac clamping andfinally ligation of the right internal iliacartery were required to control his bleeding.A retrograde urethrogram showeddisruption of the membranous urethra. Intotal 29 units of blood were required toresuscitate this patient including 9 units ofblood from a fresh donor panel, FFP andactivated Factor 7.

Amputations

A six-year-old Iraqi child who had beeninjured in an explosion 24 hours previouslypresented to the unit. His wounds had onlyreceived basic dressings. The right foot hadbeen completely destroyed. An attempt wasmade to perform an initial low tibialamputation but the muscle in the superficialposterior compartment was dead further upthe calf necessitating a higher amputationthan the normal paediatric site of election.The left first ray had also been badlydamaged and this was removed. (Figures5a, 5b).

Fig 3. Laparotomy One for suspected intra-abdominalhaemorrhage on the McVicar Table.

2. An Iraqi Fedayeen in his late 30’ssustained shrapnel injuries to his right lateralchest wall, deep penetrating injury to bothbuttocks and right tibia with a compoundproximal tibial fracture. FAST scan wasnegative. He was initially tachycardic andhypotensive. Laparotomy was negative.

3. An Iraqi civilian aged 15 sustained aclose range abdominal gunshot wound witha large entry wound on the anteriorabdominal wall with protruding omentum.Penetrating wounds to the anterior andposterior walls of the stomach were repaired.A penetrating wound of the pancreas wasseen, the bleeding was controlled and thepancreatic bed drained.

4. A US soldier aged 20 was involved in aside impact road traffic accident (RTA).Compound fractures of the left femur andtibia and a closed fracture of the lefthumerus were seen. His abdomen wasdiffusely tender and he was shocked onadmission to the AASG. The main cause ofhis hypotension was initially uncertain.FAST scan was positive for fluid in thesplenic region and showed clear splenicdamage (Figure 4). Laparotomy confirmeda ruptured spleen and a splenectomy wasperformed. His wounds were debrided, thetibia externally fixed, and a Denham tractionpin was placed in the distal femur and aThomas splint applied. The humerus wasimmobilized in a plaster cast. Post-operatively, he was completely stable andwas transferred the next day to a US facility.

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PJ Parker, SA Adams, D Williams, A Shepherd 189

Arterial Repair

A young Iraqi male sustained a gunshotwound to the left shoulder.An entry wound inthe superior aspect of the shoulder and exitwound in the left posterior chest was seen.Approximately 200mls of blood drained froma chest tube. A pulseless left arm withevidence of a brachial plexus injury wasnoted. The proximal axillary vessels wereexposed and controlled as outlined in theDefinitive Surgical Trauma Skills Manual (3).The wound was explored and the axillary veinfound to be completely transected and wastherefore ligated. The second part of theaxillary artery was partially transected with asmall bridge inferiorly. Repair was carried outwith a 5/0 prolene suture and circulation tothe limb restored. The trunks of the brachialplexus were identified as intact.

Discussion

History Forward surgery has been employed on mostof the major battlefields of the twentiethcentury. In World War II, the parachute dropsin support of the Rhine crossings weresupported by 224 and 225 Parachute FieldAmbulances and 195 Airlanding FieldAmbulance in a forward surgical role. As inOperation Market Garden, rearward evac-uation was not initially possible and casualtieshad to be held forward. During Wavell’s desertcampaign of 1940, captured Italian truckswere used to create the “self contained mobilesurgical centre”, able to attach itself to anycasualty clearing station, field dressing stationor field ambulance” (1). Only 13 light truckswere required to move the unit – the samenumber as in an AASG today. In theFalklands war, forward surgical teams weredeployed to Teal Inlet and Bluff Cove (4).During the first Gulf War (OperationGranby), forward aggressive surgical teamswere successfully used close to the forwardedge of the battle area (FEBA) (5). InAfghanistan and other recent counter-terrorist operations in remote locations, the(far) forward surgical team was often the soleavailable surgical resuscitation facility in thatcountry (10).

ManoeuvreOn the modern mechanized battlefield theFEBA can move over 100km in a day.Forward surgical teams must be prepared tobe highly mobile. The close medical supportof such a campaign requires anunderstanding of what can and cannot beachieved by forward surgery. Role 3+facilities or Static Field Hospitals will alwaysbe necessary but in theory and practicerequire at least 7 days to set up or take down.Over wide geographical areas it is generallyimpractical to ask 200 bed facilities to moveevery five days. To maintain clinical

Fig 5a. Blast Injury to both lower limbs in a 6 year old Iraqiboy.

Fig 5b. Below knee amputation for unsalvageable limbinjury from 5a.

A twenty-year-old Iraqi male sustainedinjuries to his right hand when a grenadeexploded prematurely causing extensivedamage to the right hand and forearm. Healso sustained a wound to the left forearm anda penetrating right eye injury. There wasextensive damage to the deep flexor musclesof the forearm with relative sparing of thesuperficial muscles necessitating amputationat mid forearm level. On the left side extensiveswelling occurred with vascular compromiseand exploration of the vessels with com-partmental fasciotomies was required.

Two further below knee amputations wereperformed for anti-personnel mine injuries.

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timelines, smaller elements such as AASGsor 10 bedded facilities budded off FieldHospitals, which can be erected in much lesstime (and with appropriate integraltransport), are therefore necessary.

Forward SurgeryThe nature of forward surgery itself altersfrom hour to hour depending on evacuationavailability and timelines. In a remotelocation where casevac may not be possiblefor 2-3 days - such as an airfield assault, moredefinitive surgery must obviously beundertaken. When casevac is robust and airassets immediately available, forward surgerymay involve only the placement of a clamp orshunt onto a great vessel; or placement of adamp dressing on the protruding bowel of astable patient with a penetrating abdominalinjury. Forward surgery is, therefore, bestdefined as a flexible approach to resus-citation surgery (“turning off the tap”),which might include the use of DamageControl Surgery (6), and which whengeographically or logistically necessary couldextend to more definitive surgery.

BloodThe forward availability of blood asresuscitation fluid remains paramount.Across both AASGs during Operation Telic,119 units of blood were cross-matched and66 units transfused into 19 patients. Inaccordance with recent research and bestevidence (7) a hypotensive approach toresuscitation in trauma was followed. Onlyonce the source of the bleeding had beenidentified and controlled, did resuscitationcontinue to a normotensive, normovolaemicstate. In one patient who required 29 units ofblood, such an approach was felt to be lifesaving. It was also noted that civiliancasualties whose untreated wounds had oftenoozed for 24 hours or more before admissionwere often profoundly anaemic. Peri-operative blood transfusion allowed theirsurgical debridements to be performed moresafely.

AntibioticsAll non-infected fragment wounds less than1 cm in size were treated conservatively withantibiotics and dressings and these patientshave not been included in the data presentedhere (8).Those patients with penetrating warwounds all received intravenous Benzy-lpenicillin 1.2g as prophylaxis againstclostridial infection. In addition all limbwounds were given flucloxacillin 1.0g. Inabdominal wounds, 1.5g of cefuroxime and500mg metronidazole were added. Headinjuries were given 1g of chloramphenicol.Coalition soldiers were given a 0.5ml tetanustoxoid booster; Iraqi civilians and POWswere given 250 units of tetanusimmunoglobulin. No adverse reactions werenoted.

ImagingFocused Abdominal Sonography in Trauma(FAST) scanning was performed as part ofthe ATLS survey on all patients where closedabdominal injury was suspected. A hand heldSonosite 180 with power Doppler and a 3.5MHz probe were used. The Sonosite 180weighs only 2.4 Kg and measures only 34 x20 x 6 cm. 23 Squadron had the benefit of anultrasound-trained radiographer. In 19Squadron, two military consultants, who hadtrained in the technique, performed thescans. FAST used by trained surgeons has asensitivity of 83%, a specificity of 87% andan accuracy of 85% (9). FAST scanningclearly identified a ruptured spleen (Figure4) and a retroperitoneal haematoma in twopatients and was responsible for the decisionto proceed to laparotomy in these patients. Intwo unconscious patients with severe headinjuries and multiple long bone fractures,FAST was used to exclude any abdominalinjury prior to transfer. FAST using theSonosite180 is man-portable and can beperformed by suitably trained medical staff.All forward surgical units should have themeans and training to perform FAST.

External FixationInexperienced surgeons have been pre-viously tempted to apply external fixators tofemoral fractures. Whether open or closedthis is unnecessary. In closed fractures, thepercutaneous fixator pins contaminate thesterile medullary canal within 48 hours andsubsequent infection may then precludeintra-medullary nailing at role 4 (11). In1915 when the mortality for femoralgunshot wounds was in excess of 75%, SirCharles Max Page and Colonel Sinclairadapted the Thomas splint (which hadpreviously been designed for treatment oftuberculosis of the knee) to the treatment ofthese femoral war wounds.The mortality fellto 20%- even in that pre-antibiotic era. Thejudicious use of a correctly applied Thomassplint via either a well applied trans-tibial ortrans-femoral pin (Figure 6) cannotcurrently be bettered for patient care andtransfer. If a long journey is anticipated, thewhole of the splint can be encased in plaster– the Tobruk splint of 1941 (1).

Fig 6. Correct application of a Thomas Splint for a femoralfracture on a GS stretcher.

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PJ Parker, SA Adams, D Williams, A Shepherd 191

CasevacTransfer to rôle 3 was to be either byhelicopter or wheeled (BFA) ambulance.Prior to the start of the campaign it wasenvisaged that P1 and P2 casualties wouldtransfer by helicopter and P3s by road or asspace-fillers in helicopters. However, the UKdoes not currently have any dedicated casevac(“dust-off”) helicopters and casevac requestsdepend on the occasional availability of asupport helicopter which then has to be re-rôled. In the early stages of the campaignthere was also a threat of attack on roadambulances by irregular Iraqi forces. Adverselight and weather conditions were otherconfounding factors. This meant that therewere occasions where patients had to be heldat the AASG when immediate transfer wouldhave been preferable. Only 50% of helicoptercasevac requests were ultimately fulfilled. Aspreviously stated, the indications for the typeand degree of intervention at role 2+ mayvary enormously depending on perceivedcasevac timelines to role 3. If the UK had adedicated, all weather helicopter casevacevacuation squadron, there would be no needto site surgical units forward on the classicmechanized warfare battlefield.

PersonnelSurgery at this level should be completelyand solely consultant based. However, thisdoes not preclude the attachment of SHOsand SpRs to such units as supervisedtrainees. This also applies to the anaestheticand A+ E positions.All the clinicians must beable to live and survive, not necessarily incomfort, in austere environments and still beable to perform on demand. Possession ofsatisfactory field skills in addition to requisiteclinical skills is mandatory.

TrainingAll surgical and support staff should haverecent experience of the twice yearlyDefinitive Surgical Trauma Skills Course runat the Royal College of Surgeons of England.The same applies to the ICRC War Surgerycourse held yearly in Guildford. The RoyalDefence Medical College runs a number ofcourses and practical workshops each yearon; war surgery, external fixation, emergencymaxillofacial surgery, crisis neurosurgery andmilitary obstetrics and gynaecology. Alldeploying military surgeons should attendthese courses regularly. Without suchexposure there is the temptation, seen at thebeginning of every war, to perform limitedand inadequate wound debridements andsurgical procedures which are inappropriate.The role of the Speciality DefenceConsultant Adviser in the wartime theatremust be that of roving clinical governance.This is a rôle that cannot satisfactorily beundertaken from the UK. Lessons learntfrom previous wars must be retained in aninstitutional memory for the next conflict.

SummaryThe principles of forward surgery haveremained unchanged since the Second WorldWar. The sooner the unstable patientundergoes resuscitation surgery, the better.Bleeding and peritoneal spillage arecontrolled as soon as possible. Soft tissuewounds should be appropriately debridedwithin six hours. Where lines ofcommunication are short and timelineseasily fulfilled, a policy of “scoop and run”should be undertaken and forward surgicalunits overflown by dedicated casevachelicopters to role 3 hospitals. However, asdistances extend and lines of communicationare disrupted or unacceptably extended thenthe appropriately staffed, trained andsupported, highly mobile forward surgicalunit comes into its own.

ConclusionForward military surgery has a continuedrôle to play in the modern fast movingconflict. Units can be deployed rapidly fromthe UK – often within twenty-four hours andbe working within one hour of arrival inlocation. The experiences of the AASGs of16 Close Support Medical Regiment on OpTelic should influence planning for futureoperations.

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3. Definitive Surgical Trauma Skills Manual. EdsBotha P, Brooks A, Loosemore T. 2002 The RoyalCollege of Surgeons of England.

4. Jackson DS, Batty CG, Ryan JM, McGregor WSP.The Falklands War: Army Field SurgicalExperience. Ann R Coll Surg 1983, 65:281-285.

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