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US Army split forward surgical team management of mass casualty events in Afghanistan: Surgeon performed triage results in excellent outcomes

Shawn C. Nessen, DO, FACS, Daniel R. Cronk, MD, Jason Edens, MD, Brian J. Eastridge, MD, FACS, Lorne H. Blackbourne, MD, FACS


Objective: US Army “split” forward surgical teams (FST) currently provide most of the resuscitative surgical care for combat patients in Afghanistan. These small units typically comprised 10 personnel and two surgeons each, who frequently encounter mass casualty (MASCAL) situations in geographically isolated regions. This article evaluates the effectiveness of one split FST managing 43 MASCAL situations in two separate locations for more than a 14-month period in Afghanistan.
Design: An Institutional Review Board-approved review of all admission data of the 541st FST was conducted. Comparison was made between patients treated in MASCAL situations to those of patients treated in non-MASCAL events.
Setting: Split-based US Army forward surgical elements in a combat environment in Afghanistan.
Patients: Two hundred eighty-two patients were treated during MASCAL events and 479 in non- MASCAL situations.
Main Outcome Measures: The primary endpoint was survival outcomes among trauma patients when 5 or more patients arrived simultaneously or if 3 or more patients required immediate surgery.
Results: Four patients (1.70 percent) died in the MASCAL group compared with 12 (3.30 percent) in the non-MASCAL group.The mortality of patients receiving surgery at the FST was 2.73 percent and the mortality was 0.93 percent in those transferred without surgery. In the MASCAL group, 41 patients (14.5 percent) were critically injured and the critical mortality rate was 6.25 percent. In MASCAL events, 39 percent of patients required surgery compared with 44.9 percent in the non- MASCAL group. The average Injury Severity Score (ISS) of the most severely injured patient was 21.19 and ISS rapidly decreased to scores consistent with mild injury suggesting over triage at the scene.
Conclusions: Despite very limited resources, the split FST can achieve, with appropriate triage, acceptable mortality outcomes in MASCAL situations. Over triage at the wounding scene is common and surgical intervention is frequently required.


mass casualty, forward surgical team, over triage, Afghanistan

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