ON POINT II: Transition to the New Campaign
The United States Army in Operation IRAQI FREEDOM May 2003-January 2005
Sustaining the Campaign
Taking Care of Soldiers
Following the Wounded Soldier in Iraq
A Soldier wounded in Iraq initially received what Army medical doctrine called first-response treatment, the initial stabilizing medical care rendered at the point of injury. First aid was either performed by the casualty (self-aid) or another individual (buddy aid), while enhanced first aid was provided by Soldiers who had trained to be combat lifesavers (CLS), a designation that denoted capacity to give advanced first aid and lifesaving treatment. As OIF progressed from 2003 into 2004, units increased the amount of medical training their Soldiers received, including the use of newly developed bandages containing chemical clotting agents to stop blood loss from severe wounds.
Emergency medical treatment is the first of six phases of medical care in the Army medical system. To deliver these six phases of medical care, the Army organized its medical assets into five levels of treatment facilities—Level I to Level V. The difference between phases of care and levels of care is the difference between the type of care being provided and the type of facility providing the care. Higher-level facilities are usually capable of providing multiple phases of medical care, which also (generally) makes them larger and less mobile. Lower level facilities are much more mobile, but also have a much more limited scope of treatment and are generally focused on trauma management.14 Level I assets are those medical resources and personnel at the unit level, usually at battalion and below, such as those Soldiers trained as CLS and medics, and the physician’s assistants located in the battalion aid station. Soldiers wounded in Iraq benefited tremendously from several medical advances that were employed at Level I.
Perhaps the most dramatic of these changes was the introduction of fibrin and chitosan bandages, fielded just before OIF began in 2003. Fibrin bandages were a normal pressure dressing impregnated with two natural blood-clotting agents (fibrin and thrombin), freeze dried, and formed into something like a thin wafer of Styrofoam. These were developed jointly by the US Army and the American Red Cross for use by Special Operations Soldiers far from second-level medical care. The second type of bandage, the chitosan bandage, was jointly developed by the Army and the Oregon Medical Laser Center. These bandages contained chitosan, a biodegradable carbohydrate found in the shells of crustaceans such as shrimp and lobsters. When applied to a wound, the chitosan in the bandage accelerates clot formation to greatly reduce the rate of bleeding.15 Colonel John B. Holcomb, who led the development team drawn from experts at Walter Reed Army Institute of Research and the American Red Cross, called them “a revolution in hemorrhage control on the battlefield.”16
Another critical innovation arrived in the form of a new tourniquet. At one time medical specialists viewed tourniquets in disfavor, citing them as the cause of unnecessary amputations, especially when left in place too long. Studies revealed that 7 to 10 percent of battlefield deaths in Vietnam and Somalia were caused by profusely bleeding arm or leg wounds.17 Accordingly, the Army developed a new combat application tourniquet (CAT): lightweight, equipped with a windlass for tightening the strap, and capable of locking in place once bleeding was under control. Holcomb, who was also a surgeon with the 10th CSH, said, “There is no prehospital device deployed in this war that has saved more lives than tourniquets.”18 The CAT could be applied by one person, including the victim, and most Soldiers carried one on patrol in Iraq.
After receiving buddy-aid, possibly including the use of a tourniquet, a wounded Soldier was then attended by a medic, physician’s assistant, or physician at the battalion level, the second set of Level I personnel. Though varying by unit and mission, typical Army combat medics were attached to every company of 60 to 150 Soldiers. Infantry battalions enjoyed more medics with 1 medic attached to every platoon of 30 Soldiers. The combat medic is analogous to a civilian emergency medical technician (EMT) and certified to EMT standards. Many combat medics had additionally completed sophisticated training that allowed them to provide advanced cardiac life support (ACLS) and prehospital trauma life support (PTLS) in the field and en route to treatment facilities.19
The Army wartime medical system differed significantly from the civilian system. Civilian physicians are accustomed to treating their patients from diagnosis to recovery. In peacetime Army physicians also see their patients through to recovery, or until transfer to another hospital for more specialized care. In wartime this paradigm changes, reflecting the various phases of the Army medical system in a combat zone that involve a variety of doctors and nurses. This longstanding practice has been continually “rediscovered” by generations of Army physicians, civilian physicians mobilized to support military operations, and the media who see it as something radically new, which it is not.20 The Army balances mobility and capability in its hospitals and does as much forward treatment as needed. Stabilized patients are then evacuated to the rear for more care. This may be from a medic to an aid station, from a FST to a CSH, or even back to the United States if the patient is not likely to recover soon.
After receiving emergency medical treatment in the unit, wounded Soldiers were then evacuated to a Level II facility to receive the second or third phase of casualty care, advanced trauma management or forward resuscitative surgery.21 Level II or II+ facilities included FSTs or medical clearing companies that belonged to division forward support battalions and could be located at various places in relation to combat operations.† If close enough to an FST, injured Soldiers were driven to the team’s location by ground ambulance (GA). However, as the improvised explosive device (IED) threat in Iraq mounted in the summer of 2003, most casualties were moved by air rather than risking more lives in unarmored ambulances. The FST provided emergency surgery to save life and limb, and prepared the wounded Soldier for evacuation to the next component of casualty care. Air ambulances (AA)—MEDEVAC helicopters—then evacuated the casualty, usually by taking the Soldier directly to one of the four CSHs established in Iraq during this period. The extensive use of MEDEVAC helicopters in OIF meant that wounded Soldiers could be quickly transported to the appropriate Level II or Level III facility based on their condition, time, and distance factors.
After Operation DESERT STORM in 1991, the Army invested heavily in transforming MEDEVAC helicopters from simple transportation vehicles to flying trauma-treatment centers. Although the UH-60 Blackhawk was the Army’s main utility helicopter by 1991, roughly 75 percent of the MEDEVAC helicopters used in DESERT STORM were the Vietnam-era UH-1 “Huey.” The Army’s MEDEVAC version of the UH-60A Blackhawk used a specially designed, rotating patient-holding system to carry up to four wounded Soldiers. The Army then fielded the improved UH-60L Blackhawk MEDEVAC helicopter in 1997.22 In OIF, the Army largely relied on the HH-60L, a specially modified Blackhawk helicopter that contained an oxygen-generating system, an infrared radar system for locating casualties, a reserve hoist, and a litter lift. The crew of the HH-60L included a medic and on occasion a physician’s assistant or doctor. Medics on board used the brief transportation time to monitor wounded Soldiers’ vital signs, administer resuscitative breathing, or manage bleeding if needed, all the while recording relevant data by writing on the patient’s chests, arms, or legs.23 Typically, as standing operating procedures (SOP) dictated, MEDEVAC Blackhawks were the only helicopters to fly unescorted during combat operations in OIF. If available, Apache escort helicopters would accompany them, but if poor weather grounded the Apaches, the Blackhawks flew alone. Medical evacuations could be very dangerous missions, especially when the enemy ignored the Red Cross markings and fired on the helicopters.24
In OIF, because of the extensive use of MEDEVAC AAs, few wounded Soldiers were more than 30 minutes from an FST or a CSH. This proximity placed Soldiers within easy range of surgical care and almost always ensured they could get into the operating room within the “golden hour”—the period in which a trauma victim must receive basic surgical treatment to significantly improve survival.25 On a Soldier’s arrival at an FST or CSH, the AA medic updated the waiting staff on the injured Soldier’s condition and wounds. At that point, the FST or CSH staff assumed responsibility for the injured Soldier. After April 2003, however, as casualties were flown directly from point of injury to a CSH, reliance on the FSTs decreased.
The CSHs in OIF were mobile facilities transported to a theater of operations in standard military cargo containers and assembled into self-contained tent hospitals. The CSH was a Level III medical facility in the Army’s five-level system, and the highest-level asset deployed for OIF. The CSH provided the third phase of Army casualty treatment—theater forward resuscitative surgery (and in selected cases they also provided phase four care or theater hospitalization).‡ A “full-up” CSH employed some 480 medical personnel working in support of 248 beds.26 These hospitals also assumed the burden of treating wounded Iraqi soldiers, Iraqi civilians, as well as insurgents and terrorists. (As a signatory to the Geneva Conventions, the United States provides medical care to captured enemy fighters.)
According to Colonel Casper P. Jones III, commander of the 86th CSH, the primary mission of a CSH was to stabilize wounded Soldiers before their transfer out of Iraq to receive theater.27 Jones stated that the unit’s main task was “resuscitative care. . . .Our job [was] to save life, limb and eyesight, to stabilize and move the patients.”28 The CSHs in Iraq, at Mosul, Baghdad, Tikrit, and Balad Air Base, were state-of-the-art emergency centers, with some of the best trained and experienced trauma surgeons and staffs in the world, encompassing a broad spectrum of medical specialties.29 According to Colonel John Powell, M.D., commander of the 10th CSH, “We have gynecologists, we have a dentist, we have a facial surgeon, we have people who can take care of eyes. I mean, we have infectious disease specialists, we have internal medicine physicians. We have to be able to do all the same things that a regular hospital does.”30
The CSH was also capable of providing comprehensive care for Soldiers who were lightly wounded. Department of Defense (DOD) medical policy mandated out-of-theater evacuation for those Soldiers unable to return to duty quickly (within 2 to 4 days).31 This rapid evacuation policy in OIF eliminated the need to establish a Level IV hospital in Iraq. With several in Iraq, transportation to the CSH from point of injury was extremely rapid. The availability of strategic airlift ensured wounded Soldiers were quickly evacuated out of theater directly to Level IV hospitals in Europe, and if necessary, on to Level V medical centers in the United States.
When an injured Soldier required a lengthy recovery time, the CSH transported him or her by helicopter to Balad Air Base in Iraq where they boarded aircraft and flew to Landstuhl, Germany, or to Rota, Spain, in specially equipped Air Force C-17 medical transport planes.32 Each plane was, in effect, a flying hospital, staffed with a doctor, nurse, medical technician, and state-of-the-art portable medical equipment.33 This was the most sophisticated of the various forms of en route care provided to wounded Soldiers during OIF designed to hasten their trip to the next phase of medical care and the next level of medical-treatment facility.34
En route care was followed by the fifth and sixth phases of medical care: convalescent care and definitive care. The Army medical community designed these phases to return the Soldier to duty after recovery from illness or wounds, or if necessary, to prepare the Soldier for discharge from the Army. When a Soldier arrived at one of the US medical centers in Spain or Germany, physicians assessed the level of treatment required to determine where a Soldier would receive definitive care. If the length of stay was estimated to exceed 30 days, the Soldier was re-checked and sent to a support-base hospital or medical center in the United States. The most seriously wounded Soldiers were sent to either Walter Reed Army Medical Center in Washington, DC, or Brooke Army Medical Center in San Antonio, Texas.35 If discharged, former Soldiers became eligible for further treatment, if necessary, via the Veterans Administration (VA).
During the Vietnam war, this journey from injury site to a stateside medical facility on average took 45 days. The medical system then in place was designed to cure as many patients as possible in Vietnam or to ensure they were fully stabilized before travel to the United States. In OIF, policy was to lower the medical “footprint” and use advanced medical technology and en route care to mitigate the travel risks for wounded Soldiers. During the first 18 months of the campaign in Iraq, the fastest recorded trip of a wounded Soldier from Iraq to the United States was 36 hours, but most averaged 4 days. For its troops in Iraq, the Army had developed a remarkable system of medical care that was the culmination of more than 150 years of progress since the US Civil War.
†Forward surgical teams are labeled as a Level II+ treatment facility. As the Army’s modular structure was implemented starting in very late 2004, forward support battalion medical assets became an organic part of the brigade combat team.
‡Many Army CSHs have been deployed to OIF, both Active and Reserve units. The US Air Force has also deployed its version of the CSH to OIF.
US Army Battlefield Medicine before Operation IRAQI FREEDOM
Moving Emergency Treatment Closer to the Front Lines in Operation IRAQI FREEDOM
Following the Wounded Soldier in Iraq
Personal Protection, Body Armor, and Casualty Rates
Final Honors for the Fallen: Mortuary Affairs in Operation IRAQI FREEDOM
US Army Wounded Warrior Program
Mental Health and Post-Traumatic Stress Disorder
Soldier Well-Being: Morale, Welfare, and Recreation (MWR) in Iraq
United Service Organizations
Leave and Redeployment Policy
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