BAGRAM AIRFIELD, Afghanistan, July 1, 2015--"We're on standby all of the time," Col. Colleen Kloehn, 402nd Forward Surgical Team commander said. "We can be ready to go within two hours. Here, you have to be ready and on your game, always."

At BAF since April and here for nine months, the 402nd FST held an open house last month to showcase its medical capabilities. The Army Reserve unit, from Ft. Devens, Mass., has a 10-member team that includes doctors, technicians, and surgeons. It falls under the 3rd Multi-Medical Battalion (3rd MMB), with its Command and Control (C2) out of Camp Arifjan, Kuwait. USFOR-A has tactical control (TACON) of 3rd MMB.

"This is a temporary setup so people can see what we have," Kloehn said, standing inside the "FST heavy set" tent that houses all of the equipment. "It's an emergency room, operating room and intensive care unit. It functions as all three, in one tent. We have ventilators, monitors and suction just like a standard hospital would have. We can do everything here that Craig (Hospital) can do in its ICU. We are an operationally-ready, far forward surgical team that's on the battlefield and prepared to do damage control from a role 2 or role 3 facility."

Role 1 medical care is point of injury care or what's done at a Battalion Aid Station. Role 2 medical care is usually provided by a medical company, aka "Charlie Med," and the FST can be attached or collocated with them.

"The FST provides a rapidly deployable immediate surgical capability, enabling patients to withstand further evacuation," Kloehn said. "It provides surgical support in the brigade combat team. The team provides damage control surgery for those critically injured patients who cannot be transported over great distances without surgical intervention and stabilization. It provides lifesaving resuscitative surgery, including general, orthopedic, and limited neurosurgical procedures."

Role 3 is where the patient is treated in a medical treatment facility staffed and equipped to provide care to all categories of patients, including resuscitation, initial wound surgery, damage control surgery, and postoperative treatment.

"This role of care expands the support provided at role 2," she said. "Patients who are unable to tolerate and survive movement over long distances receive surgical care in a hospital as close to the point of injury as the tactical situation allows. This role includes provisions for evacuating patients from supported units, providing care for all categories of patients in a medical treatment facility with the proper staff and equipment, and providing support on an area basis to units without organic medical assets."

According to Kloehn, 20 people in a full FST can treat 30 patients for 72 hours without getting resupply. At BAF, there are 10 people on the team. The other 10 are at Camp Dwyer, Afghanistan.
"In this theater, everyone is split to do more with less," she said. "We are to provide critical damage control surgery, within the 'golden hour.' To be able to accomplish this we need small teams located anywhere we still have troops. The two teams have the same mission and are of the same make up of personnel that consists of a general surgeon, an orthopedic surgeon, an anesthetist, two nurses, two medics, two operating room technicians and an administrative Soldier."

When the FST deploys, set up takes about three hours. And, while the setup is occurring, the team is able to provide "tailgate medicine." That means it should be able to triage and start the initial treatment while the OR and anesthesia is getting the surgical area set up. A medic or a nurse remains with the patient while the setup continues.

"It does not necessarily have to be in a tent," Kloehn said. "We have set up in schools, barracks and other hard structures."

Capt. Mark Tyo, a nurse with 20 years of experience, practices as an ER nurse at Boston Medical Center. This is his first deployment.

"Our equipment is light and ready to move," Tyo said. "We're usually hit with three or more patients at the same time. One bed is set up here right now. Typically, we'd have two."
Kloehn explained that, first, people are Medevac'd here, then triaged to determine the priority of care depending on the severity of injury and the survivability chances.

"We do damage control surgery here and it should happen within the first hour," she said. "Anything to stabilize, stop the bleeding and to save life, limb or eye sight. We only have limited resources so if we don't have to do surgery, we try not to. Life, limb, or eyesight -- that's what we operate on."
Tyo adds that because they don't have an X-ray machine, or the injury may require more in-depth surgery, sometimes the wound is left open and surgery is redone at the role 3 after transfer.
"So we can't close them up for good," he said. "This happens frequently, as we just do the initial surgery, evacuate once stable, and then role 3 continues the more definitive treatment."

Kloehn, an anesthetist for 28 years, gives anesthesia using a portable drawover anesthesia machine or most often a technique called TIVA, total IV anesthesia. This is her sixth deployment.
"Every deployment is different," she said. "I have learned from all of them and most of all have met many great people while coming together to serve our country."

Next to the operating table is also an ultrasound machine, a blood warmer, a Bair Huggerâ„¢ to warm the patient, and other medical equipment. There are also blood refrigerators that can house blood for up to 24 hours, after being unplugged.

"The FST is mobile and fairly light," Tyo said. "The entire FST light set can be loaded on two (armored tactical vehicles) that are then driven directly onto a chinook helicopter when needed. We have everything here to perform life-saving surgery for four to six patients before we need to resupply."

"And we can hold the patient for 12 to 24 hours before they go to the role 3," Kloehn added. "This is not ideal but it is possible. The real goal is to move the patient as soon as they are stable enough to make the flight to the role 3."

The second tent, or set up, is called the FST light set. It is an emergency room, recovery room, and operating room all in one. It is similar to the heavy set but has less equipment, so it's lighter.
"It's a smaller light set," Kloehn said. "We can do two surgeries at a time, if need be. This set up has less equipment and supplies compared to the first one but we can still do the same surgeries. Everyone was tasked to pack only the essential equipment and supplies to do the job. We want to remain mission capable but be as light as possible for greater mobility and speed of the set up. With the light set, we can't make it 72 hours without resupplying. We would rely on resupply for medical supplies, blood and instruments."

When the team gets a call, usually, eight out of the 10 people on the FST team go on the mission. The two others remain to help resupply and do administrative work. There are also prepackaged resupply bags called "speed balls" we have them pre-staged and loaded. They contain the instruments and supplies to do one surgery, in each "speed ball."

"All medications are put in a pelican box," Tyo said. "Everything we need is in here. We typically carry 20 units of blood in a refrigerator plus fresh frozen plasma. So once we grab our designated 'speed ball,' we're ready to go."

There is a machine called the O2 concentrator that makes oxygen on its own, a Belmont Rapid Infuser that pushes blood into the body at a warm temperature, and a fiber optic device called the GlideScope Ranger that can show a picture if landmarks or anatomy can't be seen clearly because of trauma. There's also an ultrasound machine and an anesthesia drawover that uses multiple agents to put someone to sleep.

"The GlideScope Ranger and the ultrasound are the two most important pieces of equipment that we have here to do our job better," Kloehn said. "We also have to cross train. I'm training two medics right now so they can help me run the Belmont. Everyone has to know how to work all of the equipment. We have a good mix of energetic, new, young leaders being developed here."
The team is also cross training with the Air Force, stationed at Craig Hospital.

"If the hospital ever gets hit and can't function, we will be called to set up our role 2 so that we can still do damage control surgery on BAF," she said. "They have been training with us in case they need to help set up the FST and/or work in it."

"I'm proud of the survivability rate," Tyo said. "If you arrive at our team with a pulse, there's a 98 percent chance you'll leave with one."

"I could not ask for a better team," Kloehn said. "They are very strong clinically, mentally and physically resilient and most of all have a sense of humor. This is a tough time to be on a deployment for medical teams. Surgical teams want to operate and this means people are getting hurt. I am proud of my team for taking a step back and realizing that it is a good thing that we are fairly slow. So far the slow op tempo has not led to complacency, which could happen with a lesser-dedicated team. We are a cut above."