2. Copyright @ 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Predeployment Mass Casualty and Clinical Trauma
Training for US Army Forward Surgical Teams
Bruno M. T. Pereira, MD, FCCS,* Mark L. Ryan, MD,* Michael P. Ogilvie, MD, MBA,*
Juan Carlos Gomez-Rodriguez, MD,* Patrick McAndrew, RN,Þ George D. Garcia, MD,*þ
and Kenneth G. Proctor, PhD*
Abstract: Since the beginning of the program in 2002, 84 Forward
Surgical Teams (FSTs) have rotated through the Army Trauma
Training Center (ATTC) at the University of Miami/Ryder Trauma
Center including all those deployed to Iraq and Afghanistan. The
purpose of this study was to provide the latest updates of our ex-
perience with FSTs at the ATTC. Before deployment, each FST
participates in a 2-week training rotation at the ATTC. The rotation
is divided into 3 phases. Phase 1 is to refresh FST knowledge re-
garding the initial evaluation and management of the trauma patient.
Phase 2 is the clinical phase and is conducted entirely at the Ryder
Trauma Center. The training rotation culminates in phase 3, the
Capstone exercise. During the Capstone portion of their training, the
entire 20-person FST remains at the Ryder Trauma Center and is
primarily responsible for the evaluation and resuscitation of all
patients arriving over a 24-hour period. Subject awareness concern-
ing their role within the team improved from 71% to 95%, indicating
that functioning as a team in the context of the mass casualty training
exercise along with clinical codes was beneficial. The clinical com-
ponent of the rotation was considered by 47% to be the most valu-
able aspect of the training. Our experience strongly suggests that a
multimodality approach is beneficial for preparing a group of in-
dividuals with minimal combat (or trauma) experience for the rigors
of medical care and triage on the battlefield. The data provided by
participants rotating through the ATTC show that through clinical
exposure and simulation over a 2-week period, we are able to dem-
onstrate improved function of the FST as a unit by defining provider
roles and improving communication. The mass casualty training ex-
ercise is a vital component of predeployment training that participants
feel is valuable in preparing them for the challenges that lay ahead.
Key Words: Combat casualty care, mass casualty, forward surgical
team, trauma, military training
(J Craniofac Surg 2010;21: 00Y00)
The first Forward Surgical Team (FST) was created by Dr Charles
Rob, a vascular surgeon serving in the Royal Army Medical
Corps during World War II. Its mission was the care of, and stabi-
lization of, wounded British paratroopers immediately after battle.1
The US Army adopted the concept in the early 1990s to replace
the mobile Army surgical hospital units used during Korean War,
Vietnam War, and the invasion of Grenada. The mission of the FST
is to provide far-forward surgical support during the Bgolden hour[
of traumatic injuries in the 5% to 10% of patients who would not
survive transport to a combat support hospital (CSH).2
The core of
the FST is the personnel, which consists of 3 general surgeons, 1 or-
thopedic surgeon, 2 nurse anesthetists, 1 operating room (OR) nurse,
and 3 OR technicians. They are capable of providing a maximum of
10 major lifesaving or limb-saving operations per 24-hour period
and can maintain that tempo for 72 hours consecutively without need
for resupply. Furthermore, the FST can provide advanced trauma
life support (ATLS) to 15 patients as well as postoperative care up to
6 hours with a maximum of 8 simultaneous patients before evacu-
ation. Additional members of the team include 1 intensive care unit
nurse, 1 emergency room nurse, 4 combat medics, 3 licensed practical
nurses, and an executive officer, for a total of 20 personnel. Currently,
FSTs deploy using general-purpose tents and require less than
1000 sq ft of space. Ideally, the FST will have a lightweight shelter
system with an environmental control unit for heating/cooling that
provides clean air ventilation for the surgery area.3,4
The FSTs, although
normally attached to a CSH for general support, are designed to op-
erate far forward and geographically remote from the CSH and have
been found to provide outcomes comparable to a CSH despite the
limited availability of diagnostic and therapeutic resources.5,6
Since
the beginning of the program in 2002, 84 FSTs have rotated through
the Army Trauma Training Center (ATTC) at the University of Miami/
Ryder Trauma Center including all those deployed to Iraq and
Afghanistan. We have previously described a predeployment training
exercise, which includes basic instruction for this elite unit, with
simulation or immersion components.7
The purpose of this study was
to provide the latest updates of our experience with FSTs at the ATTC.
MATERIALS AND METHODS
Before deployment, each FST participates in a 2-week train-
ing rotation at the ATTC. Teams rotate an average of 1 per month,
with 11 rotations per year. One month is reserved for the ATTC staff
to perform a curriculum review. The rotation is divided into 3 phases.
The primary aim of the ATTC rotation is to promote teamwork
and enhance the coordinated response to traumatic injury among
team members that have rarely, if ever, worked together in a clin-
ical setting. The ATTC director and 8 experienced ATTC instructors
ORIGINAL ARTICLE
The Journal of Craniofacial Surgery & Volume 21, Number 4, July 2010 1
From the *University of Miami Miller School of Medicine; †US Army; and
‡Jackson Memorial HospitalAQ1 .
Received March 5, 2010.
Accepted for publication March 11, 2010.
Address correspondence and reprint requests to Kenneth Proctor, PhD,
Dewitt-Daughtry Family Department of Surgery, Division of Trauma
and Surgical Critical Care, 1800 NW 10th Ave, T245 Miami, FL 33136;
E-mail: Kproctor@med.miami.edu
Financial support for this research was provided in part by contract
LW81K04-06-C-0021 from the Department of Defense and grant
N140610670 from the Office of Naval Research.
The authors report no conflicts of interest.
Copyright * 2010 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e3181e1e791
Copyeditor: Timi Santiago
3. Copyright @ 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
comprise the primary training staff. University of Miami/Jackson
Memorial Hospital trauma fellows, residents, and students also par-
ticipate, as space permits.
Phase 1
The primary emphasis of phase 1 is to refresh FST knowl-
edge regarding the initial evaluation and management of the trauma
patient, determining one’s role on the team and functioning as a
coordinated unit. This phase consists of several 50-minute lectures
given over the first 4 days of training. The following subjects are
addressed: principles of the primary survey as defined by the Ame-
rican College of Surgeon’s Committee on Trauma ATLS, principles
of triage, preservation of remains, critical team concepts, trauma
teamwork system, teamwork in the trauma resuscitation unit, airway
management, shock and resuscitation, head trauma, chest trauma, ab-
dominal trauma, pediatric trauma, and burns. The Combat Extremity
Surgery Course (CESC) is also given during this phase of training.
In addition to a didactic portion, the CESC includes a cadaver limb
laboratory encompassing vascular exposures, upper- and lower-
extremity fasciotomy, placement of external fixators, and nonopera-
tive orthopedics (splinting and casting).
In the practice module, the FSTs have opportunity for training
in volunteer-mock patients and advance ATLS practice dummies,
such as the METIman (METI Medical Technologies, IncAQ2 ). They are
also instructed in basic surgical anatomy as well as surgical expo-
sures for trauma and venous access. A CESC is conducted for the
surgical staff, in which exposures and procedures are conducted on
cadaveric limbs, and all teams are instructed in nonoperative ortho-
pedics (splinting, traction). Finally, there is a mass casualty simula-
tion training exercise and advanced trauma operative management
course for the FST surgeons.
The novel aspects of this training program concern the use
of simulation in the enhancement of care of the trauma patient and
functioning in a mass casualty triage situation.
Phase 1 also consists of extensive simulated training also di-
vided over the first 4 days of the rotation. The first simulated exer-
cise occurs on the second day of the rotation and is conducted on a
physiologically reactive trauma mannequin, the METIman (METI
Medical Technologies, Inc). One of several patient scenarios is con-
ducted and, rather than focusing on clinical decision making, the
ability of designated treatment teams within the FST to communi-
cate and perform assigned roles is evaluated for the first time. Con-
currently, team members are rotated through several resuscitative
skills laboratory stations. These include an airway station and an
intravenous (IV) access station where team members practice start-
ing peripheral IV access.
The next day, the surgeons and OR personnel participate
in a cadaver laboratory where they are guided through operative
exposures for trauma that they have seldom or, in some cases,
never performed. On returning to the Ryder Trauma Center, the
team is informed that a patient is arriving shortly and they will be
receiving him.
This component of the training uses a volunteer functioning
as a simulated patient. The exercise is engineered so that the expe-
rience is as authentic as possible. The volunteer is briefed on his/her
injuries and proper behavior consistent with his/her simulated con-
dition. A consent form is signed by the volunteer authorizing the
placement of IV lines.
The team is alerted to an incoming trauma over the hospital
paging system. The patient then arrives via the Miami-Dade County
Air Rescue service. The patient is then treated in accordance with
ATLS protocol, while providing challenges to treatment such as agi-
tation and altered mental status. The drill is performed under the
supervision of several ATTC instructors, and invasive procedures are
limited to peripheral IV access.
An After Action Review (AAR) is then performed to discuss
positive and negative aspects of the team’s performance during the
exercise, again focusing primarily on the team dynamic and per-
formance of assigned roles. Alternative solutions and scenarios im-
pacting treatment of the patient are discussed, and strategies to
address them are devised should they be encountered in the field.
Phase 1 culminates with a live tissue mass casualty (MASCAL)
training exercise in which the team is presented with multiple trau-
matic injuries simultaneously to evaluate them on the rapid provision
of ATLS protocols and the proper triaging of patients to the OR,
intensive care unit, or stabilization for transport to a combat support
hospital.
The exercise begins with a 30-minute briefing that reviews the
principles of mass casualty incident management as well as basic
swine anatomy. After this briefing, the team is given 60 minutes to
ready its gear and prepare for an unknown number of incoming
casualties. The combat environment is simulated with the sound of
gunfire and explosions broadcast over a speaker system within the
laboratory, making communication difficult. As in the field, the FST
will encounter supply shortages, power failures, and limited per-
sonnel in the face of mounting casualties.
Adjacent to the classroom, the casualties are anesthetized and
given a standardized set of combat relevant injuries ( T1Table 1). This
exercise relies on farm-raised cross-bred swine as simulated patients.
All procedures are performed according to National Institutes of
Health Guidelines for Use of Laboratory Animals and were pre-
approved by the Institutional Animal Care and Use Committee. If
one of the initial patients is successfully triaged and evacuated with-
out the need for surgery, they will be taken to the adjacent room
where additional injuries will be given. This Brecycled[ patient will
be reintroduced into the mass casualty simulation to further test the
resources and stamina of the team.
Casualties are dressed in patient gowns (covering their inju-
ries) and presented in 3 main incoming waves at a simulated helipad
with loud noise and excessive amount of wind provided by a large
fan. By radio, the FST is notified that a medical evacuation heli-
copter is about to land with an unknown number of war victims. In
the first wave, only 1 casualty is delivered (Abel). The FST begins
treatment, and after 15 minutes, the radio notifies the team of an
incoming second wave consisting of 4 patients (Baker, Charles,
David, and Edgar). An additional 60 minutes is given, and a final
wave is announced with 2 to 4 additional casualties. This third wave
TABLE 1. Standardized Injuries Encountered During the
MASCAL Training Exercise
Casualty Injuries
Abel Airway compromise, 50% TBSA burns (simulated),
inhalation injury (simulated)
Baker Transmediastinal penetrating cardiac injury wound,
right-sided thoracoabdominal penetrating wound
Charles Abdominal wall laceration with evisceration, IED
(undetonated) within wound
David Scalp laceration, right lower extremity traumatic
amputation
Edgar Airway compromise, anterior and posterior shrapnel
wounds, 30% TBSA upper torso burns (simulated),
neck (zone II) penetrating carotid/ jugular injury
Frank BRecycled[ (see text)
IED indicates improvised explosive device; TBSA, total body surface area.
Pereira et al The Journal of Craniofacial Surgery & Volume 21, Number 4, July 2010
2 * 2010 Mutaz B. Habal, MD
4. Copyright @ 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
can include either the Brecycled[ patient or may not come at all,
simulating faulty intelligence or dead-on-arrival casualties. The drill
concludes when all casualties have been resuscitated and stabilized
or have died of wounds.
The groups are then separated for different skills laboratories.
Surgeons participate in an operative laboratory on surviving patients
that is based on the American College of Surgeons advanced trauma
operative management course in which the animal is given an un-
known combination of intra-abdominal injuries, and the surgeon
must find and address them using a standardized protocol, again,
allowing them the opportunity to perform maneuvers that they may
not perform on a regular basis in their practice. Meanwhile, the nurses
and medics participate in a suturing and chest tube placement skills
laboratory. The final and most important component of the MASCAL
drill is the AAR. The FST is evaluated by the ATTC staff regarding
performance in several standardized metrics (preparation, leadership,
and casualty treatment). Positive and negative aspects of group per-
formance are reviewed, and alternative strategies regarding FST
planning, triage, and treatment are discussed (F1 Fig. 1).
Phase 2
The second phase of training is the clinical phase and is con-
ducted entirely at the Ryder Trauma Center. The Ryder Trauma
Center at Jackson Memorial Hospital is the only level I trauma
center in Miami and provides care for acute traumatic injuries to all
of Miami-Dade County with a population of 2.3 million people.
Because of the county’s high incidence of both penetrating and blunt
injuries, with approximately 4500 trauma admissions per year, it
provides ample clinical exposure to the teams before deployment.
The FST is divided into 2 teams, a day shift and a night shift,
who then participates in and direct care for incoming traumatic
injuries alongside Jackson attending surgeons, trauma fellows, resi-
dents, and nursing staff in 12-hour shifts. The number of patients
the FST members evaluate and resuscitate is at the discretion of
ATTC instructors and is based on team performance. After 3 days,
the team is allowed a day off, and the shifts are reversed. The team
performs another 2 days of shifts and are allowed a second day off.
Phase 3
The training rotation culminates in phase 3, the Capstone
exercise. During the Capstone portion of their training, the entire
20-person FST remains at the Ryder Trauma Center and is primarily
responsible for the evaluation and resuscitation of all patients arriv-
ing over a 24-hour period. During this portion of the training, there
is only moderate input and oversight from the attending trauma
surgeons at Ryder, although they are always readily available.
FIGURE 1. A sample form used in an AAR. The teams are graded based on performance as a team as well as adherence to ATLS
principles.
The Journal of Craniofacial Surgery & Volume 21, Number 4, July 2010 Predeployment Mass Casualty Training for US Army
* 2010 Mutaz B. Habal, MD 3
5. Copyright @ 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
RESULTS
Participants are surveyed before and after their experience
at the ATTC regarding clinical and combat experience as well as
knowledge of their purpose within the team. We have aggregated
the survey data taken from 178 participants over the past 18 months
to determine the typical profile of a participant in this rotation and
evaluate the gains that are made in terms of team building and clinical
preparedness.
The prerotation profile of the participants highlights the
necessity of didactic education and simulation in preparing partici-
pants for the challenge they will face in the field (T2 Table 2). Fifty-one
percent have 0 to 6 months’ experience, and 27% have 6 months to
1 year’s experience. Only 22% have more than 1 year of experience
in the field. Team building and role defining are essential components
of this experience, as 49% of participants have worked together for
less than 6 months. Fifty-six percent have had minimal involvement
(G25% of their day) in patient care, reflecting the need for intense
clinical education. Before the rotation, 74% of participants are un-
sure of how their team will function in the care of a trauma patient,
and 30% are unfamiliar with their role within the team structure.
After the rotation and all training exercises have been com-
pleted, there is a demonstrable improvement regarding participant
perception of team performance as well as their role within the team
(T3 Table 3). The awareness of subjects regarding the ability of their team
to function in a trauma improved from 26% to 84%, reflecting the
overall course emphasis on teamwork and communication. Subject
awareness concerning their role within the team improved from 71%
to 95%, indicating that functioning as a team in the context of the
MASCAL training exercise along with clinical codes was beneficial.
The clinical component of the rotation was considered by 47% to be
the most valuable aspect of the training, with the MASCAL training
exercise receiving the second highest votes at 21%. The METIman
simulation and team building exercises were considered to be the least
helpful (22% and 25%, respectively). These shortcomings need to be addressed to improve the clinical relevance of the exercises as well
as participant satisfaction.
DISCUSSION
Our experience strongly suggests that a multimodality ap-
proach is beneficial for preparing a group of individuals with min-
imal combat (or trauma) experience for the rigors of medical care
and triage on the battlefield.
After 9/11, the 274th FST was deployed to Afghanistan for
a period of 8 months. During that time, they cared for 153 traumatic
injuries (61% soft-tissue injury, 10% orthopedic, and 17% vascular).8,9
The ability to respond to waves of casualties threatening to overwhelm
FST resources is an essential quality to obtain before deployment.
Mass casualty training exercise is not a component of current surgical
education.10
Our previous observations of MASCAL training exer-
cise conducted at our institution noted a 20% incidence of prevent-
able death7
; by addressing failures of communication and teamwork
during the simulation, we believe that battlefield morbidity and mor-
tality will be reduced as a result.
The data provided by participants rotating through the ATTC
show that through clinical exposure and simulation over a 2-week
period, we are able to demonstrate improved function of the FST
as a unit by defining provider roles and improving communication.
The MASCAL training exercise is a vital component of predeploy-
ment training that participants feel is valuable in preparing them for
the challenges that lay ahead. Furthermore, clinical exposure to trau-
matic injury in a controlled setting is of the utmost importance in
preparing FSTs for the types of casualties they will be encountering
on the battlefield. Other models for predeployment training in com-
bat casualty care have been limited to inanimate and animal models.11
We believe that the combination of didactic, simulation, and clinical
TABLE 2. Prerotation Survey*
Combat Experience Time With Team
0 mo 51% (91) 49% (87)
6Y12 mo 27% (48) 16% (28)
12Y18 mo 15% (26) 10% (18)
18Y24 mo 3% (6) 7% (12)
924 mo 4% (7) 19% (33)
Percentage of Day Involving Patient Care
0%Y25% 56% (99)
25%Y50% 3% (6)
50%Y75% 6% (11)
75%Y100% 35% (62)
Knows Team Function Knows Role
Strongly disagree 2% (4) 7% (12)
Disagree 1% (2) 10% (17)
Neutral 71% (126) 13% (24)
Agree 19% (33) 37% (65)
Strongly agree 7% (13) 34% (60)
*Survey data taken before participation in the ATTC rotation.
TABLE 3. Postrotation Survey
Increased
Knowledge
Knows Team
Function
Knows
Role
Strongly disagree 1% (2) 0% (0) 0% (0)
Disagree 1% (1) 0% (0) 1% (2)
Neutral 5% (8) 1% (2) 3% (5)
Agree 36% (62) 29% (50) 29% (50)
Strongly agree 57% (98) 55% (94) 66% (113)
Most Valuable Least Valuable
Resuscitative skills
laboratory
2% (3) 6% (10)
Simulation training 1% (1) 22% (38)
Team exercise
(game)
2% (4) 25% (43)
Anatomy exposures
laboratory
6% (10) 5% (9)
Mock trauma 5% (9) 9% (15)
MASCAL training
exercise
21% (36) 2% (4)
Extremity course 4% (6) 5% (9)
Clinical rotations 47% (80) 2% (3)
Lectures 2% (3) 12% (20)
Capstone 11% (19) 12% (20)
*Survey data taken after participation in the ATTC rotation.
Pereira et al The Journal of Craniofacial Surgery & Volume 21, Number 4, July 2010
4 * 2010 Mutaz B. Habal, MD
6. Copyright @ 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
exposure at the ATTC represents a unique and valuable training
modality for those providing medical care to our soldiers overseas.
ACKNOWLEDGMENTS
The authors thank the ATTC Staff: LTC Darin Marchok, MAJ
Kim Blumberg, MAJ Lisa Miller, MAJ Jess Kirby, MAJ Thomas
Rawlings, MAJ Hope Williamson, CPT Daniel Coulter, SFC Rodney
Atwood, SFC Victor Salas, SGT Robert Elvir, and our research
coordinator, Ron Manning, RN, MPH, for their support. They also
thank the following Medical and premedical students for their
participation: Luke Samson, Marina Mityul, Paola AVargas, Kristin
Nicole Rongstad, Reginald Pereira, Jr, Adam Gordon, and Kathryn
Flavin.
REFERENCES
1. Stinger HK, Rush R. The Army Forward Surgical Team: update and
lessons learned, 1997Y2004. Mil Med 2006;171:269Y272
2. Stinger HK, Rush RM. The Forward Surgical Team: the Army’s ultimate
lifesaving force. Infantry 2003;92:11Y13
3. Employment of forward surgical teams: tactics, techniques, and
procedures. FM 4-02.25, Headquarters Department of the Army;
March 2003.
4. Lounsbury D, et al. Emergency War Surgery. 3rd ed. Washington, DC:
US Department of Defense, 2004
5. King B, Jatoi I. The mobile Army surgical hospital (MASH): a military
and surgical legacy. J Natl Med Assoc 2005;97:648Y656
6. Cho JM, Jatoi I, Alarcon AS, et al. Operation Iraqi Freedom: surgical
experience of the 212th Mobile Army Surgical Hospital. Mil Med
2005;170:268Y272
7. King DR, Patel MB, Feinstein AJ, et al. Simulation training for a mass
casualty incident: two-year experience at the Army Trauma Training
Center. J Trauma 2006;61:943Y948
8. Eastridge BJ, Stansbury LG, Stinger H, et al. Forward Surgical Teams
provide comparable outcomes to combat support hospitals during
support and stabilization on the battlefield. J Trauma 2009;66
(suppl 4):S48YS50
9. Peoples GE, Gerlinger T, Craig R, et al. Combat casualties in Afghanistan
cared for by a single Forward Surgical Team during the initial phases
of Operation Enduring Freedom. Mil Med 2005;170:462Y468
10. Galante JM, Jacoby RC, Anderson JT. Are surgical residents prepared
for mass casualty incidents? J Surg Res 2006;132:85Y91
11. Sohn VY, Miller JP, Koeller CA, et al. From the combat medic to the
Forward Surgical Team: the Madigan Model for improving trauma
readiness of brigade combat teams fighting the Global War on Terror.
J Surg Res 2007;138:25Y31
The Journal of Craniofacial Surgery & Volume 21, Number 4, July 2010 Predeployment Mass Casualty Training for US Army
* 2010 Mutaz B. Habal, MD 5
