Initial Deployment of the 14th Parachutist Forward Surgical Team at the Beginning of the Operation Sangaris in Central African Republic

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1 MILITARY MEDICINE, 180, 5:533, 2015 Initial Deployment of the 14th Parachutist Forward Surgical Team at the Beginning of the Operation Sangaris in Central African Republic Maj Brice Malgras, French Army, MC*; Maj Olivier Barbier, French Army, MC ; Maj Pierre Pasquier, French Army, MC ; Maj Ludovic Petit, French Army, MC ; Col Aristide Polycarpe, French Army, MC ; BG Sylvain Rigal, French Army, MC ; MG Francois Pons, French Army, MC** ABSTRACT As part of the operation Sangaris begun in December 2013 in the Central African Republic, the 14th Parachutist Forward Surgical Team (FST) was deployed to support French troops. The FST (role 2 in the NATO classification) is a mobile surgical-medical treatment facility. The main goal of the FST is to assure the initial damage control surgery and resuscitation for combat casualties, allowing for the early evacuation to combat support hospitals (roles 3 or 4), where further treatments are completed. During the first trimester of the operation Sangaris, 42 patients were treated at FST, of whom 29 underwent surgery. Almost 50% of patients operated on were French servicemen. All admissions were emergency admissions. Orthopedic surgery represented two-thirds of surgical interventions executed as a result of the high proportion of limb injuries. Fifty percent of injuries were specifically linked to combat. Surgery in an FST is primarily dedicated to the treatment of combat casualties with hemorrhagic injuries, but additionally plays a part in supporting general medical care of French troops. Medical aid to the general civilian population is justifiable because of the presence of medical treatment facilities, even in the initial implementation of a military operation. INTRODUCTION The French military operation, named Sangaris, was launched the night of December 6, 2013 in the Central African Republic (CAR). The goal of this operation was to restore the security and humanitarian situation in CAR and to help the Africanled International Support Mission to the CAR (MISCA) in the country. The French military detachment was divided into 2 tactical battle groups of 600 servicemen, supported by a dedicated logistic unit of 400 personnel, including medical treatment facilities (MTF). In addition to the 11 roles, 1 with general practitioner, 1 forward surgical team (FST, role 2 in the NATO classification), 1 and a pharmacy were deployed. The goal of this article is to describe the 14th Parachutist FST s activity during its initial deployment in CAR in order to facilitate further deployments of FSTs in overseas operations and adapt their equipment to accomplish their mission. *Department of Digestive Surgery, Val de Grace Military Teaching Hospital, 74 Boulevard de Port Royal, Paris, France. Department of Orthopedic Surgery, Begin Military Hospital, 69 Avenue de Paris, Saint Mandé, France. Intensive Care Unit, Begin Military Teaching Hospital, 69 Avenue de Paris, Saint Mandé, France. Medical Unit of the 8th French Military Parachutist Unit, Avenue Jacques Desplats Castres, France. kintensive Care Unit, Laveran Military Teaching Hospital, 34 Boulevard Laveran, Marseille, France. Department of Orthopedic Surgery, Percy Military Teaching Hospital, 101 Avenue Henri Barbusse, Clamart, France. **Department of Thoracic Surgery, Percy Military Teaching Hospital, 101 Avenue Henri Barbusse, Clamart, France. doi: /MILMED-D METHODS Initial Deployment of the 14th Parachutist FST The French procedures of medical support plan in military operations (instruction n 208/DEF/EMA/OL5) follows NATO recommendations and defines the different levels of care for wounded servicemen (role 1/2/3/4, MEDEVAC, STRATEVAC). The 14th Parachutist FST usually includes a health care staff of 12: 3 physicians (1 anesthesiologist, 1 general surgeon, and 1 orthopedic surgeon), 2 nurses anesthetist, 1 operating room nurse, 2 registered nurses, 3 auxiliary nurses, and 1 administrative officer. A radiologic technologist, a registered nurse, and a medical equipment technician reinforced the 14th Parachutist FST for its deployment in this new overseas operation in CAR. The FST has 3 air-conditioned tents, requiring a plot of land of at least m. The FST was based in the M Poko military camp next to the Bangui airport, close to the helipad and the role 1 MTF (Fig. 1). The FST was operational and ready to manage casualties with severe hemorrhage within the first 10 hours after its arrival in CAR. The FST is organized in several subunits: a 3-bed intensive care unit (ICU), an 8-bed hospitalization unit, an operating room, and a 2-bed recovery room (Figs. 2 5). Upon an initial deployment of more than 1,000 servicemen, French FST has an initial endowment (equipment /drugs) designed to perform 12 surgical acts during a period of 48 hours. After this 48-hour period, the FST equipment can be fulfilled by the pharmacy deployed at the same time. In the case of the operation Sangaris, resources were adequate. In the case of a role 2 deployment in a new military operation theater, a pharmacy (called UDPS for Unité de Distribution MILITARY MEDICINE, Vol. 180, May

2 FIGURE 1. M Poko military camp. FIGURE 4. The FST hospitalization unit. FIGURE 2. The FST ICU. FIGURE 5. The FST operative room. FIGURE 3. Injured patient admission at the FST. des Produits de Santé, Health Products Distribution Unit) is also deployed in the theater with an initial endowment. Its mission is to supply all medical facilities of the theater (role1/2, MEDEVAC team). Medical logistics for our FST during the operation Sangaris was adequate. The dedicated equipment for anesthesiology, resuscitation, and surgery was enhanced with a mobile digital radiography system, a portable ultrasound machine, a minilaboratory (allowing limited blood analysis such as hemoglobin count, electrolytes, HIV and hepatitis B/C assays, and blood type testing), a surgical instrument sterilization box, and a blood bank with red blood cell and plasma lyophilized packs. Surgical packs included 2 external fixator packs, 2 abdominal packs, 1 thoracic pack, 1 gynecology pack, 1 vascular pack, 3 soft tissue packs, and 1 neurosurgical pack. Surgical packs available in a French FST meet the NATO 534 MILITARY MEDICINE, Vol. 180, May 2015

3 TABLE I. The 14th Parachutist FST Global Activity Between December 06, 2013 and February 28, 2014 at the M Poko Camp (CAR), Operation Sangaris Orthopedic Surgery General Surgery Anesthesiology/Intensive Care Surgical Acts 25 (68%) 12 (32%) 0 Consultations 56 (43%) 44 (34%) 29 (23%) Nonsurgical Management 2 (25%) 4 (50%) 2 (25%) standard with ISO standard. Sterilization of surgical packs was performed using 2 Matachana M30-B. The role 1 performed general practice consultations, asked for specialized advice in case of surgical pathology, and assumes MEDEVAC to our FST (role 2) in case of combat casualties. Role 1 was also responsible for the organization of the whole blood collect. Finally, in case of Massive Casualties (MASCAL), role 1 had to treat T3 T4 casualties. Strategic evacuations (STRATEVAC, ground or air) were performed by the MEDEVAC teams and their equipment. Medical information was communicated initially using the 9-line MEDEVAC request and completed by the Patient Evacuation Coordination Cell. Our French FST was the only surgical military structure of the CAR. The MASCAL planning is prepared before deployment in the Cours Avancé de Chirurgie en Mission Extérieure (Cachirmex) course, during the annual training period of the FST, and in disaster medicine university course. A MASCAL simulation was also performed during the first days after arrival in CAR. Report of the 14th Parachutist FST s Activity All the patients admitted at the 14th Parachutist FST in M Poko from December 06, 2013 to February 28, 2014 were prospectively included. The M Poko FST supported approximately 1,600 French servicemen of the operation Sangaris. The 14th Parachutist FST s activity (admissions, surgical acts, and consultations) was recorded on a Numbers 09 Version 4.3 document (Apple, Cupertino, California). The data collected included age, gender, nationality, status, and reason for admission (medical or surgical). The operating activity was recorded according to the degree of urgency, the surgical specialty, and the type of injury. The data analysis was performed with the program Numbers 09 Version 4.3 (Apple). RESULTS General Activity Between December 06, 2013 and February 28, 2014, 42 patients (40 males and 2 females) were admitted at the 14th Parachutist FST in M Poko (Table I). Of these 42 patients, 21 were French servicemen (50% of admitted patients), 8 (19%) from the MISCA, and 13 (31%) concerned medical aid to population (MAP) (Table II). Mean age was 28 ± 9 years (16 to 69 years old). None of the admissions were scheduled. Patients came to our FST by Air or Ground Evac. Time between injury and admission in our FST ranged from less than 1 hour (e.g., French servicemen injured in Bangui) to several days (civilians secondary evacuated from austere locations in the country). Twenty-one patients (50%) had combat-related injuries, 13 (31%) noncombat-related injuries, and 8 (19%) trafficaccident-related injuries. Of the 21 combat-related casualties, 6 had multiple organ injuries (total of 28 combat-related injuries). Combat injuries were related to gunshot wounds (GSW) (57%), explosions (39%), and bladed weapons (4%). Of the combat-related injuries, 13% involved the head, 7% the neck, 20% the chest, 4% the abdomen, 3% the spine, 50% the limbs, and 3% the blood vessels. Of the noncombat-related injuries, 11% involved the head, 11% the cervical spine, 5% the chest, 6% the abdomen, and 67% the limbs (Table III). Five casualties were declared dead upon their arrival at the FST: 3 French servicemen (1 with neck wound, 1 with transfixing chest wound, and 1 dead in a high-speed car crash), and 2 civilians (severe penetrating brain injury). Two MISCA soldiers were transfused with fresh whole blood units. There were 126 consultations, including 56 orthopedic consultations, 44 general surgery consultations, and 29 anesthesiology consultations. There were 3 Strategic Aeromedical Evacuations to France for definitive treatment of 4 patients (3 with limb injuries and 1 with severe malaria). These Strategic Aeromedical Evacuations were conducted by the MEDEVAC team from the military airbase of Villacoublay, with Falcon aircrafts. Description of Injuries and Operations Of the 42 patients admitted at the 14th Parachutist FST in M Poko between December 06, 2013 and February 28, 2014, 29 (69%) were operated on. Of the 13 (31%) nonoperated TABLE II. Casualties Description During the Operation Sangaris in Central African Republic Between December 06, 2013 and February 28, 2014 French Servicemen (N = 21) Patients (N = 42) MISCA (N = 8) Civilians (N = 13) Injuries Combat-Related Non-Combat Related Diseases Infectious Others Treatment Surgery Medical Deaths MILITARY MEDICINE, Vol. 180, May

4 TABLE III. Nonbattle Injuries During the Operation Sangaris in Central African Republic, Between December 6, 2013 and February 28, 2014 Traffic Accident (N = 8) Traumatology (N = 7) Nontrauma Diseases (N = 6) Trauma Head 1 1 Spine 3 (1 Lumbar, 2 Cervical) Trunk 1 Shoulder 1 Limbs 3 (1 Leg/1 Ankle Open Fracture, 2 (Superficial Wounds) 1 Thigh Amputation) Knee 2 Finger 4 (2 Tendon Rupture, 1 Traumatic Amputation) Infectious Acute Appendicitis 1 Severe Malaria 1 Perineal Abscess 2 Soft Tissue Necrosis 1 Carbon Monoxide Poisoning 1 patients, 5 were declared dead upon arrival, 2 required hospitalization in the ICU (1 with carbon monoxide poisoning and 1 with severe malaria), and 6 were admitted after blunt trauma with no need for surgery (4 with trauma brain injury, 1 with spinal trauma, and 1 with limb trauma). Of the 29 operated patients, 6 incurred multiple injuries. Thirteen (45%) French servicemen were operated on, and only 3 (10%) were combatrelated. The 37 operating acts were divided into 25 (68%) orthopedic surgery acts and 12 (32%) general surgery acts. Hand surgery concerned one-fourth of orthopedic surgery acts (6/25 acts, 24%). One case of paraplegia, caused by a spinal cord injury, was treated with spinal immobilization and surgical wounds debridement. The 12 general surgical acts were divided into surgical management of 4 chest wounds (projectile wound debridement, chest tube), 3 surgical treatments of sources of infections (perineum abscess, appendicitis), 3 soft tissue injuries (wound debridement of neck, limbs) 1 abdominal injury (damage control surgery), and 1 limb vascular injury (limb arterial suture). DISCUSSION In December 06, 2013, the 14th Parachutist FST set up surgical and resuscitation tents to support French troops in the context of the deployment of a new military mission: the operation Sangaris in CAR. The French Medical Health Service developed 9 FST to support French military operations. Every 2 months a new FST is designed, ready to be deployed within 48 hours to support unexpected military operations. That is what happened in CAR for the operation Sangaris. French FSTs are designated units that trained and worked together during a period of 2 to 4 years. So, team work and deployment preparation seem adequate even in this specific case of unexpected deployment. Each French FST has to complete a training period every year at the Centre de Formation Opérationnelle Santé, Health Tactical Training Centre. In 1 week, all the 14th Forward Surgical Parachutist Team prepared to be combat ready, trained in tactical combat casualty care and management of FST equipment. Special insights are given to training in team and in immersive conditions, including full-scale exercises, using high-fidelity manikin simulation combined with casualty simulation moulaged actors management. Indeed, some stages are conducted in lifelike conditions to emphasize the importance of MASCAL plans. Moreover, specific physical tests are required and 6 parachute jumps are performed per year. Our preparation is the same to similar organizations, such as FSTs supporting combat operations in Afghanistan. However, in the case of planned deployments, special information are given, before deployment, regarding geopolitics, military operations, FST application, or health organization in the country. For the Sangaris operation, these information were given at arrival. Regardless of the reduced volume of medical equipment in this airborne FST, the surgical team performed 37 general surgical acts. This could be attributed to the small number of injured French servicemen, as a result of the high quality of combat equipment, predeployment training, and selection based on physical aptitude before departure. 2 Indeed, only 21 injured French servicemen were treated during this trimester. Thirteen of these servicemen were operated on, only 3 of which had incurred combat-related injuries. Blood resources were limited, with only 20 units of packed red blood cells fully restored every month. Blood transfusion is an essential stage in damage control resuscitation for the treatment of casualties with severe hemorrhage. Blood resources represent a potential limiting factor, especially in the event of mass casualties. 3,4 However, fresh whole blood collection is possible. 5 Computed tomography (CT) was not available during the initial deployment of the 14th Parachutist FST in CAR. The absence of CT is justifiable to decrease the size and weight of the FST. Moreover, at the beginning of a conflict, GSWs, rather than explosion-related injuries, are generally expected. The GSW always requires a surgical exploration, 536 MILITARY MEDICINE, Vol. 180, May 2015

5 regardless of CT s presence. 6,7 However, in the event of the mission s prolonged duration, providing CT in the MTFs of the operation Sangaris would seem appropriate, considering the lack of access to CT imaging in CAR s civil hospitals. CT could improve the general treatment of patients, particularly in cases of blunt traumas or nontraumatic abdominal emergencies. 8 During the first trimester of the operation Sangaris, 50% of patients suffered from penetrating traumas (GSW or shrapnel) for which surgery was mandatory, even in the absence of CT imaging. From a surgical point of view, the absence of a brilliancy amplifier and contrast medium did not allow arteriography. Arteriography is a useful tool in management of vascular lesions, found in 5 to 10% of combat injuries. 9 The 14th Parachutist FST is not yet equipped with laparoscopy, now provided in level III American MTFs However it could be helpful, in the absence of CT and/or close role 3, especially for nontraumatic abdominal emergencies or for uncertain intraperitoneal penetration cases (e.g., multiple shrapnel wounds of the back). Indeed, laparoscopy improves the accuracy of diagnoses, especially in the absence of powerful diagnostic resources, such as CT imaging. In comparison to laparotomy, laparoscopy leads to a shorter postoperative recovery time, allowing for more rapid medical evacuation, and preventing the exhaustion of the FST s hospitalization capacity. The orthopedic surgeon performed only external fixation osteosynthesis as poor sanitary conditions prohibited all internal osteosynthesis. 14 Finally, the 14th Parachutist FST is not equipped for microsurgery acts (absence of magnifying classes and adapted instruments) even if hand trauma and neuromuscular sutures represented up to 19% of operating acts during this mission. 15 From a surgical point of view, orthopedic surgery was the most commonly executed because of the high rate of limb injuries in military and civilian casualties (50% for combat-related casualties and 67% for noncombat-related casualties). 16 Limb amputations had to be performed on several civilian casualties In CAR, secondary treatment in a dedicated medical structure for reconstructive surgery and rehabilitation does not exist. For the general surgeon in FST, who is generally a digestive surgeon, a diversified training is necessary. 20 During the first trimester of the operation Sangaris, the general surgeon had to deal with classic digestive emergencies; cranial, chest, cervical, and vascular traumas; as well as with urological and gynecological emergencies. Without CT imaging, the general surgeon performed abdominal pelvic ultrasounds for the diagnosis of several abdominal emergencies. The training of digestive surgeons is considered crucially important by many nations. 21,22 The French Medical Corps has tackled the problem of the military surgeon s training specificity. In 2007, an advanced course for deployment surgery was created by l Ecole du Val de Grâce du Service de Santé des Armées, the French Military Medical School, and called Cours Avancé de Chirurgie en Mission Extérieure (Cachirmex). 23,24 This advanced course is designed to meet the needs of senior military surgeons regarding both war trauma surgery and care to civilian populations in military health care facilities or in austere environment. This advanced course aims to provide visceral surgeons the necessary skills required in life-threatening situations, particularly thoracic and vascular injuries. This course is divided in 5 modules over a 2-year period. Module 1 develops the organization of the French Medical Corps during abroad deployment (triage, vulnerating agents, medical evacuation, and equipment display). Module 2 is dedicated to the particular care of civilians as part of humanitarian aid. The other 3 modules cover opened and closed trauma of the limbs, head, neck, thorax, abdomen, and pelvis. Each module includes (i) lectures given by surgeons previously deployed abroad (surgical indications, available materials, and logistics), (ii) feedback of previous deployments with clinical based discussions, (iii) hands-on procedures realized on embalmed, fresh cadavers or pigs. Our French FST is thus comparable to the American FST. However, the French FST is limited in size, personnel, and equipment. 25 Despite modest surgical activity, the treatment of combat casualties with severe hemorrhage injuries remained the priority of the 14th Parachutist FST Medical aid to the general civilian population (MAP) is generally considered as a secondary purpose in a new military operation. 29 Nevertheless MAP represented one-third of the FST s activity during the first trimester of the operation Sangaris. Under French doctrine, MAP should supplement and join, rather than compete with, the mission of the local health care system so that the local health care system remains functional after the foreign military s departure or after a potential termination of MAP because of geopolitical context. 30 The French Doctrine also states that medical care to civilian population should not affect the capacity of health support for French servicemen. In CAR, at the beginning of the civil war, all medical facilities of Bangui were deserted. Non-Governmental Organizations (NGOs) send medico-surgical teams to provide care to civilian patients in these deserted hospitals of Bangui. The 14th Parachutist FST offered to supplement for surgical care of civilian patients. Civilian patients were transferred to NGO facilities within 24 hours after surgery to prevent the oversaturation of the FST s capacity. Local or NGOs facilities could contact the officer in charge of civil military activities. The final decision to accept a civilian patient was made by the French Medical Chief Officer (Commandant Santé), depending on the ongoing military conditions and capabilities of the FST. Moreover, MAP maintains the performance of medicalsurgical teams, and the cohesion within the group in an FST. In the current counterinsurgency strategy, MAP can be a key strategic tool, since the French troops are welcomed. 31 Communication with non-french speaker patients was performed in English, or with an interpreter. French interpreters are present usually in each military theater. Local interpreters can come also to the FST, after security checkup. The 14th Parachutist FST had to participate in MAP and, at the same time, assure permanent support to French troops, which was challenging. Also, medical MILITARY MEDICINE, Vol. 180, May

6 evacuation facilities had to be effective to prevent the oversaturation of the FST s capacity. CONCLUSION The initial deployment of a FST during a new military operation is challenging. In CAR, the 14th Parachutist FST had to deal with rustic conditions of life and limited equipment. Surgical activity was limited, with a small number of combat casualties. However, real competency in general surgery was required to assure efficient support of the French troops. The medical and surgical equipment of the FST should be supplemented to improve the treatment of both military and civilian patients in the operation Sangaris, considering the local medical structures in the CAR cannot provide an adequate standard of care. The deployment of the 14th Parachutist FST in a new theater of war in CAR led the surgeons to combine the support of French troops and the MAP in a country with poor health care conditions. REFERENCES 1. NATO: Chapter 16: Medical Support. 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