{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,8]],"date-time":"2026-04-08T03:47:01Z","timestamp":1775620021055,"version":"3.50.1"},"reference-count":26,"publisher":"Oxford University Press (OUP)","issue":"5-6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2021,5,3]]},"abstract":"<jats:title>ABSTRACT<\/jats:title><jats:sec><jats:title>Introduction<\/jats:title><jats:p>The U.S. forward military surgical assets have deployed throughout the Iraq and Afghanistan theaters of operations to maintain surgical support for injured service members in compliance with the \u201cgolden hour\u201d as specified in the Gates Memorandum. The support of evacuation times of less than 60 minutes to a surgical capability has resulted in smaller surgical teams being deployed to an increased number of locations. Over the last 5 years, the combat trauma patient encounters have decreased. Although some Role\u00a02 medical treatment facilities (MTFs) maintain a medical mission, most of them are set up to provide trauma care. The largest and busiest Role\u00a02 MTF is located near Kabul and serves the NATO population. The aims of this review are to examine the epidemiological data of the largest Role\u00a02 MTF in theater, to examine damage control surgical capability optimization in a facility with a largely medical mission, and to analyze what this may mean in the context of surgical skill atrophy.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>As part of a performance improvement project, a retrospective review of prospectively collected data at the Hamid Karzai NATO Role\u00a02 MTF was conducted. Four years of clinical and epidemiological data were reviewed. Independent source verification of the records was conducted by validating records via comparison to the ancillary services\u2019 records. When available, data on other MTFs in Afghanistan were used for comparison. Descriptive statistics were used to analyze demographics, evacuations, surgeries, and admissions.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Over the studied period, 0.7% of patients were seen for battle injuries. The average number of patients seen was 636 per month with 184 per month in 2016 and a steady increase to 805 per month in 2019. The operative volume was a mean of 2.8 surgeries per month with a median of 2 surgeries per month (orthopedic and general surgery combined). Other Role\u00a02 facilities were on average seeing even fewer operative patients, although there were some treating more operative patients. From available data, no other Role\u00a02 MTFs were treating close to as many total patients (all types combined). The two Role\u00a03 facilities evaluated saw significantly more operative patients at an average of 53 surgeries per month.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>The ratio of operative cases per surgeon is substantially higher at these Role\u00a03 facilities, when compared to Role\u00a02 facilities, although still significantly lower than would be expected at an U.S. Level 1 trauma center. This is consistent with other larger epidemiological studies on forward MTF workload. The vast majority of patient care is related to treatment of disease and preventative medicine. Only 0.7% of the large volume of patient visits evaluated were for battle injuries. There is a scarcity of both surgical and trauma patients, with a more pronounced reduction at Role\u00a02 compared to Role\u00a03 facilities. This is especially evident here with a facility that has such a large patient population but low trauma or surgical patient volume. Sustaining trauma and surgical skills for both surgeons and trauma teams with a paucity of trauma patients is a significant concern.<\/jats:p><\/jats:sec>","DOI":"10.1093\/milmed\/usaa472","type":"journal-article","created":{"date-parts":[[2020,12,7]],"date-time":"2020-12-07T03:50:26Z","timestamp":1607313026000},"page":"e599-e605","source":"Crossref","is-referenced-by-count":11,"title":["Review of a Role 2 in Afghanistan: Understanding the Data on Medical and Surgical Volumes in a Deployed Setting"],"prefix":"10.1093","volume":"186","author":[{"suffix":"MD","given":"Carly R N","family":"Richards","sequence":"first","affiliation":[{"name":"Department of Surgery, Martin Army Community Hospital, Fort Benning, GA 31905, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Constance","family":"Joel","sequence":"additional","affiliation":[{"name":"Department of Surgery, Martin Army Community Hospital, Fort Gorden, GA 30905, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"suffix":"MD","given":"Jon F","family":"Dickens","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2021,5,3]]},"reference":[{"key":"2021050313424210900_R1","article-title":"Top army surgeon blasts military\u2019s capability to handle war traumas","volume-title":"US News and World Report","author":"Sternberg"},{"key":"2021050313424210900_R2","article-title":"Military surgery in the spotlight","volume-title":"US News and World Report","author":"Yu","year":"2019"},{"issue":"6","key":"2021050313424210900_R3","doi-asserted-by":"crossref","first-page":"1190","DOI":"10.1016\/j.jamcollsurg.2018.03.001","article-title":"Army general surgery\u2019s crisis of conscience","volume":"226","author":"Edwards","year":"2018","journal-title":"J Am Coll Surg"},{"key":"2021050313424210900_R4","article-title":"Roles of medical care (United States)","volume-title":"U.S. Medical Center of Excellence","author":"US Army","year":"2019"},{"key":"2021050313424210900_R5","article-title":"Surgeons sitting idly during deployments may be leaving military patients at risk","volume-title":"www.Stripes.com November 19, 2017","author":"Montgomery"},{"issue":"3","key":"2021050313424210900_R6","doi-asserted-by":"crossref","first-page":"46","DOI":"10.55460\/6EZN-5KGE","article-title":"The Golden Hour Offset Surgical Treatment Team operational concept: experience of the 102nd Forward Surgical Team in Operation Freedom\u2019s Sentinel 2015-2016","volume":"17","author":"Benavides","year":"2017","journal-title":"J Spec Oper Med"},{"key":"2021050313424210900_R7","volume-title":"Army Times. Springfield, Sightline Media Group","author":"Jahner","year":"2016"},{"issue":"3","key":"2021050313424210900_R8","doi-asserted-by":"crossref","first-page":"603","DOI":"10.1097\/TA.0000000000001997","article-title":"A US military Role\u00a02 forward surgical team database study of combat mortality in Afghanistan","volume":"85","author":"Kotwal","year":"2018","journal-title":"J Trauma Acute Care Surg"},{"issue":"1","key":"2021050313424210900_R9","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1097\/TA.0000000000001496","article-title":"Combat surgical workload in Operation Iraqi Freedom and Operation Enduring Freedom: the definitive analysis","volume":"83","author":"Turner","year":"2017","journal-title":"J Trauma Acute Care Surg"},{"issue":"1S Suppl 2","key":"2021050313424210900_R10","doi-asserted-by":"crossref","first-page":"S145","DOI":"10.1097\/TA.0000000000001849","article-title":"Vascular surgery during U.S. combat operations from 2002 to 2016: analysis of vascular procedures performed to inform military training","volume":"85","author":"Turner","year":"2018","journal-title":"J Trauma Acute Care Surg"},{"issue":"1S Suppl 2","key":"2021050313424210900_R11","doi-asserted-by":"crossref","first-page":"S122","DOI":"10.1097\/TA.0000000000001804","article-title":"Abdominal trauma surgery during recent US combat operations from 2002 to 2016","volume":"85","author":"Stockinger","year":"2018","journal-title":"J Trauma Acute Care Surg"},{"issue":"6","key":"2021050313424210900_R12","doi-asserted-by":"crossref","first-page":"681","DOI":"10.1016\/j.otsr.2014.06.010","article-title":"French surgical experience in the role 3 medical treatment facility of KaIA (Kabul International Airport, Afghanistan): the place of the orthopedic surgery","volume":"100","author":"Barbier","year":"2014","journal-title":"Orthop Traumatol Surg Res"},{"issue":"1S Suppl 2","key":"2021050313424210900_R13","doi-asserted-by":"crossref","first-page":"S112","DOI":"10.1097\/TA.0000000000001798","article-title":"The effect of prehospital transport time, injury severity, and blood transfusion on survival of US military casualties in Iraq","volume":"85","author":"Kotwal","year":"2018","journal-title":"J Trauma Acute Care Surg"},{"issue":"5","key":"2021050313424210900_R14","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1136\/jramc-2018-001102","article-title":"Is E-FAST possible and useful on the battlefield? A feasibility study during medical courses in hostile environment (MEDICHOS): preliminary results","volume":"165","author":"Renard","year":"2019","journal-title":"J R Army Med Corps"},{"issue":"1","key":"2021050313424210900_R15","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1097\/TA.0000000000002308","article-title":"Prehospital adenosine, lidocaine, and magnesium has inferior survival compared with tactical combat casualty care resuscitation in a porcine model of prolonged hemorrhagic shock","volume":"87","author":"How","year":"2019","journal-title":"J Trauma Acute Care Surg"},{"key":"2021050313424210900_R16","doi-asserted-by":"crossref","first-page":"1223","DOI":"10.1111\/j.1553-2712.2010.00918.x","article-title":"Survival benefit of transfer to tertiary trauma centers for major trauma patients initially presenting to nontertiary trauma centers","volume":"17","author":"Garwe","year":"2010","journal-title":"Acad Emerg Med"},{"key":"2021050313424210900_R17","article-title":"U.S. Central Command Theater Trauma System Assessment Report","volume-title":"The Joint Trauma Service","author":"Shackelford","year":"2018"},{"key":"2021050313424210900_R18","doi-asserted-by":"crossref","first-page":"350","DOI":"10.9738\/INTSURG-D-14-00004.1","article-title":"The role and validity of surgical simulation","volume":"100","author":"Fowler","year":"2015","journal-title":"Int Sug"},{"key":"2021050313424210900_R19","doi-asserted-by":"crossref","first-page":"395","DOI":"10.5999\/aps.2017.01585","article-title":"Current status of simulation training in plastic surgery residency programs: a review","volume":"45","author":"Thomson","year":"2018","journal-title":"Arch Plast Surg"},{"issue":"1","key":"2021050313424210900_R20","doi-asserted-by":"crossref","DOI":"10.1186\/s12909-019-1537-7","article-title":"Perfecting practice: a protocol for assessing simulation-based mastery learning and deliberate practice versus self-guided practice for bougie-assisted cricothyroidotomy performance","volume":"19","author":"Petrosoniak","year":"2019","journal-title":"BMC Med Educ"},{"issue":"1","key":"2021050313424210900_R21","article-title":"Outcomes of a virtual-reality simulator-training programme on basic surgical skills in robot-assisted laparoscopic surgery","volume":"19","author":"Ph\u00e9","year":"2019","journal-title":"BMC Med Educ"},{"issue":"3","key":"2021050313424210900_R22","doi-asserted-by":"crossref","first-page":"824","DOI":"10.1016\/j.jsurg.2018.12.003","article-title":"Trauma technical skill and management exposure for junior surgical residents - the \"SAVE Lab 1.0\"","volume":"76","author":"Onufer","year":"2019","journal-title":"J Surg Educ"},{"issue":"2","key":"2021050313424210900_R23","doi-asserted-by":"crossref","first-page":"337","DOI":"10.1016\/j.jsurg.2019.09.006","article-title":"Systematic review of virtual haptics in surgical simulation: a valid educational tool?","volume":"77","author":"Rangarajan","year":"2020","journal-title":"J Surg Educ"},{"issue":"4","key":"2021050313424210900_R24","doi-asserted-by":"crossref","first-page":"597","DOI":"10.1097\/00005373-200104000-00002","article-title":"Patient volume per surgeon does not predict survival in adult level I trauma centers","volume":"50","author":"Margulies","year":"2001","journal-title":"J Trauma"},{"key":"2021050313424210900_R25","first-page":"288","article-title":"Hospital volume and operative mortality for general surgery operations performed emergently in adults","volume":"2","author":"Becher","year":"2019","journal-title":"Ann Surg"},{"key":"2021050313424210900_R26","volume-title":"Miller GA: Interview"}],"container-title":["Military Medicine"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/milmed\/article-pdf\/186\/5-6\/e599\/37774682\/usaa472.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/milmed\/article-pdf\/186\/5-6\/e599\/37774682\/usaa472.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,12,2]],"date-time":"2022-12-02T21:39:13Z","timestamp":1670017153000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/milmed\/article\/186\/5-6\/e599\/5989492"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,5,1]]},"references-count":26,"journal-issue":{"issue":"5-6","published-online":{"date-parts":[[2021,5,3]]},"published-print":{"date-parts":[[2021,5,3]]}},"URL":"https:\/\/doi.org\/10.1093\/milmed\/usaa472","relation":{},"ISSN":["0026-4075","1930-613X"],"issn-type":[{"value":"0026-4075","type":"print"},{"value":"1930-613X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2021,5,1]]},"published":{"date-parts":[[2021,5,1]]}}}