CAMP SHORABAK, Afghanistan -- The Taliban announced the start of the 2014 fighting season May 12, 2014, and their campaign sought to disrupt the transfer of power during the presidential elections and incite violence against the Afghan National Security Forces. During June, fighting increased across northern Helmand province, challenging the ANSF as International Security Assistance Forces prepare to depart Helmand later this year. As the ANSF have taken the fight to the Taliban, coalition medical advisors have worked closely with Afghan Army doctors to ensure quality medical care for those injured in the fighting.
In a significant milestone for the medical advisors and the Afghan National Army’s 215th Corps, the Camp Shorabak Trauma Center will open later this month. The first of its kind in Helmand province, the trauma center will include four emergency bays, a two-operating-room theater, a five-bed intensive care unit, a post anesthesia unit as well as a 30 bed ward. The facility will dramatically reduce the amount of time soldiers and police spend at intermediate levels of medical care.
United States Navy Capt. James Cole, the RC (SW) command surgeon and lead medical advisor to the 215th Corps surgeon, said the facility’s opening is a major step in the ANSF’s progress. A native of Chicago, he deployed to Afghanistan during Jan. 2014. As a military reservist, he also works as a trauma surgeon with the Advocate Good Samaritan Hospital in Chicago when not serving on military orders.
Previously, Cole served in al Anbar province, Iraq, and eastern Afghanistan with a contingent of U.S. special operations. On his current deployment, he is on-call for not only U.S. and coalition forces in Helmand, but also as the lead advisor for the Afghan medical team.
Cole said his current mission is different.
“This deployment compared to my first to Afghanistan is totally different,” said Cole. “We are at opposite ends of the spectrum. I am tasked with ensuring the ANSF have a functioning healthcare system and can provide trauma care to their people so they can be sustainable when we leave. Doing both of those things is quite challenging.”
Cole said the opening of the trauma center is vital for the ANSF’s future. With relatively little Western technology, the contractors built the center by hand.
“It is very rewarding to see the personal buy-in they have in the fruits of their labor,” said Cole. “They are great artisans. They lay every brick, bend the metal and smooth the concrete by hand and have literally taken a warehouse at Camp Shorabak and built an actual trauma center.”
Cole said whereas the ANSF once relied on ISAF medical capabilities, the regional trauma center was constructed and equipped with technology that can be maintained through Afghan means.
“We’ve specifically designed and equipped the hospital with equipment that is maintainable by someone with the 215th Corps. Everything is fixable by vendors in Kabul.”
More plans include the installation of a helicopter landing pad for Afghan Air Force Mi-17 helicopters to quickly transport casualties directly from the battlefield to the center.
“Whereas there was no air MEDEVAC capability, now, they are routinely transporting casualties via Mi-17 helicopters,” said Cole. “They will be able to take care of casualties at the Role II level, and evacuate them via air to higher levels of care at the Kabul military hospital,” said Cole.
Since his arrival, Cole said the ANSF have made dramatic improvements including the ability to care for patients with amputations, gunshot wounds to the chest as well as providing general anesthetics and post-operative care for troops.
“The improvement from what they are capable of doing since we arrived is quite remarkable,” said Cole. “When I first got here they were only able to manage complex wounds. Now they are managing Category A surgeries, (those that threaten life, limb or eyesight). We owe all of that to the mentor team who spends every morning there and time with the nurses, anesthesiologists to improve their skillset.”
When RC (SW) was established during the summer of 2010, U.S. and coalition forces partnered with newly established police and army forces in Helmand to professionalize their institutions. For the next five years, special trained military advisors partnered with Afghan security forces at all levels to train, advise and assist them in functional skillsets. During the past two years, advisors have slowly lifted off of the lower echelons as the ANSF proved competency.
From the beginning, Cole has worked with the ANSF in Helmand during critical moments including the 2014 presidential election and runoff during April and June. Often, advising has kept him up at odd hours to ensure the medical mission is making strides.
“I have to be available when they are ready to receive the assistance,” said Cole. “It’s about maintaining open dialogue and being available when they need you.”
During April and May, the ANSF conducted their first air evacuation of casualties from forward operating bases in Sangin and Delaram. Cole said this advancement has instilled a sense of confidence in the ANSF.
During the start of the 2014 summer fighting season, Cole witnessed firsthand the need for an Afghan-led medical facility in Helmand.
“The 215th Corps in Helmand province sees the most kinetic activity and most casualties,” said Cole. “Their disadvantage is that they are currently the only province in Afghanistan without a regional military hospital, and they get hurt more than any other group.”
As the end of the Helmand mission draws near, military advisors are focused on training and advising the ANSF to sustainable outcomes.
“What we all need to do is view everything through that Afghan prism,” said Cole. “What is acceptable and tolerable by Western standards may be different by Afghan standards.”
Petty Officer Second Class John P. Leverich, a native of Dayton, Ohio, and hospital corpsman with the Combined Corps Advisor Team, said increased medical training in ANSF soldiers has benefited them.
“Currently there are 500 Afghan soldiers trained and certified in combat lifesaving,” said Leverich. “The goal is to get a total of 1,800 by the end of 2014.”
Because of the nature of the violence across Helmand, many of the field medics have received real-time combat casualty care. “The medics have been here a very long time and have a lot of experience,” said Cole.
Leverich said the opening of the trauma center will alleviate medical supply concerns. The tyranny of distance from Kabul to Helmand and the threat of improvised explosive devices poses challenges to the ANSF to get medical supplies to the region. He said one of the main projects he assisted was the development of a supply system to forecast medical supply needs. This included a pie-chart system to forecast supply thresholds.
“When they are low on one medical capability, they now have a process to submit the necessary paperwork through their chain of command,” said Leverich. “Ultimately, the requests go to Kabul when a certain threshold is reached.”
Often the medical needs vary on the incidents occurring on the battlefield.
“One weekend the ANA may use ten of one thing; another weekend they may use 30,” said Leverich. “The situation depends on what the demand is based on the types of patients they are dealing with.”
Cole said the system is sustainable and proven.
“With respect to the resupply process, this is a process they have been using and practicing it. If they use it, they should have no issue with resupply,” said Cole. “They have all of the skills and tools to do a good job.”
Manpower constraints also pose a challenge to ANSF medical development. “Their biggest issue is getting more doctors, anesthesiologists, nurses and staff,” said Leverich.
“If the ANA can get the personnel, they’ll be able to equip and man the hospital with no problem.” The foreseeable solution is a modification to the “tashkiel,” or manning requirement, which would increase the amount of staff to run the facility.
The challenge will be to attract more medical professionals to Helmand. Cole said medical professionals receive most of their training in Kabul before deploying to the surrounding provinces.
“The physicians and surgeons almost exclusively receive their training in Kabul. They come out to us to rotate through after,” said Cole.
He also said advising the ANSF is important to understand the varying degree of experience and training compared to Western medicine.
“The Afghan skillset is different than the Western skillset,” said Cole. Although they have less time in school and residency training, Cole said many of the Afghan medical staff has tremendous experience dealing with trauma.
“Because that is about all you see here in Afghanistan,” said Cole.
Leverich said the challenge advising the ANSF during the final months in Helmand is advising with tough love.
“Often the hardest part of advising is not trying to do things for them,” said Leverich. “Because of our makeup, we want to do things and get it done. We have to get them to understand that this is all theirs. They have the knowledge and they know the process and have the tools in place and just need to remember to maintain when we leave.”
The deployment has been a balancing act for Cole and the medical advisors. As ISAF prepares to close RC (SW), maintaining expeditionary medical readiness and advising is also a significant challenge. While focusing on advising the ANSF toward sustainable solutions, he and his team have worked to draw down their own capabilities during the redeployment and retrograde process.
In the coming months, the U.K.-led Role III hospital will close. Currently the facility provides ISAF with major surgical capabilities. Despite this, Cole said there will be no major impact to medical care during the final months. He and the medical team have ensured all U.S. and coalition forces will receive adequate medical care until the very last minute.
“A Role II facility will be established to care for U.S. and U.K. personnel in the final months,” said Cole. The expeditionary facility will have four emergency room bays, two operating rooms and some critical care extending capabilities and ward beds. We are incorporating into that some medical evacuation, tactical evacuation and medical emergency response teams.”
Determining the right time to retrograde key medical assets is like playing a game of chess, said Cole. “We are carefully off-ramping those capabilities until as close to the end as possible. We have to remove everything from theater, and as the command surgeon, I still have to provide for adequate medical coverage until the very last day, including damage-control surgery during the last 24 hours.”
SUSTAINING THE TRANSITION
Cole said the future will be a strong commitment by all levels of the Government of the Islamic Republic of Afghanistan. “It all has to do with leadership,” said Cole. “If the Afghans make a commitment to the future of this capability, they will do as well as they are doing now.”
In the weeks leading up to the trauma center’s opening, Cole said Afghanistan’s deputy and head surgeon general visited Helmand to see the advancements. “The Afghan surgeon general has told me that Helmand province and the Shorabak Trauma Center is his number one priority,” said Cole. “They recognize that this is the only region without Afghan medical capability.”
Both Leverich and Cole said the tools are in place for a bright future. As advisors, they see progress in motion, and although they often feel the urge to jump in hands-on with patients, they advise from a distance.
“There is a little bit of tough love,” said Cole. “We spent a lot of time here, but we responsibly transitioned from coalition to Afghan-led practices. That transition in itself is a success.”
It is also no secret that by the end of the year the ANSF in Helmand assume full security responsibility.
“They know we are leaving, and they have made this project a priority to care for their people,” said Cole. “As a physician, all life is valuable, and everyone deserves compassionate care. We have made a promise to them to help build this capability. As we transition, we will continue to train and mentor until we leave.”
During the past five years of operations in RC(SW), military advisors and their Afghan counterparts have built medical capacity from the ground up. Cole said the tremendous sacrifices of Afghan, U.S. and coalition forces who who served in Helmand will be realized in the sustainment of major projects like the Camp Shorabak Trauma Center.
“This is historic,” said Cole. “The ANA will continue to have the will and confidence to maintain their campaign against the threat of the Taliban as we transition out. If it goes well, which it should, I think it could be the standard for which other campaigns follow.”