The views expressed herein are those of the author(s) and do not necessarily reflect the official policy of the Department of the Army, Department of Defense, or the U.S. Government.
The Fall of Kabul in August 2021 resulted in the largest volume of combat casualties taken care of by the U.S. Army in the past decade. The hospital was a small Role 2 facility with two large operating rooms, seven ICU Beds, 10-15 ward beds, four trauma bays in the emergency department, three other ED beds, one portable X-ray machine, one CT Scanner, simple lab and blood bank (~100 units), as well as a medical maintenance section. Staff consisted of four trauma teams (one general surgeon, one ED physician, one anesthesia provider, two nurses, two medics) backed up with a radiologist and two orthopaedic surgeons. The ICU team was staffed by a cardiologist and fellowship-trained critical care anesthesiologist. There was also a small primary care team. As the situation deteriorated, additional personnel were sent to theater consisting of four additional trauma teams (with one additional orthopaedic surgeon) at the main hospital, and two more teams—both with an orthopaedic surgeon—at the opposite end of the runway with the 82nd Airborne Division.
An excerpt describing conditions at the airport from a report to U.S. Army Forces Command (FORSCOM) follows:
"There were 151 credible threats to base personnel, including 19 perimeter breaches, several incidents of small arms fire, and four IDF attacks, forcing medical personnel to shelter in place multiple times. The most significant threat occurred on 16 AUG 2021 when thousands of Afghans chaotically stormed the airfield, and small arms fire incidents ensued. A crowd of approximately 400 amassed just over 50 meters outside the hospital. At that time MTF staff were instructed by the hospital’s Deputy Commander to ready weapons and prepare to defend the hospital while simultaneously providing patient care in the Emergency Department."
Over the 2 weeks prior to the final exit of U.S. forces, the hospital took care of 187 patients with 45 trauma activations (excluding the MASCAL on 26 Aug) to include a four patient ‘mini’ MASCAL on 23 Aug. They simultaneously conducted refugee operations, evaluating ~1250 patients during the evacuation of approximately 120,000 Afghans. This covered all aspects of medicine, including complex pediatric syndromes, chronic untreated diseases, and atypical treatments (in the U.S.) of common problems, such as an intertrochanteric fracture treated with an external fixator. The hospital personnel also ran an orphanage for displaced / unaccompanied children. An inpatient ward was converted to support this mission; approximately 147 children came through the MTF; 10 were reunited with family but most were transferred to Norway.
On 26 AUG 2021 at 1740L, ISIS-K conducted an attack at the HKIA Abbey Gate in which two suicide bombers detonated IED vests with follow-on small arms fire. This killed or wounded 200 U.S. military personnel and Afghan civilians. After securing the hospital, U.S. and Coalition partners activated MASCAL protocols with 10 Joint and Multi-National surgical teams responding. Within 15 hours, HKIA R2E MTF triaged 70 patients, managed over 30 major traumas, and performed resuscitative surgery throughout the night to stabilize casualties, preserving and evacuating 55 patients, while also delivering one baby.
Training and prior preparation has been consistently brought up as the key factor that allowed successful management of this MASCAL. The teams were running a robust training protocol all summer leading up to the Fall of Kabul. The primary method was a weekly mock trauma code for each team, led by one of the other teams. This usually included moulaged patients who volunteered to assist and often allowed IVs, splints, and other basic procedures to be practiced on them. The training also often included Belmont use, tourniquet placement, IV/IO placement, splinting, and actual patient movement around the hospital, allowing the teams to test their response times and policies as well as establishing familiarity with their equipment. A Grand Rounds style conference schedule on Tuesday and Saturday afternoons (high energy trauma and war topics) was also established.
COL Kenneth J. Nelson, MD
Deputy Consultant, Orthopaedic Surgery
Dr. Nelson is a member of the OTA Disaster Management Preparedness Committee.