How better to present this article on the Health Service in Afghanistan than by repeating these words of the Chief of the Defence Staff, reported below by the author: "The reason we can ask so much of our men is because they know the medical support is there"? The French SSA enjoys a reputation for excellence, particularly in external operations, due as much to the quality and commitment of its members as to an original and rigorous organisation. Through a very personal, lively and committed testimony, the Chief Medical Officer of the Monségu services describes its principles, shows us the interactions with the different actors in the theatre and takes us through the evacuation chain in a realistic way. The Cahiers thank him warmly for his testimony, and are happy, thanks to him, to pay tribute to our Health Service.

For many years now, our armed forces have been deployed in many foreign theatres of operations where the commitment is sometimes very intense. Afghanistan has left a lasting impression on all minds, both civilian and military, because nearly 10 years of presence in this region of Central Asia has enabled us to build a strong and effective military presence in the region.The Army Medical Service (AMS) has not escaped an evolution in its regalian mission of supporting the forces.

Having had the honour and privilege of being the Chief Medical Officer of KAIA's Role 3,[1] also known as MTF[2] or HMC[3], from 5 April to 7 July 2011, here is a quick and of course non-exhaustive overview of the SSA's activities.u of the organization of the health chain as it had been set up during this period when the French forces were around 4.The French forces numbered around 1,000 soldiers, mainly in the eastern RC[4] (Kapisa and Surobi provinces) where Task Force La Fayette (TFLF) and the central RC (Kabul and its suburbs) were deployed, to which should be added the OMLTs[5] distributed among the Afghan companies in the TFLF sector.

As a preamble, I would like to report the words of Admiral Guillaud, then Chief of the Army Staff, who, during one of his visits at the very beginning of my term of office, had told me "You know, Doctor, if we can ask so much of our men, it's because they know you're there!». These few words have taken on their full importance over the weeks of our mission, proof of the strength and effectiveness of our SSA. In fact, they simply summarize the SSA doctrine in OPEX, where everything is done to ensure that medical care is provided in advance, which sets us apart from other armies present on the territory.

Above all, it is essential to have a vision of the background in which our soldiers were evolving. In this very mountainous part of Afghanistan, the mineral world made land travel difficult and long because of a very precarious road network and also because of the danger associated with the potential attack on convoys by the particularly active insurgency. On the other hand, the area of responsibility covered by the TFLF was extensive (about 100 km by 60 km wide), and the positions held were multiple, divided between three FOBs[6] and several COPs[7] whose size and isolation varied greatly.

With this geographical element in mind, how was the first link in the health chain organized in the field? Each FOB had a permanent infirmary (Role 1) with several doctors, IDE[8] nurses (Technical Certificates 1 and 2) and medical auxiliaries, capable of taking in several wounded.They were able to take in several wounded soldiers, perform medical and surgical procedures in order to put a seriously wounded soldier in good condition before his transfer, but also to hospitalize a soldier whose injuries were not born in the field.Within the UCCs, there was usually a more rudimentary first-aid post, but with means adapted to the pre-treatment health personnel.The most common nurse was a CT2 nurse, and sometimes a doctor in very remote POCs (as in Surobi), whose role was more to act as a place of retreat for the rehabilitation of an injured person. But beyond this static aspect of the system, the French SSA stood out from other nations by the fact that it was mobile behind its combatants. Indeed, each operation was prepared upstream with the headquarters of each operational sub-group and the health system was then defined according to several parameters (dangerousness of the mission, duration, distance, number of men involved, etc.). If the presence of a doctor was required, he was positioned in his VAB SAN, whose equipment, albeit basic, enabled the recovery of a wounded man lying down in acceptable conditions. Nevertheless, as the human resources in terms of doctors were not extensible, many missions were supported only by CT2 nurses with proven medical expertise, enabling an injured person to be put in condition and the degree of seriousness of the injuries to be assessed. In addition to this system, there was a medical assistant in each combat section, capable of taking the first steps to treat a vital emergency, as part of an approach known as the RYAN MARCH, aimed at keeping the injured person alive before the arrival of the doctor. It is a simple plan where each letter is associated with a specific action, which is described below:

• M for Massive bleeding control[9],
• A for Airways (freedom of the airways),
• R for Respiration (ventilation efficiency),
• C for Circulation (presence of a pulse),
• H for Head and Hypothermia (search for neurological disorders and fight against hypothermia),
• E for Evacuation.

Then follows the RYAN to prepare for evacuation:

• R for Re-evaluation,
• Y for eyes and ears,
• A for analgesia
• N to clean.

But it is also necessary to insist on the individual training of each fighter in survival skills with a medical kit containing a tourniquet, bandages, an infusion kit and a self-injectable morphine syringe. This forward medicalization, which the SAMU were inspired by in the practice of civilian medicine, allowed an optimal and very early care of the war wounded, and we know that the speed and quality of the medical conditioning are essential in the vital prognosis of the victim.

Here is a brief summary of the first link in the health chain in the field on which a few thoughts should be given. This health "network" is very specific to the French armed forces and is particularly envied by our NATO partners; The COMSANTÉ of RC-East and my counterpart who commanded the Role 3 of Bagram (both Americans) made this highly revealing confidence to me: "We don't know how you manage to achieve such a medicalization of the front line!». The corollary is the exposure of a masterpiece of the device (which the insurrection had quickly understood, imposing the trivialization of the medical armoured vehicles with the removal of the red cross), but also an important physical load because, in addition to the energy and the energy of the soldiers, it is also an important physical load.It is also a major physical burden because, in addition to the personal equipment carried (protection and armament), the health personnel are equipped with a heavy and cumbersome bag containing the equipment essential for the care of the wounded because it is not enough to provide expertise, they must also be given the means to do so. Here again, it is important to stress the quality of training of the medical teams who are given additional training in the care of war emergencies in metropolitan France in specific training centres (CITERA [10]), prior to each mission.

The second link in this health chain consisted in organising the transport of the conditioned wounded to the medical-surgical hospital of attachment (MEDEVAC [11]). Although the TFLF was operating in RC-East and therefore theoretically attached to Role 3 at Bagram under American responsibility, it was agreed that the woundeds of the French forces would be directed in priority to Kabul because of a similar distance and the French leadership given to Role 3 of KAIA. The first rule for this transport was to be as rapid as possible, making every effort to respect a time limit of less than one hour between initial medical care and arrival at the hospital. For every MEDEVAC, this "golden hour", triggered by the sending of the 9-line message, was one of the rules imposed and evaluated by ISAF.

The second rule for this transport was that it used heliborne means because of the geographical configuration of the terrain and in order to meet the deadline. For the TFLF, these assets were stationed at Kabul airport (helicopter battalion) where a transport aircraft (Cougar or Caracal) was quickly (10 to 15 minutes) packaged in a medical version in order to transport the wounded. A new French singularity, and not the least: the presence on board of a CT2 doctor and a CT2 nurse who were experienced in the continuation of the initial medical care during the transport, while the US forces were still in the process of providing medical care to the wounded.American forces had helicopters specifically dedicated to transporting the wounded, but with only one paramedic on board. The outward journey was a maximum of 20 minutes, giving the medical team on the ground time to condition the injured person, to evacuate him or her and to provide him or her with the necessary medical care.The outbound trip was a maximum of 20 minutes, giving the field medical team time to condition the injured person, evacuate him to a secure landing site where the aircraft crew would pick him up and evacuate him to the hospital.

The implementation of this transport went through an essential stage, that of the regulation carried out by the PEEC[12] doctor, who was the real conductor who coordinated this second stage of the treatment of the injured person. Based on the TFLF headquarters in Nijrab, after having established an injury assessment of the casualty or casualties in direct co-ordination by telephone or radio with the field doctor, he categorised the casualty in order to implement the rapidity and prioritisation of the evacuation with three levels of severity:

• esaf where the vital emergency is engaged,
• bravo requiring rapid transfer
• charlie where transport can be delayed because it is not urgent.

At the same time, he checked with the head doctor of Role 3 to make sure that the logistical possibilities of care were available, while giving him the first information on the situation.This enabled the hospital medical-surgical team to prepare for the reception of the injured person.

Role 3 was the third link in the health chain and was going to provide the first medical and surgical care specific to the injured person, taking stock of the wounds while carrying out an initial therapeutic sequence of "damaged control", which we will come back to later.

A few words about HMC KAIA before going further. Built in one year on NATO credits, it became operational in July 2009 and the leadership was given to France, which will bring all the medical and surgical equipment needed for the operation.to the French "standard", so that the medical teams will work under the same conditions as they do in the Army Training Hospitals (HIA). Located in the KAIA camp (which groups together nearly 4,000 people, including the ISAF [13] operational centre), it is positioned on the military side of the airport runways. This position was chosen in order to reduce the time needed to take charge of the MEDEVACs and to facilitate evacuation to metropolitan France. As the hub of the health chain, its purpose is to get the injured person into condition in order to evacuate him to mainland France where he will receive the complementary treatment adapted to his injuries. Its missions are clearly defined by a NATO memorandum with the main and priority mission being to provide health support to ISAF personnel and to the Afghan military and police; to take care of the wounded; to provide medical assistance to ISAF personnel and to the Afghan military and police; to provide medical care for the wounded; and to provide medical assistance to ISAF personnel and the Afghan police.s collateral Afghan civilian casualties is also a priority, with medical assistance to the population (MPA) authorized, at the discretion of the Chief Medical Officer and provided it does not compromise the main mission. During my mandate, I have always made it a point of honour to pursue this PMA, which is part of the maintenance of the operational capability of all personnel, but also in keeping with the tradition of the French armies present in the various external theatres of operations.

Located on a single level and very functional with wide corridors, the HMC's capacity in terms of number of beds is therefore limited (in order to satisfy its main mission), which means the most optimal possible management, sometimes delicate because of the risk of a massive influx of wounded. However, its level of technical expertise is high, with personnel who are familiar with the particularly specific war emergency, to which we shall return later. In addition to a chieftaincy with an operational room adjoining it for the management of the MEDEVACs, the structure includes a reception and emergency service (SAU) with eight beds, an operating theatre with three surgical rooms adjoining it, and an emergency room with a capacity of up to three beds. the intensive care unit (with seven beds), a 30-bed hospitalization sector, a consultation sector, a radiology unit including a scanner, a biology laboratory, a pharmacy and a biomedical unit. While leadership has been given to France, the international character prevails at the staff level, with a quarter of the staff being of foreign nationality (Czech Republic, Bulgaria, United States, Belgium, Great Britain and Hungary). We had set up three surgical teams, making it possible to open three surgical sites simultaneously in the three operating theatres. Each surgical team consisted of an orthopaedic surgeon, a visceral surgeon, an anaesthetist and a team of three nurses. A neurosurgeon, an ophthalmologist and a dentist were added to each team according to the injuries encountered. A key and essential element was represented by the versatility of each one who, in addition to his or her speciality, was able to bring his or her knowledge and help during the various operations, and this element particularly singularizes the corps of doctors of the French armies.

Before addressing the elements of the care of the wounded, we should bear in mind a few particularities of the wounded in Afghanistan, beyond their relative distance from Role 3. These are war wounds most often caused by automatic weapons, to which must be added wounds related to the explosion of IEDs [14], causing particularly vulnerable injuries.14], causing particularly vulnerable injuries and often also responsible for multiple injuries to the combatant, but also affecting several soldiers simultaneously, particularly during actions against convoys of vehicles. This led us to set up the organisation of a MASCAL plan[15] in which the teams had to be capable of dealing with an influx of wounded soldiers, requiring a triage to be carried out in order to prioritise the treatment to be carried out, as well as the rapid treatment of victims.

Let us return to the particularities of the injuries encountered. The war wounded person presents as a serious polytrauma victim from the outset. He is initially exposed to six risks:

• a risk of haemorrhage with heavy bleeding, externalized or not,
• rapid hypoxia (lack of oxygenation) rapidly worsening the condition of the injured person,
• major bone lesions with decay of the limbs in particular (because not protected by special equipment),
• the severity of brain damage that could potentially cause impairment of consciousness,
• pain
• and finally rapid hypothermia.

Behind these risks, two other characteristics must be kept in mind: the lack of knowledge of a lesion which can affect the vital prognosis and the underestimation of the initial seriousness of an injury.

Among the keys to optimizing the care provided to an injured person, it is necessary to insist on the very protocol character of this care in Rôle 3 of which I will outline, knowing that while there is no room for improvisation, each situation is unique and the team must know how to adapt.

The proximity of the tarmac therefore allowed the injured person to arrive very close to the aircraft, where the resuscitator accompanied by the head doctor would recover from the injury.The proximity of the tarmac therefore allowed the injured person to arrive very close via the aircraft, where the resuscitator accompanied by the chief medical officer retrieved from the transport doctor the outlines of the injuries and the first aid already given, allowing him to categorize the nature of the injuries and the potential orientation of the victim. Transported by the medical ambulance to the UAS,[16] where everything was prepared for the injured person, he was going to be treated there.the injured person would undergo a "damage-control" or shocking procedure, performed by a team consisting of an anesthetist, a physician, a nurse, a nurse's assistant, a nurse's assistant and a nurse's assistant.the two surgeons (visceralist and orthopedist), a nurse anaesthetistThe team consisted of an anaesthetist/resuscitator (the real conductor), two surgeons (visceral and orthopaedic), a nurse anaesthetist, two nurses, two stretcher-bearers and a script to record all the steps of the procedure.

The purpose of this damage-control sequence was to recognize and treat vital distress, make a brief but exhaustive assessment of the lesions, prioritize future treatments and decide on short-term therapeutic modalities. For this, three phases were distinguished:

• the injured person was first placed on a stretcher with a heated mattress, undressed and subjected to a complete clinical examination for signs of distress.He was stripped naked and subjected to a full clinical examination for signs of vital braiding, which was immediately corrected, without omitting to check for possible injuries, in particular to the back; the dressings were unpacked, and any tourniquets applied were checked. A rapid abdominal ultrasound would inform the surgeon of any intra-abdominal bleeding lesions that might require urgent surgery.
• A second phase, most often carried out in parallel, consisted of setting up large venous lines to infuse the injured person and carrying out an emergency blood test including blood grouping, which made it possible to launch a whole blood collection in the camp if necessary. This last aspect deserves to be underlined as its importance could be so crucial for the injured person (as the HMC had a limited bank of blood products due to their limited speed). The solidarity was exceptional, with an average delay of less than an hour between the call for donations and the passage of the first bag of blood. The soldier's identity was recovered, and this is a reminder of the importance of wearing an individual identity plate, too often neglected by some fighters!
• The third phase was to direct the wounded person either to a radiological check-up directed according to the type of wound, and most often using a scanner examination, which every Role 3 is equipped with, or directly to the operating theatre for urgent surgical management of haemostasis most often or trimming of major wounds affecting the vital prognosis. The configuration of our HMC allowed a fluidity and speed in this orientation decision. At this stage, and therefore very early on, the head doctor and his medical-surgical team, depending on the seriousness of the injuries and the number of casualties, decided on the means to be implemented for the evacuation of the victim(s): either a return to mainland France via a regular RAPASAN [17] link, or an urgent return to a Parisian HIA (Percy in Clamart most often) in order to ensure the continuation of medical-surgical care. As soon as such a STRATEVAC[18] was decided, the means were requested from the operational staff.The means were requested from the medical operational staff in Paris, either one or two aircraft (Falcon 50 or 900 of the French Republic with a medical team) or one or two aircraft of the French Republic with a medical team.dicale transport team including at least one resuscitator), or the triggering of the MORPHEE plan[19] allowing the repatriation of several wounded with a C-135 equipped with medical equipment, the delay of which required a little less than 24 hours and used once during our stay. A last possibility of evacuation to the American rear base in Germany via the Bagram base remained a possibility, but was never used during our mission. Thus, all of our seriously injured were evacuated in less than 36 hours, the vast majority in less than 24 hours, the time between the time of the injury and the arrival at the Paris HIA for optimal care.

One last mention, and not the least, must also be underlined, that of the early treatment of the soldiers' psychological wounds (battle stress),victims or mere witnesses, by our psychiatrist, who also carried out the psychiatric action to the closest possible extent.He also took psychiatric action as close as possible to the combatant in the various FOBs, allowing for a treatment that proved to be crucial in the future for certain personalities sometimes strongly destabilized during the physical traumas suffered or encountered.

This health chain in Afghanistan has worked particularly well and has been tested many times in difficult conditions, always exemplary. It has enabled us to treat our wounded from the place of injury to treatment in mainland France within a short time, and to provide very high quality medical and surgical care thanks to the high quality of the medical and surgical care provided by the medical team.It has enabled the treatment of our injured from the point of injury to the point of care in mainland France in a short time, and in a very high level of medical and surgical care thanks in particular to this concept of medicalisation of the front with the support of a particularly well-equipped Rôle 3 and teams trained in the care of such injured people.

It is the pride of the French SSA and is in keeping with its tradition of providing support to the forces as close as possible to the combatant. As part of the disengagement of French forces in Afghanistan, on 30 June 2014, the transfer of authority from the KAIA HMC to Task Force 31 of the USArmy took place. It was logical that a tribute be paid to all the French medical teams committed to the fighters and having served in Role 3 during the July 14 parade in Paris with the presence of the KAIA HMC pennant honoured this year.

[1] Kabul International Airport

[2] Medical Treatment Facilities

[3] medical-surgical hospital

[4] Region Command

[5] Operational Mentoring Liaison Team

[6] Forward Operating Base

[7] Combat Outpost

[8] State Registered Nurse

[9] control of a hemorrhage

[10] Forward Life Support Training Centre

[11] Medical Evacuation

[12] Patient Evacuation Coordination Cell

[13] International Security Assistance Force

[14] Improvise Explosive Device

[15] mass casualties

16] Emergency Reception Service

17] Medical repatriation

[18] Strategic Evacuation

19] Resuscitation modules for patients with high evacuation strain

Jacques MONSÉGU, Chief of Medicine (ER), graduated in 1984 from the Army Medical School in Bordeaux. His first assignment as assistant medical officer of the Gendarmerie du Nord - Pas-de-Calais will lead him to carry out an OPEX in Beirut. Appointed assistant to the army hospitals, specialising in cardiovascular medicine, he joined the Val-de-Grâce in 1989. In 1995, he was appointed specialist there and became assistant to the head of the cardiology department, a department that he will head from 2005, after being appointed associate professor of Val-de-Grâce in 2001. In 2011, he volunteered to go on an OPEX in Afghanistan where, during his stay, he has the privilege of sharing this experience with his eldest son, a young OMLT officer. In April 2013, he left the SSA but continued his medical activity in Grenoble within the mutualist hospital group which he joined out of a passion for cardiology, patients and teaching.

A great sportsman, Professor MONSÉGU is a triathlon enthusiast.