FALLS CHURCH, Va. — If they stood on the roof of the abandoned one-story home they were working out of, at night they could see bombs dropping on the city three kilometers north. Limited resources, limited manpower, limited backup, and limited time didn’t stop this Air Force Special Operations Surgical Team from treating more than 750 patients in eight weeks during a recent deployment to the Middle East.

SOSTs are teams of mobile surgical specialists with advanced medical and tactical training, with the mission of reducing time between the point of injury and the inevitable surgery.

In medical terms, a mass casualty is anything that overwhelms the team’s capabilities and resources. This team dealt with 19 mass casualty events during that two-month period.

Air Force Lt. Col. Benjamin Mitchell, the team leader, said “We had one surgeon and five other guys. If we had three or four critically injured patients show up, that’s too many for us to give them all the best care if they were there by themselves.”  At that point, they go into a “crisis mode” to try and do the best they can for everyone and determine the best way to treat each patient as quickly as possible.

Mitchell and one of the other doctors on his team, Air Force Maj. Justin Manley, spoke at the 2016 Air Force Medical Service Senior Leadership Workshop recently. Their presentation focused on many of the injuries they saw during their deployment, including knife and bullet wounds, explosion damage and chemical burns.

SOST Airmen often carry specialized equipment and gear designed to support a wide spectrum of operations and mission sets from cities to remote areas. This flexibility enables them to be highly adaptable and operate with a smaller footprint than most conventional surgery teams. So while they had some of their own equipment and a small supply line that could bring them some resources, they had to rely on a local hospital for help sometimes as well.

“I was blown away and awed by the support the locals gave us,” Mitchell said. “Here’s this war-torn country that doesn’t have a whole lot, and when we told them we’re running out of gloves, they brought us gloves.”

He said the local hospital also supplied the team with morphine for the patients and as much as 90 units of whole blood with a cooler to store it in. “It was just amazing. They don’t have a lot, but they gave us what they had because they saw our capabilities.”

And they needed as many resources as they could get because many of their patients were dealing with pretty serious injuries, including more than 400 gunshot wounds or blast injuries.

Mitchell described one patient who had a gunshot wound that entered his collarbone and exited through his chest. He was hypotensive and bleeding to death in the emergency room. They started blood resuscitation on him, but needed to pull blood from the men who had brought him in just to keep him alive.

He said it didn’t end up being enough because while they were operating he started to bleed out again, which basically reversed all the work they had done before.

“I thought we were going to lose this guy,” Mitchell said. “But Justin (Manley) stayed cool and tied off the artery. We didn’t have any of the local supply of blood that was a match, and all the guy’s buddies were gone because we had been in the operating room for 45 minutes to an hour at that point.”

Mitchell said in order to save the patient’s life he had to pull blood from one of the nurses on his team who happened to be a match. They gave it to the patient, finished their work, and sent him on his way.

“We’d had a lot of hard days. The mass casualties took a toll on my team. But one of our best days was about 11 days later, when this guy walked in and said ‘Thanks for saving my life.’”

With no access to any of the tools and devices you’d find in a modern hospital, the SOST had to rely on a little innovation. He said the best diagnostic tool at their disposal was a handheld ultrasound device.

“When I had six patients show up with injuries in the chest and belly, I could use the ultrasound to triage them. I can tell which of those six needs surgery right now,” he said. “It’s a must-have for teams trying to do similar type of care in an austere environment.”

Manley also relied on the unusual, but instead of using a modern tool for a modern age he used a technique first described to treat soldiers during the Korean War called REBOA, or Resuscitative Endovascular Balloon Occlusion of the Aorta.

“It’s a minimally invasive technique to occlude bloodflow,” Manley said. “Using an artery in the groin, you place the balloon up into the aorta, inflate it and occlude the blood flow.”

According to Manley, this is a technique that had fallen out of favor until recent technological developments, like smaller catheters, helped military officials recognize its strength in downrange situations.

He said using the REBOA catheter during damage control surgeries showed immediate response from the patients and allowed his team to catch their breath and catch up to what was happening.

The work they were doing was intense and stressful, and there wasn’t always a lot of time to think about the gravity of the situation unfolding around them.

“You put it in the back of your head during the trauma, but any moment your brain starts to slow down it jumps right back in the forefront of your mind and can be overwhelming,” Manley said. “There were several times I reached a point where I had to walk away. I knew everything was under control with the rest of the team, so I could walk away, compose myself, and get right back into it.”

Mitchell said, “I specifically remember one of the pediatric mass casualties. We got through all the patients and got them transported out and two of our team just broke down crying. Sitting there, spent. Sometimes being the team leader I was more worried about having that responsibility of keeping the team functioning.”

Despite the difficulties, both Airmen said it was a time they never want to forget. They called it the “pinnacle” of their career so far.

Mitchell said, “I think I'll always look back on it as... I don't know…”

His voice started to crack as Manley finished his sentence for him: “Amazing. Humbling.”

“Probably one of the most important things I’ll ever do. I try to focus on the good we did, the lives we saved. We changed the course of their lives.”

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