peripheral venous access (success of 75% during flight and 100% in the Role 2)62, cerebral oximetry (Invos® monitor) has been used satisfactory in the combat casualty63, BIS® hypnosis sensor position has been modified to adapt it to the tactical situation and the regional anesthesia64, and the hemoglobin monitor Massimo® has been used with good results57. Ultrasound scanning has been established as a preferred diagnostic method in the military environment65. Telemedicine has been fundamental during these years. According to information provided by Spanish Military Telemedicine Unit, 441 videoconferences, 119 teleconferences by phone and 186 e-mails between Role 2E and telemedicine service of the Role 4 have been carried out. Role 1 and Role 2 have also been connected for this purpose, it has been v erified the possibility of performing nervous plexuses anesthetic blockades with ultrasound66, telelaringoscopy67, telesurgery to support the surgical team68-70 (Figure 5) and telecardiology capacity71. Figure 5: Telesurgery directed from telemedicine unit in the Central Hospital of Defense "Gómez Ulla" (Role 4) - left to a remote Center (Role 2) - right.
collection of this medical information45. Furthermore, all the medical information of the patients was also scanned under the Spanish Law on information protection and currently they are guarded in the Air force Medical Direction. Finally, the statistics daily (MEDSITREP), report EDO’s and weekly of the attentions realized (Weekly Staff of Pathologies) in the different NATO medical levels has been sent regularly to Medical Section (J4B) of the Spanish Joint Command for Operations in Madrid (Spain).
TEAM WORK AND HUMAN FACTOR
Human factors, team work, non-technical skills, crosssectional medical environment and leadership have been basic in casualty care the in actual conflicts120-122. Over ten years of deployment, medical personnel from Bulgaria, United States, United Arab Emirates, Italy and Spain have worked closely in the Spanish Role 2 in Herat. Multidisciplinary teams have been formed with members from different nationalities and cultures but have achieved a common goal: maintain a medical care similar to that provided in their home countries45, 123-125. From our point of view, the paradigm of this collaboration has been the initial trauma team. It is composed of an anesthesiologist, two nurses, two paramedics, a transcriptor (medical assistance) and a trauma leader (intensive care physician). In mass casualties event, this capacity would be supplemented by another NATO contingent physician (Figure 6). The experience obtained has been the basis for other medical deployments in different areas of operation 126-128. Figure 6: Spanish trauma teams attending to combat casualties in triage area of Spanish Role 2E in Herat (Afghanistan).
The transfer of knowledge is essential to export the lessons learned on the battlefield. Spanish medical officers have participated in congresses of their respective scientific societies sharing the experiences in Afghanistan, there have been organized specific congresses of Military Health and about transfusion in military environment. Books about life support in combat, telemedicine, or hemotherapy have been developed and reviews and clinical cases have been exposed in scientific journals. The Journal of the Spanish Armed Forces Medical Service has served as a way of publication for many of these papers and the line of investigation on the combat casualty care is the most active of the Joint Institute of Biosanitary Research of the Defense (Madrid, Spain) having generated doctoral theses. Thanks to this effort, Spain is in the first third of medical articles citations related to the Afghanistan war72-118.
DATA ANALYSIS: SCAN AND GESCLIN PROGRAM
For Gawande119 one of the main reasons for which mortality from casualties in the Afghan war has been the smallest in history, has been the effort in compilation of an important number of injured men medical information. This fact has allowed to improve medical guidelines and recommenda