Page 51 - JSOM Summer 2018

Special Operations Force Risk Reduction

Integration of Expeditionary Surgical and Resuscitation Teams

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Steven Satterly, MD, FACS *; Owen McGrane, MD ; Thomas Frawley, MD ;
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William Bynum, MD ; John Martin ; Charles Clegg ; Nate Pearsall ; Sean Reilly, MD, FACP ;
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Eric Verwiebe, MD ; Matthew Eckert, MD, FACS 10
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ABSTRACT
Hemorrhage in the presurgical setting has been the most sig- DCS and modern techniques such as balanced blood product
nificant cause of death on the battlefield. Damage control transfusion, permissive hypotension, rewarming, limitation of
surgery (DCS) near the point of injury (POI) is not a new con- crystalloid fluids, and use of hemostatic adjuncts to optimize
cept, but having conventional medical teams supporting Spe- physiologic conditions for overall improved survival. 6–8
cial Operations Forces (SOF) beyond robust military medical
infrastructure is unique for the US military. The Expeditionary Special Operations missions present a distinct challenge to ef-
Resuscitative Surgical Team (ERST) was formed by the US fectively incorporate contemporary trauma care. These mis-
Army Medical Command as a pilot team to fulfill a request sions are often conducted in hostile, denied, semipermissive,
for forces to provide DCS and personnel recovery near POI. or politically and/or diplomatically sensitive environments and
are characterized by one or more of the following: time sensi-
Keywords: Expeditionary Resuscitative Surgical Team; dam- tivity, clandestine or covert nature, low visibility, work with or
age control surgery; “Golden Hour”; presugical setting through indigenous forces, greater requirements for regional
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orientation and cultural expertise, and a higher degree of risk.
The ERST is not the first and only attempt by the US military
Introduction to place DCS near POI. Likewise, the US Air Force and US
Navy have branch specific teams with a similar purpose but
Hemorrhage in the presurgical setting has been the most sig- distinct capabilities. Many of these teams are not specifically
nificant cause of death on the battlefield. This fact continues constructed to provide the scope of care from POI, DCR, and
to be true in today’s modern battlefield. As early as The theater evacuation at an expeditionary level. Given the accep-
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Iliad, time to surgical care for penetrating combat injury has tance of the “Golden Hour” into operational planning, the
been associated with mortality. In modern times, the funda- mitigation of risk for SOF has incurred further complexity.
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mental concept of controlling battlefield hemorrhage rapidly The goal of this study was to determine if a conventional med-
has not changed. DCS near the POI is not a new concept, but ical team can effectively reduce “time to ED [emergency de-
conventional medical teams supporting SOF beyond robust partment physician]” level care and “time to DCS,” resulting
military medical infrastructure is unique for the US military. in decreased SOF mission risk.
The ERST was formed by the US Army Medical Command as
a pilot team to fulfill a request for forces to provide “Golden
Hour” DCS and personnel recovery near POI for Special Materials and Methods
Operations.
Fielding the ERST
Damage control resuscitation (DCR) and DCS are tenets of Composition
modern military trauma care. DCS was originally described as The ERST was composed of conventional medical support
an efficient temporary surgical technique to control exsangui- personnel. Three teams of eight personnel were constituted
nating hemorrhage and limit intestinal spillage while avoiding from conventional military medical professionals; members
further physiologic injury from prolonged definitive surgery. were specifically selected by their specialty assignment of-
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DCS uses transitory techniques of vascular shunting or liga- ficers. The ERST teams were generally subdivided into two
tion, enteric discontinuity, and temporary cavity closure to ad- components: the damage control surgical team (DCST) and
dress immediate lethal hemorrhage and sources of sepsis. After the critical care evacuation team (CCET). The DCST included
critical care resuscitation, subsequent care and complete defin- a general surgeon, an orthopedic surgeon, a certified registered
itive surgery can be pursued in a delayed fashion under ideal nurse anesthetist, an emergency physician, and an operating
conditions. DCR is a comprehensive approach combining room scrub technician. The CCET was composed of a critical
*Address correspondence to steven.satterly@gmail.com
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1 MAJ Satterly is a general surgeon at Womack Army Medical Center, Fort Bragg, NC. MAJ McGrane is the assistant program director of the
Austere and Wilderness Medicine Fellowship at Madigan Army Medical Center, FT Lewis, WA. MAJ Frawley is the Curriculum Director of the
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Emergency Medicine Residency at the San Antonio Military Medical Center, San Antonio, TX. Dr Bynum is an assistant professor of family
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medicine at Duke University School of Medicine, Durham, NC. MSG Martin is the senior enlisted medical adviser for Special Operations Com-
mand Africa. Mr Clegg is a Combat Medic. Mr Pearsall is a Combat Medic. LTC Reilly is the chief, Internal Medicine Department, Landstuhl
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Regional Medical Center, Landstuhl, Germany. LTC Verwiebe is the Orthopedic Trauma Director at Tripler Army Medical Center, Honolulu,
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HI. LTC Eckert is the trauma director, assistant program director, General Surgery Residency, Madigan Army Medical Center, Fort Lewis, WA.
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