Page 43 - JSOM Spring 2026

The STEP Method

A Structured Approach to Optimize Team Performance
of Army Forward Resuscitative Surgical Detachments (FRSDs)

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Tim Bongartz, MD, MS *; Kevin High, RN, MPH, MHPE ; Joshua P. Smith, DO ; Jakob Palubicki, MD ;
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Christine Cleaves, DNAP, CRNA, ACNP ; Charles Sweigert, CRNA, MS ; Mark D. Buzzelli, MD 7
ABSTRACT
Background: The U.S. Army Forward Resuscitative Surgical Introduction
Detachment (FRSD) provides rapid damage control resus-
citation and surgery near the point of injury within combat The U.S. Army Forward Resuscitative Surgical Detachment
zones. To improve team performance and operational read- (FRSD) is a specialized medical unit tasked with providing rapid
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iness within two FRSD units preparing for combat deploy- damage-control resuscitation and surgery in combat zones.
ment, we developed a systematic, evidence-informed standard Comprising a total of 20 medical professionals and support
operating procedure (SOP) to address the unique challenges of staff of various types (for a detailed list of FRSD personnel, see
far-forward trauma resuscitation. Methods: This project was Appendix 1), this team operates in austere surroundings, often
conducted under unit-level authority as an internal readiness splitting into two 10-person teams to cover a larger area effi-
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optimization effort, consistent with every FRSD’s responsibil- ciently and/or reduce their footprint. Challenges faced include
ity to develop its own SOPs. We created a theoretical frame- the imperative to achieve medical mission success under enemy
work for team performance optimization based on literature threat, time-pressured clinical and operational decision-making,
and interdisciplinary expert input. The prototype SOP was clear communication in chaotic environments, and dynamic
refined through simulation training and real-world trauma re- role changes based on resources and situations. FRSDs are com-
suscitations during two FRSD deployments. Performance feed- posed of Active Duty and Reserve Component Army person-
back and after-action reviews were used to iteratively optimize nel, often lacking regular experience with high-acuity (military)
the “STEP” system. Results: The STEP method is a framework trauma care in either their civilian or military roles while not
for optimizing Army FRSD team performance, based on four deployed. Additionally, physicians and certified registered nurse
crucial elements: Skill, Team organization, Equipment, and anesthetists (CRNAs) are assigned to a FRSD from a central
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Process. “Skill” emphasizes proficiency in performing trauma pool and may not have trained or worked together before.
resuscitation procedures and cross-training of team members
for adaptability in mass casualty scenarios. “Team organiza- To address some of these challenges, a 2-week training, the
tion” includes clear roles and responsibilities, and a commu- Army Trauma Training Course (ATTC), is mandated prior to
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nication standard to avoid miscommunication and confusion. deployment. However, this training primarily emphasizes in-
“Equipment” includes equipment maintenance, positioning, dividual and collective trauma care skills (e.g., Individual Crit-
and familiarization. “Process” refers to the “game plan,” a ical Task Lists [ICTLs] and Advanced Trauma Life Support
structured sequence of diagnostic and therapeutic steps that [ATLS] algorithms), Joint Trauma System [JTS] clinical prac-
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supports organization and efficiency. Conclusion: The STEP tice guidelines [CPGs]), and clinical immersion at a busy civil-
method introduces a standardized approach to trauma resus- ian Level 1 trauma center. By itself, ATTC cannot cover every
citation by Army FRSDs, offering a replicable SOP template component of clinical and operational readiness, nor sustain
with broad applicability across Army medical units. It holds individual and collective proficiency if the FRSD does not im-
potential beyond trauma resuscitation, offering a versatile plement its own complementary training program. Aspects
framework for optimizing team performance in high-stress, of team organization, performance optimization, communi-
high-stakes environments. cation, and trauma resuscitation flow are not standardized
among FRSDs. Instead, these elements are governed by unit
standard operating procedures (SOPs). These are often gen-
Keywords: forward resuscitative surgical detachment;
Army; trauma resuscitation; damage control resuscitation; erated by FRSD commanders just prior to deployments and
team performance; patient care team; military medicine; vary significantly between units. This leads to difficulties with
clinical protocols; standard operating procedures; team timely adaptation and personnel rotation between teams.
communication
Establishing a comprehensive cross-unit SOP would provide
FRSDs with a training framework to foster high-performance
*Correspondence to Vanderbilt University Medical Center, Department of Emergency Medicine, 2215 Garland Avenue, Light Hall Suite 203,
Nashville, TN 37232 or tim.bongartz@vumc.org
1 LTC Tim Bongartz is an Emergency Physician affiliated with the Department of Emergency Medicine, Vanderbilt University Medical Center
(VUMC), Nashville, TN, and the United States Army Medical Department (AMEDD). Kevin High is a flight nurse affiliated with VUMC.
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3 LTC Joshua Smith is a Trauma Surgeon affiliated with AMEDD. MAJ Jakob Palubicki is a General Surgeon affiliated with AMEDD.
5 LTC Christine Cleaves is a CRNA and nurse practitioner affiliated with the VA Medical Center, Department of Anesthesia, Lebanon, PA, and
AMEDD. MAJ Charles Schweigert is a CRNA affiliated with the VA Medical Center, Washington, DC. COL Mark Buzzelli is a Trauma Surgeon
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affiliated with the Division of Trauma, Burn and Surgical Critical Care, University of Miami, Coral Gables, Florida, and AMEDD.
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