Page 44 - JSOM Spring 2026

team dynamics well in advance of deployment. Furthermore, Results
a consistent standard across all Army FRSDs would facilitate
smoother integration of team members transferring from other The first step in our SOP development included a targeted
units. This paper proposes an FRSD SOP that incorporates review of pertinent literature focused on performance opti-
evidence-based strategies from high-stress, high-stakes teams, mization in high-stress, high-stakes teams. We found that the
such as aircrews and Special Operations Forces, to improve principles governing effective performance in trauma teams
training, task execution, and overall team performance. closely mirrored those observed in other domains such as avi-
ation and space crews, firefighters, special operations teams,
and Formula 1 pit crews, where success depends on coordi-
Methods nated, time-critical actions under pressure. 8–13
This work was conducted as a unit-level standard operating
procedure (SOP) development effort under the authority of the Based on this initial review and further interdisciplinary ex-
Forward Resuscitative Surgical Detachment command struc- pert input, we identified four core elements that consistently
ture across two different U.S. Army FRSDs. emerged as critical to team effectiveness: Skill, Team organiza-
tion, Equipment, and Process (STEP). These elements formed
As a first step, we conducted a targeted review of the existing the foundation of our prototype system, which was subse-
literature to identify evidence-based strategies and principles quently refined through trauma simulation exercises and, later,
for improving team performance in high-stress, high-stakes real-world casualty resuscitation in combat environments.
environments. Subsequently, we synthesized the findings to es- The feedback from 48 simulated trauma scenarios resulted
tablish a theoretical framework for developing the proposed in several system modifications. For example, team members
system, focusing on key factors influencing team effectiveness. highlighted delays in blood delivery when personnel were si-
We used interdisciplinary expertise from trauma team leaders multaneously tasked with other critical duties, prompting the
(TTLs), emergency physicians, trauma and orthopedic surgeons, creation of a dedicated “blood runner” role. This change de-
CRNAs, nurses, and combat medics to optimize usability and creased the mean time for blood delivery by approximately 2.2
integrated our system with current Advanced Trauma Life Sup- minutes. Conversely, the prototype “ballistic survey” (a rapid,
port (ATLS) and European Trauma Resuscitation guidelines. 6,7 complete casualty exam performed after the primary survey)
was judged to delay critical interventions. It was removed,
Subsequently, we subjected this prototype system to a simula- with detection of penetrating injuries incorporated into the
tion-based refinement process using trauma resuscitation sim- FAST (focused assessment with sonography in trauma) exam
ulation scenarios conducted by two separate FRSDs. We used and secondary survey for a more streamlined approach.
moulage with role players, simulated wounds, and synthetic
blood. Initial vital signs were written on silk tape and attached AARs following real-world combat zone resuscitations further
to the patient. As soon as the patient was attached to a mon- refined the final SOP. Two instances highlighted delays due to
itor, we displayed simulated vital signs on a digital device po- unfamiliar equipment (an airway suction device and a femo-
sitioned above the stretcher using the SIMPL monitor ( Apple ral traction splint), prompting us to place greater emphasis on
©
App Store). The scenario was supervised by a simulation coach equipment drills and familiarity within the “E” component of
who controlled the vital-sign display and monitored the overall STEP. In addition, when our teams were reduced due to per-
execution of CPGs, critical action items, and the resuscitation sonnel unavailability, the importance of “skill redundancy” be-
flow. Role players received detailed instructions beforehand came apparent. As a result, we introduced daily cross- training
on what mental status to simulate, what level of distress to to ensure all core resuscitation tasks could still be executed
display, and how to respond to certain interventions (such as effectively even with reduced staffing. These examples illus-
improved breathing after chest decompression). trate how our SOP evolved through an iterative process based
on both simulation and operational experience. The following
The simulation scenarios spanned the full spectrum of com- sections describe our final “STEP” SOP.
bat-relevant trauma: facial and neck injuries with airway ob-
struction, massive hemorrhage, blunt and penetrating thoracic Skill
and abdominal trauma, large body surface area burns, severe Mastery of procedural skills forms the foundation of every
traumatic brain injury, pelvic and extremity trauma (includ- trauma resuscitation. Since these skills are perishable, they re-
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ing amputations), and mass casualty situations. Each scenario quire regular training and simulation to maintain proficiency.
was followed by a structured After Action Review (AAR), with For an FRSD to remain agile and adaptable, it is paramount
emphasis on adherence to JTS CPGs, time to first blood trans- that all team members can execute the full spectrum of basic
fusion, clarity of communication, individual situational aware- trauma resuscitation techniques regardless of specialization.
ness, and clarity of roles and responsibilities. This “skill redundancy” fosters better team dynamics, with
each member understanding their role and able to assist others
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As a final step, the system was implemented as the preliminary with theirs. Moreover, it enables anticipation and adaptation
SOP for trauma resuscitation during two FRSD combat zone in challenging scenarios, such as mass casualties or the replace-
deployments. Following each real-world casualty resuscitation ment of an incapacitated team member. The technical skills
during these deployments, structured AARs were conducted required during a trauma resuscitation can be separated into
focusing on CPG adherence, identification of communication “basic” and “advanced.” Every FRSD team member should be
errors, and the timeliness of interventions (e.g., time to first familiar with and able to execute the “basic” skills depicted
blood transfusion) to further improve our system. While op- in Table 1. These skills are largely consistent with the skillset
erational security restrictions preclude disclosure of casualty taught as part of Tier 3 (combat medic) Tactical Combat Ca-
specifics, these AARs provided essential real-world validation sualty Care (TCCC), the Army’s basic system of initial trauma
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and refinement. care.
42 | JSOM Volume 26, Edition 1 / Spring 2026