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the patient with hemorrhagic shock and cardiac injury or in casualty scenarios. The standardized nature of team roles may
the patient who just underwent successful resuscitative thora- seem rigid, but our field experience suggests it fosters clarity
cotomy, the rapid progression from damage control resuscita- and enables swift adjustments in dynamic situations, minimiz-
tion to damage control surgery may supersede the completion ing duplication of effort and miscommunication. Our iterative
of a full secondary survey. approach in developing the STEP method as a unit SOP for the
involved FRSDs also highlights an important implication for
The “advanced trauma toolbox” comprises damage control Army medical training: SOPs should not remain static but in-
resuscitation techniques not routinely used in every trauma stead undergo continuous cycles of simulation, feedback, and
resuscitation. These interventions (including blood transfu- field validation. Embedding this approach into both training
sion, chest tube insertion, permanent airway placement, and and operational practice provides a mechanism for ongoing
trochanteric [pelvic] binder) are ordered by the TTL after com- refinement and adaptation. This mirrors the doctrinal empha-
pletion of the primary survey. A complete list of “advanced sis on continuous unit-level improvement and may serve as a
trauma toolbox” interventions is depicted in Figure 2. model for other specialized Army medical units facing similar
challenges in high-stress, resource-limited environments.
The standardized Trauma Resuscitation Process (Figure 2)
guides the resuscitation procedure until the casualty is stabi- Future research should formally evaluate the STEP method
lized, after which evacuation to a higher level of care or tran- against other systems aimed at enhancing team performance
sition to the surgical phase is initiated. during trauma resuscitation. Nevertheless, existing evidence
supports the benefits of a standardized process, which offers
structure, facilitates mental offloading, and ensures essential
Discussion
steps are not overlooked. In a large-scale combat environment
With the STEP method, we propose a standardized approach against a peer adversary, forward surgical teams will face in-
to the high-stress, high-stakes mission of trauma resuscitation tensified challenges due to the rapid tempo of operations, the
executed by U.S. Army FRSDs. We identified the four corner- sheer volume of casualties, and the increased lethality of the
stones of this approach: Skill, Team organization, Equipment, battlefield with more serious injury patterns. This type of en-
and Process through a targeted review of literature focusing vironment will demand even clearer communication amidst
on team performance optimization. Our approach integrates chaos, improved structure and standardization to prevent men-
components of established trauma care algorithms, such as tal overload and exhaustion and maximized team effectiveness
ATLS, European trauma guidelines, and TCCC. The com- to deal with the expected high caseload. Derived from various
munication standard adopted for our system is validated and high-stress domains, we believe the STEP method holds prom-
implemented across the Army Healthcare system, facilitating ise beyond trauma resuscitation, providing a framework for
widespread acceptance. 31 optimizing team performance across diverse contexts in high-
stress, high-stakes environments.
A notable strength of the STEP method lies in its iterative de-
velopment process, which combines literature-informed the- Author Contributions
ory, interdisciplinary stakeholder expertise, trauma simulation TB, KH, and MB developed the initial STEP framework. TB
cycles, and real-world combat casualty resuscitation reviews. and KH performed the literature review. TB, KH, JS, JP, CC,
This approach ensured that the framework is not only con- CS, and MB orchestrated simulations, performed in real-world
ceptually grounded but also pragmatically adapted to the trauma resuscitations, and refined the system through AARs.
realities of far-forward trauma care. The integration of sim- TB and MB wrote the first draft of the paper. All authors par-
ulation-based refinements (e.g., introducing the blood runner, ticipated in refining the initial draft and read and approved the
eliminating the ballistic survey) with lessons learned during final manuscript.
combat deployments (e.g., equipment familiarization, skill
redundancy) created a system that is both evidence-informed Disclaimer
and operationally validated. Command of the involved FRSDs approved this publication
for universal distribution. This project was conducted as a
Limitations unit-level quality improvement and SOP development effort,
While the inclusion of both simulation and real-world feed- focused on improving team dynamics and performance. No
back strengthens the validity of our system, it also introduces patient-level data were collected or analyzed, and all trauma
limitations regarding generalizability. Our refinement process care adhered to JTS CPGs. The information, content, and
involved two FRSD units and a finite number of combat sce- conclusions do not necessarily represent the official position
narios, so our system may not perform equally well across or policy of the United States Army Medical Department
all possible operational environments or team compositions. (AMEDD).
Nevertheless, the consistency of AAR-derived themes in both
simulated and real-world settings suggests that the STEP prin- Disclosures
ciples may have broad applicability to FRSDs and potentially The authors have nothing to disclose.
to other military medical teams.
Funding
Conclusion No funding was received for this work.
Implementing the proposed system presents challenges. Teach- References
ing the “basic trauma skill” set requires significant effort from 1. Headquarters, Department of the Army. The Medical Detachment,
all team members and leaders, necessitating frequent cross- Forward Resuscitative and Surgical. ATP 4-02.25. Department
training to adapt quickly to changing conditions and mass of the Army; December 7, 2020. Accessed May 27, 2024. https://

48 | JSOM Volume 26, Edition 1 / Spring 2026