Page 78 - JSOM Winter 2017

Expeditionary Resuscitation Surgical Team

The US Army’s Initiative to Provide Damage Control Resuscitation
and Surgery to Forces in Austere Settings

Matthew R. D’Angelo, DNP, CRNA *; John Losch, MPAS, PA-C ; Bret Smith, MPAS, PA-C ;
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Mark Geslak, MPAS, PA-C ; Shon Compton, MPAS, PA-C ; Kenneth Wofford, PhD, CRNA ;
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Jason M. Seery, MD ; Michael Morrison, DSc, PA-C ; Ian Wedmore, MD ; James Pairmore, MPAS, PA-C ;
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Kirby R. Gross, MD ; Peter Cuenca, MD ; Matthew D. Welder, DNP, CRNA 13
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ABSTRACT
Improvements in surgical care on the battlefield have contrib- Although most prehospital battlefield deaths are due to non-
uted to reduced morbidity and mortality in wounded Service- survivable injuries, data from the Joint Theatre Trauma System
members. Point-of-injury care and early surgical intervention, suggest that as many as 25% of those who died in Iraq and
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along with improved personal protective equipment, have pro- Afghanistan died of injuries that were potentially survivable
duced the lowest casualty statistics in modern warfare, result- if it had been possible to get the injured person to a surgeon. 4
ing in improved force strength, morale, and social acceptance
of conflict. It is undeniable that point-of-care injury, followed The purpose of this manuscript is to briefly review casualty
by early resuscitation and damage control surgery, saves lives movement from the point of injury to surgical care on the bat-
on the battlefield. The US Army’s Expeditionary Resuscitation tlefield, describe ad hoc methods to improve battlefield access
Surgical Team (ERST) is a highly mobile, interprofessional to surgical care, and describe the unit composition and medi-
medical team that can perform damage control resuscitation cal capabilities of the ERST.
and surgery in austere locations. Its configuration and capa-
bilities vary; however, in general, a typical surgical element Surgery on the Battlefield
can perform one major surgery and one minor surgery with- In the long-standing model of battlefield casualty evacuation,
out resupply. The critical care element can provide prolonged patients are evacuated through echelons of care that are Role
holding in garrison, but this diminishes in the austere setting dependent and at increasing distances from the battlefield.
with complex and acutely injured patients. Typically, injured Servicemembers receive treatment at the
point of injury. Based on initial triage and geographic location,
Keywords: expeditionary, healthcare teams; military, capa- injuries that require additional in-theatre care can progress to
bilities; austere environment Role 1 or Role 2 facilities like the battalion aid station, medi-
cal company, and forward surgical team (FST), or progress to
the technologically more advanced Combat Support Hospi-
tal platform (Role 3). Patients with complex injuries or those
Introduction
requiring prolonged rehabilitation are evacuated after initial
Improvements in surgical care on the battlefield have contributed stabilization to fixed facilities (Role 4) outside the theatre of
to reduced morbidity and mortality in wounded Servicemem- operations. 5
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bers. Point-of-injury care and early surgical intervention, along
with improved personal protective equipment, have produced Patient evacuation through the continuum of care depends on
the lowest casualty statistics in modern warfare, resulting in im- the phase of war, the maturity of the theatre, and air superi-
proved force strength, morale, and social acceptance of conflict. It ority. The availability of transportation resources (air versus
is undeniable that point-of-care injury, followed by early resusci- ground), tactical environment (secure versus hostile), geo-
tation and damage control surgery, saves lives on the battlefield. 2 graphic location (austere versus well developed), and weather
all influence the flow of casualties to Role facilities of increas-
Prolonged hypovolemia and ischemia increase morbidity and ing levels of care. Although evacuation technologies have
mortality risks for patients suffering from hemorrhagic shock. evolved from the horse-drawn ambulances of the US Civil War
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*Address correspondence to matthew.dangelo@usuhs.edu
1 MAJ D’Angelo, AN USAR, is at the Uniformed Services University of the Health Sciences, Daniel K. Inouye Graduate School of Nursing,
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Bethesda, MD. CPT Losch, SP USA, is at the AMEDD Center and School, Center for Predeployment Medicine, Tactical Combat Medical Care
Course, Fort Sam Houston, TX. MAJ Smith, SP USA (Ret), is at the AMEDD Center and School, Center for Predeployment Medicine, Tactical
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Combat Medical Care Course, Fort Sam Houston, TX. MAJ Geslak, SP USA (Ret), is at the AMEDD Center and School, Center for Predeploy-
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ment Medicine, Tactical Combat Medical Care Course, Fort Sam Houston, TX. MAJ Compton, SP USA (Ret), is at the AMEDD Center and
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School, Center for Predeployment Medicine, Tactical Combat Medical Care Course, Fort Sam Houston, TX. CDR Wofford, NC USN, is at the
Uniformed Services University of the Health Sciences, Bethesda, MD. LTC(P) Seery, MC USA, is at Martin Army Community Hospital, Surgical
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Services Service Line, Fort Benning, GA. MAJ Morrison, SP USA, is at the AMEDD Center and School, Center for Predeployment Medicine,
Tactical Combat Medical Care Course, Fort Sam Houston, TX. COL Wedmore, MC USA, is at the Department of Emergency Medicine, Madi-
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gan Army Medical Center, Joint Base Lewis-McChord, WA. LTC Pairmore, SP USA, is at HQDA, Office of the Surgeon General, Falls Church,
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VA. COL Gross, MC USA, is at the Army Trauma Training Department, AMEDD Center and School Health Readiness Center of Excellence,
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Ryder Trauma Center, Miami, FL. COL Cuenca, MC USA, is at the AMEDD Center and School, Center for Predeployment Medicine, Tacti-
cal Combat Medical Care Course, Fort Sam Houston, TX. LTC Welder, AN USA (Ret), is at the Uniformed Services University of the Health
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Sciences, Bethesda, MD.
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