Page 79 - JSOM Winter 2017

and World War I to the technologically advanced aeromedical Care Team. Through this design, the ERST can provide emer-
9
evacuation of modern war, the model of patient movement re- gency medical care, damage control resuscitation and surgery,
mains nearly the same. Injured patients are triaged and cared critical care patient transport, and patient holding for periods
6
for at the site of injury, then moved over distances to receive where evacuation is delayed.
surgical intervention. Patient movement is time and distance
dependent and, therefore, may prolong medical intervention. ERSTs are composed of eight persons with a standardized
equipment set. The team includes a general and orthopedic
The military medical community has made several attempts to surgeon, two registered nurses (emergency department and in-
reduce the time from combat injury to damage control care. tensive care unit nurses), a surgical technologist, an emergency
The Special Operations Forces (SOF) medical community has medicine physician, a critical care physician, and a certified
pioneered the use of damage control surgery and damage con- registered nurse anesthetist (CRNA). Through this configura-
trol resuscitation near the point of injury for decades. Role tion, the ERST is lightweight, highly mobile, and can provide
7,8
2 platforms like the Special Operations Resuscitation Teams resuscitation and surgical care in an austere outstation or near
(SORTs), Special Operations Surgical Teams, and Special Op- the tactical objective with minimal logistical support. The
erations Critical Care Evacuation Team provide resuscitative, ERST is used to mirror the mobility of the SORTs and tai-
surgical, and evacuation assets far forward, near, or at the lored to the needs of conventional and unconventional forces
point of injury. 7 located in underdeveloped theatres of operation.

SOF resuscitative and surgical teams have a long history of ERST Training
supporting unconventional warfare units in austere locations; The ERST comprises licensed healthcare providers credentialed
however, the paradigm of embedding or strategically position- to practice in military treatment facilities. ERST members are
ing these teams near conventional forces had not been routinely selected from MEDCOM based on the recommendation of
practiced until the war in Afghanistan. The complexity of the subspecialty branch managers. An ERST completes a total of
Afghan theatre has challenged traditional medical doctrine. 21 days of training before deployment. Eight training days—
Vast mountain ranges, hostile locations, and an immature and a 5-day Tactical Combat Casualty Care course and a 3-day
inadequate highway infrastructure present several limitations Emergency War Surgery course—are conducted as prerequisite
to timely evacuation of those injured on the battlefield. coursework before ERST-specific training. In addition to these
courses, the critical care physician, critical care nurse, and
In response to evacuation barriers, Golden Hour Offset Surgical emergency room nurse attend the Joint Enroute Care Course.
Teams (GHOSTs) were developed to improve Servicemember The entire eight-person team completes the ERST specialty
access to resuscitation and surgical care. GHOSTs are ad hoc training together, which is a rigorous 13-day program con-
resuscitative and surgical teams developed from conventional ducted by the Center for Predeployment Medicine, Division
FSTs. GHOSTs are split from their organic units and can move of Tactical Combat Casualty Care. ERST training focuses on
to austere locations to provide critical services to units outside team development and equipment familiarization using au-
the range of rapid medical evacuation. Although GHOSTs have thentic tactical medical scenarios to refine operational skills
proven effective in bringing damage control care closer to the and prepare the team to function in an austere setting with
point of injury, they lack standardized training, use inefficient limited resources.
and less-mobile FST equipment, and require specific transpor-
tation assets to deploy. The disadvantages of the GHOST sug- ERST Resuscitative and Surgical Capabilities
gest a need to develop a standardized resuscitative and surgical An ERST initially deploys with appropriate medical supplies
team that can support units serving in austere locations. to perform 10 major surgical cases. The equipment and sup-
plies are packaged and stored in Pelican cases (Pelican Prod-
ucts, http://www.pelican.com/) with the intention that these
Expeditionary Resuscitation Surgical Team
supplies and equipment will be used out of individual back-
To meet the challenges of the evolving battle space and provide packs when the team is not in garrison. In addition to an-
a formalized, discrete medical platform to serve in austere lo- cillary medical supplies (e.g., intravenous catheters, gloves,
cations, the US Army Medical Command (MEDCOM) has in- intravenous fluids, dressings), the team is equipped with surgi-
troduced the concept of expeditionary medicine. The ERST is cal sets designed for general, thoracic, and neurologic surgery.
at the forefront of this campaign. A formal request to develop The general surgery set includes a diverse selection of staplers
ERST training was made by the Office of the Surgeon General for use in a variety of anatomic regions (e.g., gastrointestinal,
of the Army in January 2016 to the US Army Medical De- vascular, lung). The small chest set (thoracic) includes a Leb-
partment Center and School, Center for Predeployment Medi- sche sternal knife, Finochietto rib spreader, and mallet. The
cine, division of Tactical Combat Medical Care. Formally, the craniotomy set includes a hand drill and wire saw for burr
ERST’s mission is to field a rapidly deployable team to pro- holes and craniectomies. In addition to the predesigned sets,
vide immediate forward resuscitation, surgery, prolonged field the ERST has a variety of vascular tools, clamps, loops, ties,
care, and en route critical care in support of SOF missions to and shunts that can be used for major vessel injuries. The or-
include foreign internal defense, counterterrorism, direct ac- thopedic surgeon has the equipment and supplies to perform
tion, security force assistance, and counterinsurgency in aus- immobilization and external fixation of orthopedic injuries.
tere environments. The ERST is not equipped with orthopedic plates, screws,
brackets, or advanced orthopedic imaging technology.
ERST Composition
The ERST concept was designed to provide forward care Anesthesia delivery is the primarily responsibility of the CRNA.
similar to the SORT and blend with the additional capabili- In the event of a mass casualty scenario, or in the absence of the
ties of the US Air Force Mobile FST/Expeditionary Critical CRNA, the critical care physician is cross-trained to deliver

Expeditionary Resuscitation Surgical Team | 77