Page 80 - JSOM Winter 2017

general anesthesia. Anesthesia is prepared to provide a spec- can go forward with a two-part CTOMS backpack (http://
trum of care ranging from limited peripheral regional anesthe- ctoms.ca) and one hand-carried hanging bag per team mem-
sia to a full general anesthetic. Total intravenous anesthesia is ber. This number of bags equates to sufficient medical materi-
the primary method of anesthesia; the ERST is not equipped als to perform two major surgical cases and enough supplies
to deliver volatile anesthetics. The anesthetist is equipped with to resuscitate and/or hold two fewer serious casualties without
traditional airway management tools and adjuncts, standard resupply.
monitors, an AutoMedx SAVe ventilator (http://automedx
.com/), a variety of venous access devices, and traditional med- In practice, the ERST has been fielded to forward positions
ications required for intraoperative and perioperative care. carrying three bags per team member. The bags include two-
part CTOMS shoulder packs and personal 36-hour bags. In
In addition to its surgical capabilities, the ERST has resusci- addition to the three bags, the team must have a way to store
tative and prolonged holding capabilities. The ERST is sup- component therapy (e.g., a Collins Box, cooler, or refrigerator/
plied with crystalloid solutions (e.g., Ringer’s lactate, normal freezer) and a Doak table (surgical element; Doak Medical En-
saline), Hextend, and hypertonic saline. The team also has gineering) or two litter stands (one for the surgical component
component therapy and a standing issue of 20 units of fresh in place of the Doak table, and one for the critical care ele-
frozen plasma and 20 units of packed red blood cells, which ment). The team may opt to bring additional equipment (e.g.,
depend on blood product resupply. The ERST can manage a oxygen concentrator, light sets) as dictated by the mission and
walking blood bank and initiate fresh whole-blood transfu- limitations on weight and volume.
sions as required. Component therapy is distributed among
the resuscitation, surgical, and critical care elements as antici- ERST Limitations
pated by a mission. The greatest limitation to the ERST concept is its dependence
on the host unit for support. Although the ERST can maintain
The ERST’s patient-holding capabilities are variable and de- its class VIII materials, it does not have organic communica-
pend on patient acuity. While in garrison, the team has the tions, vehicles, supply, administration, or intelligence person-
ability for prolonged holding capacity (i.e., several days), nel. ERST members are proficient with individual weapons
which lessens with higher acuity, multiple casualty scenarios but unable to provide their own security.
in austere environments. The critical care team members are
trained to provide critical care transport over land and for Results
aeromedical evacuation in fixed and rotary wing airframes.
The ERST concept is growing and proving successful in a va-
The ERST critical care element is equipped with powered and riety of theatres of operation. In fiscal year 2016, five teams
nonpowered suction devices, an AutoMedx SAVe ventilator, were fielded to support operational units in austere settings.
Impact 731 portable ventilators (Zoll Medical, https://www It is projected that an additional nine teams will be fielded
.zoll.com), SeQual SAROS oxygen concentrator (3L/min max- in fiscal year 2017. Case data are limited; however, Satterly
imum flow; Caire, https://www.cairemedical.com/), Philips and colleagues demonstrated a significant reduction in time
10
portable vital signs monitor (Koninklijke Philips, https://www to emergency care and damage control surgery for SOF with
.usa.philips.com), North American Rescue Hypothermia Pre- the addition of an ERST. This small analysis demonstrated
vention and Management Kit (https://www.narescue.com/), a nearly 6-hour difference between care for forces with an
Belmont Buddy Lite fluid warmers (Belmont Instrument, ERST compared with those without an ERST. The integra-
http://www.belmontinstrument.com), and a variety of critical tion of the ERST concept demonstrated a risk reduction
care pharmaceuticals. The critical care team has limited labo- for SOF.
ratory capabilities; it is equipped with an i-STAT handheld
blood analyzer (Abbott Point of Care, https://www.pointof Conclusion
care.abbott). The critical care element maintains a defibrillator
at their static facility and has a portable automated external The ERST is a highly mobile, interprofessional medical team
defibrillator unit for forward movement. that can perform damage control resuscitation and surgery in
austere locations. Its configuration and capabilities vary; how-
Package Size ever, in general, a typical surgical element can perform one
The ERST was conceptualized to provide maximum flexibility major surgery and one minor surgery without resupply. The
to support operational forces. Although there is no set pack- critical care element can provide prolonged holding in garri-
age, the most commonly use ERST configuration, thus far, son, but this diminishes in the austere setting with complex
consists of split surgical and critical care elements. Under this and acutely injured patients. Although the ERST depends on
model, the surgical element moves forward with the opera- a host unit for administrative, communications, and logistics
tional element while the critical care element remains at a fixed support, the small unit footprint has been proven effective
location. The split ERST surgical element has typically con- operationally and is rapidly becoming an asset to operational
sisted of the two surgeons, the emergency room physician, the forces. The ERST was conceptualized to fill a void in emergent
CRNA, and either a registered nurse or the surgical technician. battlefield care and is showing promise to care for those in
The critical care element includes the critical care physician, harm’s way.
both nurses, or a nurse and the surgical technician.
Acknowledgments
ERST equipment is transported using a series of shoulder- We thank the many subject matter experts who gave their time
carried packs (jump bags) and hanging bags commonly used and energy toward the development of the ERST. The team’s
by the Special Operations community. Based on team configu- accomplishments and the development of this manuscript
ration and mission weight and volume limitations, the ERST would have been impossible without their support.

78 | JSOM Volume 17, Edition 4/Winter 2017