Page 27 - JSOM Summer 2020

Joint Trauma System Clinical Practice Guideline

Austere Resuscitative and Surgical Care
30 October 2019

Summary of Recommendations and Guidelines clinical guidance for this unique Austere Resuscitative and Sur-
gical Care (ARSC) environment. Small teams from every service
• The intent of this Clinical Practice Guideline is to pro- have been tasked with the mission of supporting operational
vide guidance for Austere Resuscitative and Surgical units (usually Special Operations Forces [SOF]) in far-forward
Care (ARSC) teams, which often comprise conventional environments. The ARSC environment uses surgical capabil-
forces surgical units used in support of Special Opera- ity outside of the conventional doctrinal guidance. The devel-
tions missions. opment of this CPG is not indicative of Joint Trauma System
• All ARSC teams should receive ARSC-specific, team- (JTS) support for nondoctrinal use of ultrasmall teams with
centric, predeployment readiness training to include limited capabilities but rather to provide guidance for teams
medical aspects and operational aspects of ARSC, with deployed in support of missions that require ARSC to facilitate
the result that ARSC teams are capable of protecting the best outcomes for casualties managed by ARSC teams.
themselves and their patients and function well in a tac-
tical environment. It is recognized that teams are working in the ARSC environ-
• The purpose of the ARSC team is to mitigate risk for ment, frequently without specific training for the unique chal-
the Operational Commander by providing surgical and lenges, clinical and tactical, that these teams encounter. Small
resuscitative care for combat casualties. ARSC teams are surgical teams have been increasingly used and have an evolv-
smaller and more mobile than other conventional surgi- ing role in providing care to US and partner forces on the bat-
cal assets and have less clinical capability and holding tlefield over the past two decades of global conflict. The Task
capacity. Realistic assessment of the risks and benefits Force Commanders or their designees will be referred to as
of this capability must be clearly communicated to the the Operational Command to represent all services through-
Operational Commander. out this document. Operational forces place high value on the
• Limited resources and staffing require that medical deci- support of surgical capability in their area of operations and
sions be made in the context of the following variables: may be constrained by policy to perform forward military op-
time and distance to the next role of care, capability erations within defined evacuation rings. During the course
of the next role of care, availability of blood products, of current conflicts, US Army Forward Surgical Teams (FST)
sterility, anticipation of additional casualties, evacua- and others were split into ever smaller elements and employed
tion capability, security, mobility, and patient-holding outside of published doctrinal concepts to meet operational
capacity. demand for close surgical support, often in support of SOF.
1–7
• Patient care must focus on rapid triage, initial resuscita- The demand for smaller and more mobile surgical teams has
tion with blood products, rapid control of hemorrhage continued to grow and many different models have emerged
and contamination with a damage-control approach, over the past two decades. Examples include the Joint Med-
and subsequent transfer to higher echelon. ical Augmentation Unit Surgical Resuscitative Team; Army
• Ultrasound of the chest and abdomen in patients with Expeditionary Resuscitative Surgical Team and split Forward
penetrating trauma to chest, abdomen, or pelvis or Resuscitative Surgical Team; the Air Force Ground Surgical
severe blunt trauma should be performed to rule out Team and Special Operations Surgical Team; and Navy Dam-
life-threatening injuries. age Control Surgical Team and Expeditionary Resuscitation
• A ruck-truck-house model, explained later in the guide- Surgical System. 1–11
lines, can help frame logistical considerations for plan-
ning purposes to maximize mobility and flexibility. There is no standard definition or joint doctrine specifying the
• Documentation (e.g., Joint Trauma System [JTS] Aus- exact capabilities of these small surgical teams. Although this
tere Trauma Resuscitation Record, operative note) must CPG has been developed on the basis of ground combat sup-
be completed for all patients treated by ARSC teams and port, the concepts can be applied to maritime environments.
submitted to the JTS or uploaded into the Theater Med- Recently, the Austere Surgery Teams Subcommittee of the JTS
ical Data Store.
Committee on Surgical Combat Casualty Care defined the
care environment of these small teams as follows: “Austere
Resuscitative and Surgical Care is advanced medical capability
Introduction
delivered by small teams with limited resources, often beyond
The intent of the Clinical Practice Guideline (CPG) is to pro- traditional timelines of care, and bridging gaps in roles of care
vide small, conventional surgical teams both operational and in order to enable forward military operations and mitigate

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