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risk to the force.” The goal of this guideline is to provide specific for this mission presents both a risk to mission and
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guidance for the leaders and personnel of ARSC teams who risk to force, and is highly discouraged. 3,13,14 Being an asset
are tasked to deploy and provide advanced medical and sur- in the operational environment, not a liability, requires that
gical capability on the battlefield spanning the spectrum from ARSC team members have sufficient training to integrate with
point of injury (POI) up to conventional Role 2, noting that the supported operational force and throughout the entire en
this environment of care has nuances from conventional/doc- route chain of care. The smaller the ARSC team, the more
trinal surgical support. These teams often comprise conven- technical and clinical expertise is required for all team mem-
tional forces personnel in support of SOF missions and have a bers. Likewise, the farther forward the ARSC team deploys,
unique placement in the battlefield system of care; their ability the more tactical and clinical proficiency the team requires.
to support these teams and remain small and agile relies on the
proximity and capabilities of adjacent roles of care. Mission planning is essential to effective use of the ARSC team
and begins well before deployment. Surgeon involvement with
ARSC leadership is essential. ARSC leadership elements in-
ARSC Mission Readiness
clude the officer in charge (OIC), senior surgeon, and senior
Expertise in trauma care is the cornerstone for ARSC teams, enlisted member. They should be involved in all phases of the
and trauma training to achieve and sustain clinical expertise Joint Operations Planning Process. Communicate early and
of all team members is foundational. Historical, abbreviated often with the line command to establish mutual trust and
“just-in-time” training for trauma care is highly discouraged. shared realistic expectations of the ARSC team’s capabilities,
Combat trauma patients already present the most demanding limitations, and requirements for each individual mission
challenges to an experienced trauma team in the unconstrained while deployed. The Operational Command must be advised
environment. ARSC team members should be selected to pos- by the OIC and/or senior surgeon of the decreased capability
sess a mission-first mindset, perform well under duress, work (as compared with a conventional Role 2) that ARSCs can
effectively as part of a team, and demonstrate resilience to pe- deliver and accept the increased risk to their forces. The Com-
riods of sustained levels of stress. Individual members should mand must be aware of the number of critically injured casu-
be proficient in Tactical Combat Casualty Care (TCCC) and alties that can be managed before personnel are overwhelmed
their respective specialties of resuscitative, surgical, and post- or resources exhausted. Dedicated security from anticipated
operative care of critically ill trauma patients. Ideally, ARSC threats must be provided when the ARSC team is decisively
teams will achieve expertise by working routinely as a team engaged in patient care. Successful integration of resuscitative
in high-volume, high-quality trauma centers to develop trust, trauma care within the operational environment begins before
fluid team dynamics, and cross-train on key roles and tasks to the first patient contact.
maximize use of limited available hands.
Operational Influences on Clinical Decision-Making
It has been well recognized that certain teams supporting these
missions may not maintain the appropriate clinical volume for Expert clinical decision-making in the austere environment
skill sustainment. This fact emphasizes two elements of the is the most important asset the ARSC provides. It is multi-
current trauma system in the Department of Defense (DoD): factorial and may differ from traditional Role 2 and Role 3
(1) maintaining surgical trauma skills while not deployed and settings on the bases of the operational context and the time
(2) keeping deployments short for individuals with life-saving and distance to the next role of care. Availability of resources,
critical skills that have been demonstrated to be perishable. It personnel, blood products, sterility, anticipation of additional
is important that deployed clinical and operational leadership casualties, evacuation capability, 15,16 security, mobility, and pa-
recognize the value of personnel flexibility (e.g., intratheater tient-holding capacity must all be considered. In addition, the
rotations) to ensure providers get clinical exposure during dynamic nature of the tactical environment may result in fre-
deployments. quent changes; constant situational awareness is required. As-
sumptions on duration of transport and time to intervention
ARSC teams should be prepared to function outside of the at the next level of care may increase the risk for the patient,
boundaries of forward operating bases; therefore, success re- the team, and the mission. Therefore, in most cases, damage
lies on proper integration with the operational mission. The control surgery should be done before transport of a casualty.
ability to balance resuscitative trauma care within the tacti- A patient should never be transported from this environment
cal mission requirements and constraints is the greatest chal- with any question of instability if there is any uncertainty of
lenge. ARSC teams should undergo training to function in the transport timeline.
tactical environments, including training in survival, evasion,
resistance, and escape, and be proficient in tactical commu- Surgeons are responsible to communicate real-time clinical
nications and weapons management. Specific guidance from risk assessments regarding tactical conditions, operational
the supported ground force should guide the training require- constraints, and potential impact on patient outcomes. How-
ments. Personnel must have the ability to defend themselves ever, surgeons must recognize that the operational commander
and their patients. Teams require expeditionary maneuverabil- retains legal decision-making authority to assume risk and
ity with a compact resuscitative surgical package that is rap- to decide when operational objectives and tactical mission
idly deployable and collapsible. Pre-mission tactical training requirements supersede the recommended clinical course of
for the team should be supported by hospital and ground force action. Priorities may be weighed against the current threat
leaders and include technical skills and knowledge, team train- situation, necessity for tactical maneuver, opportunities to
ing, and professional development. accomplish mission objectives, and so forth. ARSC team in-
tegration in operational planning phases not only determines
Using ad hoc teams without specialized equipment or more the medical plan but clarifies the overall tactical intent and
intensive, sustained predeployment and team-centric training the Operational Commander’s desired end state. This allows

26 | JSOM Volume 20, Edition 2 / Summer 2020