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Our involvement of CPT Hoemann helped attenuate the be- Conclusion
havioral health impacts of living in such a violent area. Re-
search indicates that early discussions related to traumatic The adoption and implementation of widespread TCCC train-
events can lead to better outcomes in terms of decreasing the ing, the empowerment of medics with more knowledge and
incidence of PTSD, major depressive disorder, or moral in- responsibility, the integration of a medical component within
jury, especially when coupled with healthy, adaptive spiritual every FOB battle drill, the “Mobile Role 1,” and the positive
coping mechanisms. Regardless of one’s spiritual beliefs, the working relationships with the Role 2 all played a part in lay-
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chaplain’s presence as the first-line behavioral health provider ing the groundwork to help treat numerous casualties and
allowed him to provide immediate pastoral and spiritual care save the life of a critically wounded US Servicemember during
to Servicemembers after any traumatic events on the FOB. a MASCAL. As the nature of the conflicts in Afghanistan and
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Our team found that the presence of the chaplain helped cul- Iraq change in intensity there is a concern that TCCC’s impor-
tivate trust among the casualties and care team, creating emo- tance may dampen; however, as the potential for a future near
tional safety for further one-on-one counseling. Thus, greater peer conflict rises, the continued need for widespread imple-
integration and collaboration among all unit caregivers, both mentation of TCCC training before and during combat deploy-
medical and spiritual, is a vital and holistic response to trau- ments cannot be overstated. The success seen by 3-501 Assault
matic events that will lead to better outcomes in the immediate Helicopter Battalion, Task Force Apocalypse should serve as
event and long term. a model for other conventional combat units throughout the
Army and Department of Defense who are involved in Role 1
treatment.
Experience
It can prove quite challenging to prepare for all for the horror
and chaos that a MASCAL event brings upon a healthcare Lessons Learned
team, but the experience that SSG Keasal had from his pre- • Ensure completion of TCCC training for all service-
vious deployments to Iraq allowed for lessons learned to be members ideally in garrison and certainly early in the de-
seamlessly integrated into our own plan. As knowledge plus ployment. Use the resources available through the DHA
experience equal wisdom, medics who have prior experiences Deployed Medicine Starter Kit to help with instruction.
tend to have real-world applications and references for con- • Teach and grow your medics so they feel more empowered
text. We used his experience to develop the Mobile Role 1, to take on greater roles within your trauma plan.
essentially outfitting our field and litter ambulance to be able • Perform regular rehearsals and integrate both your spiri-
to perform Role 1 trauma care en route to the Role 2. The con- tual and administrative personal into the trauma plan to
cept of the Mobile Role 1 or ground MEDEVAC ambulance, enhance your team dynamics and effectiveness.
provided a physician and medical capability at or near the • Build symbiotic relationships early with everyone on the
most critically wounded and allowed for continued medical FOB to get a seat at the table with commanders to better
care during transport. The Mobile Role 1 would be activated integrate a medical plan into all battle drills.
during any attack on the FOB and would accompany the ser- • Use the prior combat experience in your formation to inno-
geant of the guard and quick reaction force to the site of IDF vate solutions to get medical care as far forward as possible
impact or enemy breach. The idea of getting care so close to and develop your trauma plan.
the impact was to optimize time to treatment which has been • Introduce yourself to the next higher level of care to set up
shown to improve casualty survival. 6
the communication forum and develop a plan on how to
efficiently move patients through the roles of care.
For CPT Shukla, the “Bushmaster” field training exercise he
had as a medical student at the Uniformed Services University Author Contributions
of the Health Sciences allowed him to mentally organize how AS wrote the initial draft and performed the background re-
to manage a MASCAL event and the importance of commu- search and edits. BH helped review the draft and contributed
nication. Experiences such as Bushmaster are often the first his perspective to the article. CP helped review and contribute
exposure most new military medical providers, especially mil- his perspective to the article. MK also reviewed the article and
itary medical students, have to the operational constraints of helped in the editing process, and all authors read and ap-
providing medicine in austere locations. proved the final manuscript.
Relationship With the Role 2 Financial Disclosure
By complete chance, the surgeons at the Role 2 and CPT The authors have indicated they have no financial relation-
Shukla knew each other from their residency training days. ships relevant to this article to disclose.
This relationship, along with their experience working to-
gether on previous traumas involving Afghan soldiers earlier Acknowledgments
in the deployment, helped refine procedures, develop a com- We would like to thank the following individuals for reviewing
munication forum and methodology that prevented the Role the manuscript and providing feedback: Dr Russ Kotwal, Dr
2 from ever becoming overwhelmed. The regular communica- Chetan Kharod, and Harold Montgomery.
tion and pre-existing positive relationship between the medical
professionals at the Role 1 and Role 2 streamlined care during References
emergencies and especially during the MASCAL. While there 1. Eastridge BJ, Mabry R, Seguin P, et al. Death on the battlefield
are few studies looking at medical teams in combat and their (2001–2011): implications for the future of combat casualty care. J
performance based upon the presence or absence of previous Trauma Acute Care Surg. 2012;73:S431–S437.
working relationships, anecdotally knowing the physicians 2. Joint Trauma System. Available at: https://jts.amedd.army.mil/
and surgeons at the Role 2 helped integrate the trauma plan 3. Deployed Medicine. Available at: https://deployedmedicine.com/
4. Tarpey MJ. Tactical Combat Casualty Care in Operation Iraqi
between the roles of care. Freedom. US Army Med Dep J. 2005;Apr–Jun:38–41.
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