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the pre-Role 2 setting for a variety of emergent indications, 2. Sauer SW, Robinson JB, Smith MP, et al. Saving Lives on the Bat-
including cranial decompression, emergent orthopaedic inter- tlefield (Part II) ? One year later A Joint Theater Trauma System
ventions, control of NCTH, and shunting or repair of arterial and Joint Trauma System review of prehospital trauma care in
injuries to restore distal perfusion. combined joint operations area?Afghanistan (CJOA-A) final re-
port, 30 May 2014. J Spec Oper Med. 2015;15(2):25–41.
3. Lairet JR, Bebarta VS, Burns CJ, et al. Pre-hospital interventions
Our reported experience demonstrates that an SRT can effec- performed in a combat zone: a prospective multicenter study of
tively employ a unique capability in a variety of roles – from 1,003 combat wounded. J Trauma Acute Care Surg. 2012;73(2
augmentation of a Role 2 facility during mass casualty events, suppl 1):S38–S42.
to independent action, or even in facilitating critical care trans- 4. Freel D, Warr BJ. Surgical and resuscitation capabilities for the
port of severely injured casualties. The small size and flexible “next war” based on lessons learned from “this war.” US Army
Med Dep J. 2016;(2–16):188–191.
capabilities of the SRT may provide a useful life-saving capa- 5. Kotwal RS, Mazuchowski EL, Stern CA, et al. A descriptive
bility in response to a wide variety of contingency operations study of US Special Operations Command fatalities, 2001–2018.
that require speed and mobility of medical support. In this J Trauma Acute Care Surg. 2019;87(3):645–657.
context, the SRT is capable of rapidly and effectively support- 6. Nessen SC, Eastridge BJ, Cronk D, et al. Fresh whole blood use
ing both resuscitation and DCS within one hour of POI in the by forward surgical teams in Afghanistan is associated with im-
austere military environments, with the goal of delivering opti- proved survival compared to component therapy without plate-
lets. Transfusion. 2013;53(suppl 1):107S–113S.
mal casualty care in closest feasible proximity to POI. 7. Cap AP, Pidcoke HF, DePasquale M, et al. Blood far forward:
time to get moving! J Trauma Acute Care Surg. 2015;78(6 suppl
Our present report does have important limitations that must 1):S2–S6.
be acknowledged, including those inherent to retrospective re- 8. Hooper TJ, Nadler R, Badloe J, et al. Implementation and exe-
view. The AARs from which these data were abstracted do cution of military forward resuscitation programs. Shock. 2014;
not constitute a formal casualty care database. Although these 41(suppl 1):90–97.
documents accurately recorded team roles and interventions, 9. Russo RM, Williams TK, Grayson JK, et al. Extending the golden
the granularity of data available was not consistent with an hour: partial resuscitative endovascular balloon occlusion of the
aorta in a highly lethal swine injury model. J Trauma Acute Care
a priori database designed explicitly for the purpose of com- Surg. 2016;80(3):372–380.
prehensive data collection. Some variables, including specific 10. Welch A. “Golden hour” policy saved hundreds of U.S. troops.
vital signs at delivery to the next echelon of care, were not CBS News. http://www.cbsnews.com/news/golden-hour-policy
consistently available for review. It is also important to note -decreased-combat-deaths-among-u-s-troops/. Accessed Septem-
the context of conflict in which these results were obtained. In ber 10, 2020.
future “near peer” conflict, aeriel denial of active battlespaces 11. Kotwal RS, Howard JT, Orman JA, et al. The effect of a Golden
Hour Policy on the morbidity and mortality of combat casualties.
may represent a different challenge to the utilization of in- JAMA Surg. 2016;151(1):15–24.
flight interventions. As such, caution should be taken when 12. Remmick, KN, Schwab CW, Smith BP, et al. Defining the opti-
attempting to extrapolate the results outlined in our report mal time to operating room may salvage early trauma deaths.
with other care settings or capability configurations. J Trauma Acute Care Surg. 2014;76(5):1251–1258.
13. Childers R, Parker P. The cost of deploying a Role 2 medical asset
to Afghanistan. Mil Med. 2015;180(11):1132–1134.
Conclusion 14. Malgras B, Barbier O, Petit L, et al. Surgical challenges in a new
theater of modern warfare: the French Role 2 in Gao, Mali. In-
An SRT provides a unique resuscitative and damage control jury. 2016;47(1):99–103.
surgery capability that can be effectively employed in a variety 15. Malgras B, Barbier O, Pasquier P, et al. Initial deployment of the
of roles, including in-flight DCS delivery, with good outcomes. 14th Parachutist Forward Surgical Team at the beginning of the
Additional research is required to determine optimal SRT uti- operation Sangaris in Central African Republic. Mil Med. 2015;
lization in present and future conflicts. 180(5):533–538.
16. Apodoca AN, Morrison JJ, Spott MA, et al. Improvements in the
hemodynamic stability of combat casualties during en route care.
Disclaimer Shock. 2013;40(1):5–10.
The viewpoints expressed in this manuscript are those of the 17. Lehmann R, Oh J, Killius S, et al. Interhospital transport by
authors and do not represent official positions of the United rotary wing aircraft in a combat environment: risks, adverse events
States Air Force, the United States Army, or the Department and process improvement. J Trauma. 2009;66(4 suppl):S31–S36.
of Defense. All data contained herein has been reviewed and 18. Garner A, Rashford S, Lee A, et al. Addition of physicians to
paramedic helicopter services decreases blunt trauma mortality.
approved by appropriate Joint Special Operations Com- Aust N Z Surg. 1999;69(10):697–701.
mand Operational Security and Public Affairs processes for 19. Darocha T, Kosinski S, Serednicki W, et al. Prehospital emergency
publication. thoracotomy performed by helicopter emergency medical team:
a case report. Ulus Travma Acil Cerrahi Derg. 2019;25(3):303–
306.
Disclosure 20. Pieper MA, Vonderharr MJ, Knutson TL, et al. Versatility with
The authors have no financial or other conflicts of interest to far forward damage control surgery: successful resuscitative tho-
disclose. racotomy in an HH-60 Black Hawk. J Spec Oper Med. 2019;19
(1):20–22.
Author Contributions 21. Ter Avest E, Griggs J, Prentice C, et al. Out-of-hospital cardiac ar-
All authors contributed to the design, writing, editing, and ap- rest following trauma: what does a helicopter emergency service
proval of the manuscript. offer? Resuscitation. 2019;135:73–79.
22. Van Vledder MG, Van Waes OJF, Kooij FO, et al. Out of hospital
thoracotomy for cardiac arrest after penetrating thoracic trauma.
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