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mission that inspired development of this kit involved a KLE casualty response, treatment of an entrapped, injured patient,
that required surgical support by a four-person team with only and humanitarian response after natural disasters.
essential, self-carried equipment. The authors have since car-
ried and used this kit during convoy operations, and while
the surgical team site was dismantled or established. These are Conclusion
times when most of the team’s surgical equipment is packed We describe an equipment list for an ultramobile, surgeon-
and not easily accessible. carried equipment set that can be utilized for austere missions.
It is specifically designed for missions that require the extremes
This bag was inspired by the experience of one of the authors of constraints on personnel and resources conducted outside
(JBL) as a surgeon on the US Army Burn Flight team. The Burn the ring of golden hour access to DCS capabilities. The for-
Flight team carries a personal bag for in-flight critical care ward deployed surgeon should consider their team capabili-
17
emergencies during global casualty evacuation. The equip- ties, resources, and mission while augmenting this equipment
ment was chosen based on the injuries seen during the prior list as appropriate.
two decades of Combat Casualty Care, applying the princi-
ples of DCS to stop hemorrhage and control contamination. References
It is imperative to consider what interventions are essential to 1. Nessen SC, Cronk DR, Edens J, et al. US Army two-surgeon teams
save life or limb and which can wait until reaching a more re- operating in remote Afghanistan: an evaluation of split-based for-
sourced surgical environment. The surgeon must balance their ward surgical team operations. J Trauma. 2009;66:S37–S47.
available resources and situational awareness as it pertains to 2. Nessen SC, Cronk DR, Edens J, et al. US Army split forward
surgical team management of mass casualty events in Afghani-
the mission with the injuries that demand immediate attention. stan: surgeon performed triage results in excellent outcomes. Am
Some challenges that we discussed included end-of-life care J Disaster Med. 2009;4:321–329.
and futility in the face of a catastrophically injured casualty or 3. Remick KN. The surgical resuscitation team: surgical trauma sup-
during a multiple casualty incident. We also discussed unique port for US Army Special Operations Forces. J Spec Oper Med.
scenarios including management of combatants, pediatric pa- 2009;9:20–25.
tients, elderly patients, and military working dogs. We did not 4. Hale DF, Sexton JC, Benavides LC, et al. Surgical instrument sets
for Special Operations expeditionary surgical teams. J Spec Oper
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occupying intracranial lesion in extremis that needs urgent 5. McKenzie MR, Parrish EW, Miles EA, et al. A case of prehospital
decompression in this setting can be temporized by maneuvers traumatic arrest in a US Special Operations Soldier: from point of
to decrease intracranial pressure and immediate evacuation to injury to full recovery. J Spec Oper Med. 2016;16:93–96.
a neurosurgeon. 18 6. Holcomb JB, McMullin NR, Pearse L, et al. Causes of death in
US Special Operations Forces in the global war on terrorism. Ann
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This kit is intended for DCS and not prolonged field care. It 7. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
should also be noted that this ultralight surgical set does not (2001–2011): implications for the future of Combat Casualty
encompass all equipment needed in the austere environment. Care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431–S437.
These missions always included an anesthesia provider, per- 8. Mwipatayi BP, Jeffrey P, Beningfield SJ, et al. Management of
sonnel, and preparation to conduct a walking blood bank for extra-cranial vertebral artery injuries. Eur J Vasc Endovasc Surg.
fresh whole blood collection and transfusion. The anesthesia 2004;27:157–162.
provider carried equipment specific for advanced airway, me- 9. Edens J, Beekley AC, Chung KK, et al. Longterm outcomes after
combat casualty emergency department thoracotomy. J Am Coll
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esthesia. The authors have also discussed the possible benefits 10. Morrison JJ, Poon H, Rasmussen TE, et al. Resuscitative tho-
of augmenting this equipment for future missions, including racotomy following wartime injury. J Trauma Acute Care Surg.
items for endovascular balloon occlusion of the aorta during 2013;74:825–829.
trauma resuscitation, such as REBOA (Prytime Medical, 11. Mitchell TA, Waldrep KE, Sams VG, et al. An 8-year review of
https://prytimemedical.com/clinical/reboa/). Operation Enduring Freedom and Operation Iraqi Freedom re-
suscitative thoracotomies. Mil Med. 2015;180(3 Suppl):33–36.
12. Monchal T, Martin MJ, Antevil JL, et al. Emergency resuscita-
This report is a guide based on the authors’ experiences during tive thoracotomy in the combat or operational environment. Mil
multiple deployments. It is not an absolute direction for future Med. 2018;183:92–97.
missions. This report is not a recommendation for such small 13. Fisher AD, Miles EA, Broussard MA, et al. Low titer group O
surgical elements. There are limits to the quality of care that whole blood resuscitation: military experience from the point of
injury. J Trauma Acute Care Surg. 2020;89:834–841.
can be provided when extreme limits are placed on personnel 14. Fisher AD, Miles EA, Cap AP, et al. Tactical damage control re-
and equipment. These limits and the impact of efficacy of the suscitation. Mil Med. 2015;180:869–875.
surgical assets must be considered by surgeons and ground 15. Meledeo MA, Fisher AD, Peltier GC, et al. Volumetric control of
force commanders when planning. Surgeons on future simi- whole blood collection in austere environments. J Trauma Acute
lar missions should take our conclusions and apply their own Care Surg. 2017;82:S26–S32.
ingenuity and adapt what is needed based on their personnel, 16. Joint Trauma System Clinical Practice Guideline. Damage con-
resources, capabilities, DCS/DCR needs, and the demands of trol resuscitation. 12 July 2019. https://jts.amedd.army.mil/assets
the mission. The authors have provided operational planning /docs/cpgs/Damage_Control_Resuscitation_12_Jul_2019_ID18
.pdf. Accessed 5 August 2021.
and support for full size North Atlantic Treaty Organization 17. Barillo DJ, Renz E, Broger K, et al. An emergency medical bag set
(NATO) Role 2E teams, as well as non-doctrinal modular for long-range aeromedical transportation. Am J Disaster Med.
teams that have ranged in size from eight to as few as four per- 2008;3:79–86.
sonnel. The addition of this kit was vital for preparation and 18. Joint Trauma System Clinical Practice Guideline. Neurosurgery
deployment of ultralight, ultramobile teams. This ultramo- and severe head injury. 2 March 2017. https://jts.amedd.army
bile surgical set concept is applicable to the combat environ- .mil/assets/docs/cpgs/Neurosurgery_and_Severe_Head_Injury
_02_Mar_2017_ID30.pdf. Accessed 5 August 2021.
ment and can be considered for natural disasters, initial mass
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