Austere Resuscitative And Surgical Care Teams

Supporting Far-Forward Trauma Care On The Future Battlefield

By 2nd Lt. Mason H. Remondelli, 2nd Lt. Joseph Rhee, 2nd Lt. Isaiah Gray, 2nd Lt. Ryan M. Leone, Col. Jay B. Baker,and retired Lt. Col. Dan S. Mosely

Article published on: March 16th, 2025 in the Special Warfare 2025 E-edition

Read Time:< 20 mins

Special Operations Surgical Team (SOST) members assigned to the 24th Special Operations Wing perform a field cricothyrotomy on a simulated patient at Northeast Alabama Regional Airport, Alabama, Mar. 17, 2022. The SOST team is an extremely lightweight, mobile, and rapidly deployable element that is medically and tactically trained to provide trauma resuscitation and life-saving surgical care on or near the battlefield. (U.S. Air Force photo by SrA Christopher H. Stolze)

INTRODUCTION

Over two decades of conflict in the Middle East, deployed military medical capabilities have made significant advancements in tactical combat casualty care, damage control resuscitation, and damage control surgery. Among these improvements include the austere resuscitative and surgical care (ARSC, pronounced ärsk) teams, whose history extends back to Operation Eagle Claw in 1980 when special operations forces (SOF) identified a need for far-forward surgical teams. The concept of ARSC teams expanded to conventional forces in the 1990s, later proving crucial during Operation Enduring Freedom and Operation Iraqi Freedom.

The ARSC can be defined as an “advanced medical capability delivered by small teams with limited resources, often beyond traditional timelines of care, and bridges gaps in roles of care to enable forward military operations and mitigate risk to the force.”⁰¹ The recent deployment of these highly skilled teams closer to the front lines has made combat surgical capabilities readily accessible in the most restricted operational environments.

Military operational and medical planners now focus on understanding the future battlefield landscape.⁰² Potential conflicts with near-peer adversaries could result in large-scale combat operations (LSCO), as demonstrated in the ongoing Russo-Ukrainian War, which carries significant challenges for casualty care and austere surgical assets as they involve daily mass casualty events, a lack of timely aeromedical evacuation, and the need for prolonged field care.^03,04 These issues highlight the austere environment where access to clean water, electricity, and a fixed or mobile medical facility is significantly degraded or denied, and where diagnostic and treatment resources and medical personnel are unavailable or limited for extended periods.⁰⁵

There are important lessons being learned from the ongoing military medical experiences in Ukraine. The ARSC teams face challenges both currently and in the context of potential future battlefields. The training, skill maintenance, and employment of ARSC teams remain critical, as they ensure the highest standards of far-forward trauma care, especially in the demanding environment of LSCO.

TRAINING AND INTEROPERABILITY

Manning, training, and facilitating the relevant developmental experience for ARSC teams is presently inadequate for managing the medical needs that future LSCO environments will impose on SOF and conventional forces. Adept ARSC teams, much like SOF units, cannot be created after conflicts occur.⁰⁶ Just as effective military operations necessitate upfront commitments of time and resources, the same principle applies to ARSC teams. They require meticulous preplanning, manpower allocation, equipment provisioning, and comprehensive training, well before any potential need of an ARSC team. With proper training, ARSC teams can achieve a high level of tactical and clinical proficiency and stand ready to swiftly mobilize at the commander’s discretion.

Currently, several “just-in-time” pre-deployment combat trauma training courses compensate for the limited practice

A Special Operations Surgical Team member assigned to the 24th Special Operations Wing applies a chest seal on a simulated patient to cover a gunshot wound at Northeast Alabama Regional Airport, Alabama, Mar. 17, 2022. The SOST team is an extremely lightweight, mobile, and rapidly deployable element that is medically and tactically trained to provide trauma resuscitation and life-saving surgical care on or near the battlefield. (U.S. Air Force photo by SrA Christopher H. Stolze)

A U.S. Army medical team assigned to 8th Forward Resuscitative and Surgical Detachment, 18th Medical Command, and a Port Moresby General Hospital surgical team conduct a surgical ligation of patent ductus to correct a breathing abnormality due to a birth defect on a 2-year-old girl during the inaugural Papua New Guinea Trauma Rotation in Port Moresby General Hospital at Port Moresby, Papua New Guinea, Dec. 10, 2023. The Trauma Rotation follows the recent signing of the Defense Cooperation Agreement between the U.S. and Papua New Guinea; it is a first-of-its-kind engagement between the U.S. Army and Papua New Guinea, which mutually offers parties a chance to exchange medical expertise and techniques in an austere environment. (U.S. Army photo by Sgt. 1st Class Timothy Hughes/Released)

opportunities available in military treatment facilities. These training programs include the intensive week-long Tactical Combat Medical Course, a concise three-day Emergency War Surgery course, and immersive two-week rotations for forward surgical teams preparing for deployment at the Army Trauma Training Center, situated at Ryder Trauma Center in Miami, Florida.⁰⁷ The primary objective of these courses is to prepare forward resuscitative surgical detachments for a relatively stable environment, such as a Role 2 facility focused on a small quantity of surgical patients or a Role 3 theater hospital. However, there are currently no courses offered as part of a readiness requirement that prepare small surgical teams to operate in the austere environment.

Additionally, most deployable small surgical teams are manned by general surgeons, who do not take care of surgical trauma cases in their daily practice. The dearth of experience in trauma management for general surgeons in the Army is evident in the data. Currently, there are just 150 deployable active-duty Army general surgeons with 50 having received specialized training in trauma, surgical critical care, or burn care.⁰⁸

A shortage of qualified, trauma-trained surgeons is also evident in the Russo-Ukrainian conflict. A Global Surgery report from 2014 concluded that Ukraine had approximately 87 surgeons per 100,000 citizens, though this number could not be subdivided by specialty.⁰⁹ The Global Surgical and Medical Support Group utilizing the American College of Surgeons Military Clinical Readiness Curriculum “M-Course” has been teaching Ukrainian Surgeons damage control resuscitation, surgery, and emergency wartime operations.⁰⁴ While supplemental training from the Global Surgical and Medical Support Group enabled the rapid acquisition and transfer of relevant surgical trauma skills, Global Surgical and Medical Support Group must adapt from focusing exclusively on just-in-time surgical care training to incorporating new concepts from recent war surgery experiences that will support the United States in future conflicts.

The United States should learn from the challenges in Ukraine. Providing longitudinal sustainment training, emphasizing exercises that ensure interoperability with line units, and drilling home tactical skills that can elevate ARSC maneuverability on LSCO battlefields would go far in adapting ARSC for the future operating environment. Including high-fidelity simulated practice under various lighting conditions and involving intermittent transportation between or even during operations would be small contributions that could further evolve ARSC operational prowess and tactical capacities.

SKILL MAINTENANCE AND READINESS

Across the Military Health System there is a well-documented challenge that is hampering the ARSC capability, as well: Military surgeons often struggle to attain the required case volume and complexity necessary to maintain trauma readiness.¹⁰ This challenge may exacerbate the “Peacetime Effect” or the “Walker Dip,” a phenomenon observed in military medicine in which combat casualty care improves during periods of armed conflict, only to see these advancements diminish once the conflict subsides.^{11, 12} If lessons learned in war are not reinforced during peacetime or non-deployed periods, they risk fading from practice and may need to be relearned over time. Projections of casualty rates in possible future LSCO indicate that the price of overcoming a “Walker Dip” during the next conflict could be extremely severe.

One effort to quantify the value of surgeon workloads comes from the Clinical Readiness Program, which explains the knowledge, skills, and abilities of combat casualty care. For instance, from 2015 to 2019, the number of general surgery procedures generating knowledge, skills, and abilities points at military treatment facilities decreased by 19.1%.10 This trend is concerning since it is well-established that high-quality outcomes are often a direct result of surgeons’ exposure to high-volume caseloads across various surgical specialties, including trauma care.^7,14,15 Similarly, civilian academic trauma centers have identified a robust correlation between case volume and patient outcomes, observing a noteworthy reduction in both mortality rates and hospital length of stay when the annual case volume exceeds 650 cases.¹⁶

Two primary strategies to increase provider knowledge, skills, and abilities currency are to either increase the volume and complexity of surgical care at military treatment facilities or to send surgeons outside of military treatment facilities to civilian centers with pre-existing volume and acuity through military-civilian partnership medical programs.¹⁷ For the former, the recent military health system stabilization memo published in December 2023 directed the DoD to improve staffing and recapture care within the military health system that has previously gone to the private sector.¹⁸ However, military health system-based training for small surgical teams is just one necessary component of the comprehensive training required to maintain and advance surgical capabilities. There are other skills that must be cultivated and refined to succeed in the contemporary military operating environment. The diverse set of situations an ARSC team may find itself confronting requires a firm understanding of the principles of medical team interoperability, advanced surgical planning, and operational flexibility. Military-civilian partnership can help hone these principles for ARSC personnel training for a variety of missions. Combining military-civilian partnership with lessons learned recapture strategies and adding on dedicated austere surgical team training could support the appropriate skill balance.

Maintaining robust surgical proficiency in military medicine will be more critical than it has been in recent memory if the U.S. continues facing the likelihood of full-scale war with another major power like the People’s Republic of China, Russia, or Iran. Enhanced outcomes and increased survivability during Operation Enduring Freedom, Operation Iraqi Freedom, and Operation Inherent Resolve set a new standard for delivering quality trauma care that is likely unattainable in LSCO. Recent LSCO simulations projected staggering casualty numbers, such as 50,000 casualties in battles involving 100,000 soldiers with daily estimates as high as or even greater than 3,000.⁰² The Russo-Ukrainian War, for example, has so far witnessed over 300,000 casualties, averaging around 500 per day.⁰³ A lack of surgeon readiness due to low case volumes will exacerbate such high casualty rates.

Moreover, past conflicts have benefited from the swift evacuation capabilities observed in the Global War On Terror, which may be uncommon in future conflicts. Given the new challenges of providing prolonged care in austere conditions, ARSC teams may find themselves operating near the front lines, often with limited resources and confronting complex battle injury patterns.¹⁹ To meet the expectations of delivering complex polytraumatic care to service members under these demanding conditions, ARSC teams must receive additional skill sustainment through military-civilian partnerships and austere trauma training through dedicated courses.

EMPLOYMENT FLEXIBILITY, ADAPTABILITY, AND MOBILITY

With proper training and experience, ARSC teams are highly proficient in both tactical operations and far-forward pre-hospital trauma support, making them irreplaceable assets in battlefield operations. During LSCO, ARSC teams can become high priority targets of anti-access/area denial systems, long-range artillery, and unmanned combat aerial vehicles.⁰³ For instance, Russian forces have previously targeted Ukrainian hospitals and medical facilities located approximately 400 kilometers from the Russian border.⁰⁴

U.S. Army Soldiers assigned to the Austere Resuscitative Surgical Team perform a simulated surgery during the U.S. Army Special Operations Command Capability Exercise 2024 at Fort Bragg, North Carolina, April 5-12, 2024. The CAPEX is a week-long demonstration and immersive experience of the Army Special Operations Forces’ capabilities and equipment. This exercise demonstrates how ARSOF transforms in contact and practices innovation as a mindset. ARSOF’s small formation allows for quick development and dissemination of new equipment, tactics, techniques, and procedures to support transformation in contact. During CAPEX, guests had the opportunity to experience how ARSOF Soldiers from each of our units conduct operations, as well as an opportunity to immerse in the technology that enables ARSOF Soldiers.

Maintaining continuous analytical and resource investments to find the right balance between operational risk and the medical capabilities of ARSC teams is of utmost importance. These teams must exhibit exceptional flexibility, mobility, and adaptability by seamlessly integrating into both conventional forces and SOF while ensuring the highest level of casualty care.²⁰ A prime example can be seen in Ukrainian ARSC equivalents, who often receive and treat casualties within a mere 500 meters of the ever-shifting front lines.⁰⁴ That fluidity of the frontline trace underscores the critical need for the ARSC capability’s agility in rapidly changing combat situations. Likewise, in situations where ARSC elements need to provide extended care to a patient, they must possess the capacity to swiftly relocate to secure, hardened areas or structures to minimize potential risks.²¹

CONCLUSION

The significance of ARSC teams in modern warfare cannot be overstated as they represent an irreplaceable medical advantage on the battlefield. Balancing tactical and clinical competence is essential for ARSC teams to seamlessly integrate into conventional and SOF orders of battle to provide far-forward trauma care. As is seen in Ukraine, the need for rapid access to high-quality trauma care is evident, underscoring the importance of continuous investment in manpower, training, and readiness well before conflicts arise. Like SOF, ARSC teams require robust resource investments, standardized skills sustainment strategies, and cooperative multinational education to address future battlefield demands.

U.S. Army Soldiers assigned to the Austere Resuscitative Surgical Team perform a simulated surgery during the U.S. Army Special Operations Command Capability Exercise 2024 at Fort Bragg, North Carolina, April 5-12, 2024. The CAPEX is a week-long demonstration and immersive experience of the Army Special Operations Forces’ capabilities and equipment. This exercise demonstrates how ARSOF transforms in contact and practices innovation as a mindset. ARSOF’s small formation allows for quick development and dissemination of new equipment, tactics, techniques, and procedures to support transformation in contact. During CAPEX, guests had the opportunity to experience how ARSOF Soldiers from each of our units conduct operations, as well as an opportunity to immerse in the technology that enables ARSOF Soldiers.