Employment of the Role 2-Plus : Lessons Learned in a Time of High OPTEMPO

MILITARY MEDICINE, 179, 12:1412, 2014 Employment of the Role 2-Plus : Lessons Learned in a Time of High OPTEMPO MAJ David C. Lynn, MC USA*; CPT Rebecca K. Lesemann, MS USA ; LTC John F. Detro, SP USA ; LTC Jason M. Seery, MC USA OVERVIEW From 2009 to 2014, the medical units at Fort Bragg, North Carolina, gained extensive experience in the nondoctrinal employment of the Forward Surgical Team (FST) combined with an Area Support Medical Company (ASMC) or Brigade Support Medical Company (BSMC). The setup and execution of the so-called Role 2-plus offers multiple operational and clinical advantages over solitary employment, but also presents some significant logistical challenges without proper planning. At the time of authorship, current literature describes this entity, 1 but information or guidance as to the actual employment of the Role 2-plus (including web-based outlets such as Center for Army Lessons Learned) is almost nonexistent. 1 6 Former commanders of these units would like to share and document some of the lessons learned during a time of exceptionally high operational tempo (OPTEMPO). BACKGROUND The current Department of Defense (DoD) Emergency War Surgery textbook (4th Revision) describes the roles of military medical care (formerly called echelons or levels), and they are listed in Table I. 7 The U.S Army Role 2 includes a Medical Company, with or without an FST, and is simply described as having a greater resuscitative capability than the Role 1. The NATO definition of Role 2, however, includes the ability to perform damage control surgery. During the last decade of armed conflict, FSTs have often been located with a Role 1 Battalion Aid Station, by themselves, and/or split into 2 roughly equal halves, sometimes referred to as an FST-minus, or FST ( ). In all these instances, the Forward Surgical Element is still referred to as a Role 2. *Department of Surgery, Womack Army Medical Center, 2817 Reilly Road, Fort Bragg, NC 28310. Bush School of Government & Public Service, Texas A&M University, 4220 TAMU, College Station, TX 77843-4220. Office of the Corps Surgeon, Headquarters, XVIII Airborne Corps, Department of the Army, 2175 Reilly Road, Stop A, Fort Bragg, NC 28310. U.S. Army Trauma Training Center, Jackson-Memorial Hospital/Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136. This article was presented as an abstract and poster at Womack Army Medical Center s Research Day, May 15, 2013 and again at the AMSUS annual meeting, November 3 8, 2013. doi: 10.7205/MILMED-D-14-00099 The term Role 2-plus is therefore often used to describe the combined employment of an FST with an Area Support Medical Company (ASMC) or Brigade Support Medical Company (BSMC). The FST consists of 20 personnel to include surgeons, nurses, nurse anesthetists, medics, and operating room technicians. They are able to provide initial resuscitation, damage control surgery, and critical care for approximately 30 patients over a 72-hour period before needing reconstitution of both supplies and personnel. They are extremely limited when it comes to their ability for patient hold, life support (food, water, fuel, etc.), command and control, communications, and security. An ASMC is a much larger Role 2 unit consisting of over 70 personnel and also provides trauma treatment and services, but without any surgical component. They provide a wide range of health service support to include radiology, diagnostic laboratory, dental, behavioral health, and gynecologic services as well as ground evacuation and patient holding (40 beds) for up to 72 hours. They also have organic evacuation assets, far superior C2, and life support (including ground and generator maintenance) as well as food services. The BSMC, also known as the Charlie Med, has capabilities similar to the ASMC with the addition of physical therapy, environmental science, and medical logistics. However, they have a smaller patient hold area (20 beds), and they lack the ground maintenance and life support (provided by the Brigade Support Battalion), and as such cannot truly function as a stand-alone element. The combined capabilities of the FST employed with the ASMC or BSMC offer numerous advantages. Although the FST provides a unique skill set to perform life-saving surgery and treat life-threatening injuries, the ASMC/BSMC enables sustained operations far beyond 72 hours or 30 patients. The combined element, with the addition of radiology and lab services, also provides better preoperative, intraoperative, postoperative, and critical care, particularly in scenarios when immediate patient evacuation is unavailable or impractical because of weather or mission circumstances. The sheer manpower provided by the ASMC/BSMC, along with the FST provider support, dramatically increases the ability of the combined unit s performance during a mass casualty (MASCAL) scenario. The capabilities of the combined whole are greater than the sum of its parts. Maintaining some sense of unit autonomy, however, retains the ability for either the FST, a portion of the FST, or a jump team from the 1412

TABLE I. Roles (Echelons) of Military Medical Care 7 Role 1 Self-Aid, Buddy Aid, and Combat Lifesaver Battalion Aid Station Shock Trauma Platoon (USMC) Role 2 Army Medical Company Forward Surgical Team Air Force Mobile Field Surgical Team Small Portable Expeditionary Aeromedical Rapid Response Expeditionary Medical Support (EMEDS, Basic or +10) Navy Casualty Receiving and Treatment Ship Aircraft Carrier Battle Group USMC Surgical Company Forward Resuscitative Surgical System En Route Care Team Role 3 Army Combat Support Hospital Air Force EMEDS + 25 Air Force Theater Hospital Navy Expeditionary Medical Facility Hospital Ships Role 4 CONUS-based hospitals Landstuhl Regional Medical Center, Germany USMC, United States Marine Corps; CONUS, Continental United States. ASMC/BSMC to advance forward ahead of the main element as mission needs dictate. MISSION Over the last several years, the medical units at Fort Bragg have supported various operations in addition to continued deployments in support of Overseas Contingency Operations (Operation Enduring Freedom [OEF], Operation Iraqi Freedom [OIF], and Operation New Dawn [OND]). These include the XVIII Airborne Corps Global Response Force mission and Joint Task Force Civil Support s Defense CBRN (Chemical, Biological, Radiological, and Nuclear) Response Force (DCRF), as well as homeland support for severe weather events. The XVIII Airborne Corps Global Response Force (formerly known as the Defense Readiness Brigade) includes a brigade (usually an 82nd Airborne Division Brigade Combat Team) on 24/7 standby, ready to deploy anywhere in the world within hours of notification. 8 10 Its mission, if called, would be to forcibly enter and seize a defended airfield, then build up combat power to support follow-on military operations. Fort Bragg s airborne FSTs continuously train with and are prepared to support this mission, and are organized to conduct both airborne (parachute) and airland insertions. Employment for this mission is trained on a regular basis through the Joint Operations Access Exercise (JOAX), and FSTs are routinely colocated with their BSMC counterparts to evaluate, treat, and evacuate casualties. DCRF represents the military s part of Defense Support of Civil Authority s Crisis Management Response Process, and consists of 5,200 personnel, ready to deploy within 24 to 48 hours of notification. 11 13 These units are prepared to support local, state, and federal authorities in managing the effects of a domestic CBRN accident or incident. The medical task force portion of the Force currently includes 4 FSTs and 4 ASMCs, geographically paired for employment at or near an incident site (as well as various other medical units). This mission, currently one of Army North and U.S. Northern Command s top priorities, highlights the need for an expedited, smooth-functioning Role 2-plus medical unit. METHODS All FSTs, ASMCs, and BSMCs at Fort Bragg, North Carolina, have deployed numerous times over the last decade in support of OEF, OIF, and OND. This has included many split FSTs, as well as those colocated both Role 1 and Role 2-plus units that have evolved over time, many of which now operate within hardened structures. In surveying various commanders and providers, there is a great variability in terms of how units are located, resources are allocated, and personnel are utilized. The experiences put forth in this article focus rather on lessons learned through Field Training Exercises (FTXs), predeployment certification exercises (CERTEXs), and JOAXs that simulate how units would employ and execute during their initial entry to an incident site or area of operations. Several FSTs, ASMCs, and BSMCs from Fort Bragg, Fort Hood, Fort Campbell, and Joint Base Lewis-McChord, each conducted numerous joint exercises over an 18-month timeframe. These multiple attempts at rapid employment of the Role 2-plus over a relatively short period of time yielded significant lessons learned and improvements in setup configuration, triage, patient care, and evacuation procedures. RESULTS Initial attempts at colocation of the above units essentially consisted of the traditional setting up the FST and ASMC side-by-side (Fig. 1). Once patient role-play was initiated, after-action reviews (AARs) revealed significant room for improvement. Many patients were inappropriately triaged because of a lack of understanding of each unit s organic capabilities and training level. Patient movement between tents, particularly at night, was difficult if not dangerous; personnel carrying litters in the dark were also forced to negotiate obstacles such as tent stakes and 550 cord. As FSTs have no radiologic equipment based on Modified Table of Organization and Equipment (MTOE), patient X-rays were unavailable for the most severely injured patients without significant difficulty. The physical separation of the two units also caused considerable communication issues, and the roles of certain personnel during MASCAL scenarios (such as the executive officer or first sergeant/detachment sergeant) were not clearly defined. Finally, lack of coordination with regard to patient evacuation produced significant confusion as units attempted to communicate separately with the evacuation company, and it was unclear as to who made the final decision with regard to patient prioritization. These AARs were brought to light as teams participated in Operation Vibrant Response at Camp Atterbury, Indiana, in 1413

FIGURE 1. Initial attempt at colocation of 36th ASMC and 759th FST, with units set up side-by-side. DEN, dental; OR, operating room; ICU, intensive care unit; ATLS, advanced trauma life support. preparation to take the DCRF mission for FY12. Leaderships from the FSTs and ASMCs met to establish points of contact, discuss capabilities and expectations, and build general rapport among counterparts. Training was better planned regarding didactic and hands-on classes to help fill knowledge gaps among personnel, and a crawl-walk-run phase of patient role-play was deliberated. Perhaps most importantly, using critical and creative thinking skills, teams brainstormed an improved setup design and method of employment, and leader roles were better defined. Standardized methods of medical documentation were also established, as the team used standard Joint Theater Trauma System reporting forms (now called DoD trauma registry forms). Subsequent field exercises yielded highly superior results. Unit alert rosters were activated simultaneously, and both units mustered to a common area. All personnel were briefed together as to the scenario, mission, and intent. The FST, being smaller and more mobile, was able to arrive at the incident site first, and was fully operational with its alpha echelon setup in less than 1 hour. As ASMC personnel arrived, additional medics were available to assist with triage, point-of-injury care, and medical treatment. Within 4 hours, the ASMC was also set up and functioning (Fig. 2). At this point, the FST s bravo echelon was set up immediately adjacent to the ASMC, with the Advanced Trauma Life Support section located inside the ASMC treatment tent (Figs. 3 and 4). As time permitted during breaks in patient care, the FST alpha echelon equipment was moved to supplement the main element (Figs. 5 and 6). The benefits of this fully integrated setup (vs. the previous colocation) were immediately realized. Surgical and anesthesia providers were able to visualize all patients within the main treatment area, and provide assistance and guidance when needed. Medics were given greater flexibility to assist each other based on patient acuity and individual expertise. Communication was greatly improved among team leadership as well as between unit counterparts. Chest and pelvic radiographs were immediately available to all patients. The FST s executive officer was given a seat in the ASMC Tactical Operations Center (TOC), and functioned as a liaison between unit commands, particularly when the FST commander/surgeon was in the operating room, or otherwise engaged in patient care. The FST detachment sergeant assisted at the triage point. TheASMCassignedanadditionalseniornoncommissioned officer to prioritize patient evacuation in communication with FST and ASMC providers. All patient evacuation and 9-line MEDEVAC/patient movement requests were submitted through the ASMC TOC. General patient flow was also improved as all patients were triaged and entered at one end of the combined unit and evacuated at the other end. After each MASCAL or patient care scenario, AARs were conducted jointly as one unit. This higher level of functioning allowed the authors to add additional complexity to a MASCAL scenario, introducing a CBRN element (Fig. 7). A hasty decontamination (DECON) area was set up and utilized. DECON personnel consisted mostly of ASMC personnel as well as one soldier from each FST section. DISCUSSION As stated earlier, the FST alone can treat approximately 30 surgical patients over 72 hours before becoming mission incapable. Although difficult to quantify, the Role 2-plus 1414

FIGURE 2. Subsequent field exercise during which 759th FST personnel (in black) arrive and set up first, ready to conduct patient care within 1 hour. 550th ASMC arrives next (in gray), and is functional within 4 hours. element, properly employed, is no longer tied to this limit. Although provider fatigue is a limiting factor, the access to additional medical supplies and support personnel, while utilizing proper work-rest cycles, would certainly increase the number of operative cases that could be conducted, without any hard end time. Certain specific surgical or anesthetic supplies, as well as blood products, still may be a limiting factor. A field exercise to truly test the number of surgical patients that could be treated within a 72-hour period would make for an arduous, albeit informative future project. The advantages to the integrated employment shown in Figures 5 7 were most evident in the trauma/treatment room. Although the Soldiers make their best attempt at triage, patients in a MASCAL scenario often arrive in waves. FIGURE 3. FST sets up bravo echelon of equipment adjoining ASMC. TOC, tactical operations center. 1415

FIGURE 4. Team members from the 759th Forward Surgical Team (Airborne) set up their operating room tent adjacent to the 550th Area Support Medical Company on January 17, 2012 as part of a field training exercise at Fort Bragg, North Carolina. FST personnel and providers can easily find themselves engaged in managing 1 patient, while one or more urgent surgical or critically injured patient arrives minutes later. Over and under triage are known to be associated with poorer patient outcomes. Over-triaging a patient will lead to a nonsurgical patient being sent to the surgical facility when in fact the patient does not require immediate surgery or care by a surgeon. Under-triaging leads to delayed care of preventable causes of death. These patients with unrecognized subtle, but lethal injuries may remain in the triage area or medical treatment facility. Delay in diagnosis of these surgically correctable injuries greatly increase morbidity and mortality. When the units work together, it allows surgical and anesthesia providers the flexibility to better distribute resources, oversee procedures, and move the most severely injured to the operating room. It also allows for some simple procedures to be done in the trauma room without having to take up the space in the operating room. This alone allows more patients to be seen and disposition to be expedited, allowing for quicker evacuation. The authors recommend that DoD trauma registry forms be used for all patients, as it currently represents the only standardized form used across military settings and is in keeping with current clinical practice guidelines. If a Medical Communications for Combat Casualty Care (MC4) network is set up, the patients can also be tracked on the internet via their live records and used in both the ASMC and FST as time allows. The benefit of participation in a military-wide joint trauma registry has been well documented. 14 16 The personality factor, as it relates to mission success, cannot be overstated. The authors have all experienced difficulties related to command and control, and units desiring to control everything in their battle space. For example, there is no reason for the FST to use one of their personnel to call in their own MEDEVAC when there is an ASMC with that capability and designated personnel available. Egos can become a major distraction, hindering patient care. By integrating the FST and ASMC during various levels of training and during a real mission, the individuals and units will develop increased cohesiveness, esprit de corps, and be able to keep the patient as the center of gravity for all actions. They will no longer function as two separate units but as a single forward emergency care facility. This cohesion and increased communication will significantly improve the efficiency of the Role 2-plus, resulting in improved patient outcomes. FIGURE 5. FST moves all equipment into adjoined structure, forming the fully integrated Role 2-Plus, allowing for additional Operating Room table and patient care litters. 1416

FIGURE 6. Alternate configuration proposed by MAJ Kelly Blair, Commander 250th FST, JB Lewis-McChord, Washington, to accommodate for various METT-TC or professional preference factors. Intensive Care Unit is placed before the Operating Room, as most casualties are non-operative. When the Army Forward Surgical Element concept was first developed, the original medical command structure placed some FSTs under the control of the major maneuver divisions, whereas others fell under medical brigades. The FSTs that fell within the various divisions had a strong bond with their sister BSMC counterparts, conducting joint individual- and unit-level training. After the 2006 realignment, all FSTs fell under the medical brigades; this bond FIGURE 7. Role 2-plus with hasty decontamination site set-up. TX, treatment, XR, X-ray; L/D, laboratory and dental. 1417

of collective training and shared, integrated employment was lost. There is a distinct advantage to Role 2 elements working together over a long period. Not only does it allow for rehearsal and coordination, but may also lend itself to agreement on the equipment and supplies. A common set of equipment and supplies allows for resource sharing as well as medic and technician cross-training and flexibility. Having these supplies on order with the medical logistics company allows for push packages to be sent to the unit. CONCLUSION The concepts described above are likely not new. But lack of doctrinal documentation has led to multiple command teams reinventing the wheel, figuring out what others have done in the past, but lost in time. Unfortunately, taking care of the critically injured leaves little room for error; one does not want to repeat the mistakes of their predecessors that would hinder or distract from the mission: treating preventable causes of death and returning the warfighter to duty. These experiences and lessons learned have been shared locally among the FSTs, BSMCs, and ASMCs at Fort Bragg, North Carolina, and the benefits immediately realized. They have also been shared at the AMEDD Forward Surgical Commanders Course and the Brigade and Divisions Surgeons course, as well as the 2012 DCRF final AAR. FSTs from Joint Base Lewis-McChord, Fort Hood, and Fort Campbell also had leadership at the abovementioned courses and conferences, and methods were employed during the 2013 Vibrant Response field training exercise. All members immediately recognized the improved benefit of the integrated Role 2-plus model over the traditional colocation. Recently, these lessons learned and information gathered from AARs were applied as FST assets were utilized to augment a Special Operations Resuscitative Team (SORT) during a predeployment validation exercise. Units were combined in a similar manner, and FST surgical providers, CRNAs, and enlisted personnel worked side by side with special operations emergency medicine providers and medics. Outside observers were unable to tell the difference between the two teams in the treatment area. Surgery was performed on 7 of the 24 notionally injured patients, including one with an embedded unexploded ordinance (UXO). This model may pave the way for future surgical augmentation or addition of organic assets to support special operations units. The Role 2-plus element is a rapidly deployable, surgically robust unit that can arrive to a needed area quickly. With proper training, units can deploy within 24 hours of notification and provide patient care within hours of arrival. As OEF draws to a close, focus should return to a state of readiness and preparation for contingency operations. Consideration should be given to regional alignments of FSTs with their ASMC/BSMC counterparts in garrison. Partnering of said units under the same battalion would also aid units and allow for better collective training, personnel management, and resource sharing; all the more important during the current environment of fiscal prudence. REFERENCES 1. Stinger HR, Rush R. The Army forward surgical team: update and lessons learned, 1997 2004. Mil Med 2006; 171(4): 269 72. 2. FM4-02.25. Employment of Forward Surgical Teams: Tactics, Techniques, and Procedures. Washington, DC, U.S. Department of the Army, 2003. Available at https://archive.org/details/ost-military-doctrinefm4_02x25; accessed May 14, 2014. 3. FM4-02.6. The Medical Combat: Tactics, Techniques, and Procedures. Washington, DC, U.S. Department of the Army, 2002. 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