The Military Services recognize the importance of, and are highly invested in, Role 2 Surgical Care. This support is evidenced by the rapid development of multiple Role 2 surgical capabilities during the past 20 years. The US Army, Navy, and Air Force have each developed three-to-five constructs of small mobile surgical teams to support operations in the Central and Africa Command areas of responsibility.
These Role 2 surgical teams are designed to provide lifesaving resuscitation and surgical care in far forward austere, resourced-limited environments. This capability is commonly referred to as Austere Resuscitative Surgical Care (ARSC).
Some examples of ARSC teams over the years include: For the Army, FRSD–Forward Resuscitative Surgical Detachment, GHOST–Golden Hour Offset Surgical Team, and SRT–Surgical Resuscitation Team; for the Air Force, GST–Ground Surgical Team and SOST–Special Operations Surgical Team; and for the Navy, ERSS–Expeditionary Resuscitative Surgical System and FST–Fleet Surgical Team. The US Marine Corps has also experimented with different variations and configurations of the FRSS–Forward Resuscitative Surgical System and the smaller TS3–Tactical Scalable Surgical System.
ARSC capabilities are more agile and maneuverable than the standard (or non-split) doctrinal Role 2 surgical team. This allows the team to provide a surgical/resuscitative capability closer to the point of injury in battlefield/contingency environments. ARSC teams most commonly function as Role 2 surgical teams bridging the gap between point of injury care and more definitive surgical care that occurs at Role 3 military treatment facilities (MTFs).
While ARSC teams fall within the spectrum of Role 2 forward resuscitative care, they are less resourced and deploy further forward than a fully manned and equipped Role 2. Despite the increasing number and frequent deployment of these teams by the military Services, there remains no joint training program that fully prepares these teams for the strategic, operational, and tactical challenges of performing complex surgical care in far forward, austere, or resource limited environments.
While pilot training programs have been developed (ESRT-A training, STaRC Course), none have continued and there still remains no joint collective training requirement for these teams despite their zealous utilization. In response to the rapid development and frequent deployment of ARSC capabilities, the Joint Trauma System (JTS), Committee on Surgical Combat Casualty Care (CoSCCC) defined ARSC (2016) and developed comprehensive Clinical Practice Guidelines (2019). ARSC is defined as “advanced medical capability delivered by small teams with limited resources, often beyond traditional timelines of care, and bridges gaps in roles of care in order to enable forward military operations and mitigate risk to the force.” ARSC teams are an essential part of the deployed military trauma system.
The lack of standardized ARSC team training standards has been identified in the Department of Defense (DoD) Inspector General (IG), Report No. DODIG-2020-087 “Audit of Training of Mobile Medical Teams in the US Indo-Pacific Command and U.S. Africa Command Areas of Responsibility,” which specifically recommends “surgical and tactical training to better prepare mobile medical teams for… austere environments.”
Based on these recommendations and authorities given by the National Defense Authorization Act 2017 and the Joint Requirements Oversight Council Memorandum 125-17, “Forward Resuscitative Care in Support of Dispersed Operations Change Recommendation,” the JTS chartered a formal curriculum development work group (WG), led by members of the CoSCCC to develop a Joint ARSC curriculum to close this gap. This WG consisted of nominated representatives from the Navy, Army, Air Force, Marine Corps, and Special Operations Command as voting members and dozens of other passionate and committed subject matter experts from both the DoD and civilian medical sectors.
Through a comprehensive iterative process led by military Service appointed subject matter experts, the JTS and CoSCCC membership, during the course of 24 biweekly meetings reviewed 12 different military and civilian courses and identified 82 clinical and nonclinical common objectives.
The diverse group of experienced forward-deployed caregivers also sought to identify best practices and look for potential curricular gaps through this process. One of the key findings of the Joint curriculum development WG is that current ARSC training programs focus on supporting counter insurgency operations (COIN), typical of the past 20 years of war, characterized by short holding times, and not the type of austere surgical care that is anticipated to be needed during potential future large scale combat operations (LSCO). Specific gaps identified included training for the provision of definitive surgical care with limited resources, austere critical care, and prolonged casualty holding—capabilities not doctrinal to current ARSC teams. Other identified curricular gaps included the lack of standardized procedural skills training for nonsurgeon team members, skills cross training, ethics training, and expectant casualty care management.
Figure 1 (below) demonstrates the 10 modules created by this diverse group of experienced forward deployed caregivers. The 20 terminal learning objectives and 259 enabling learning objectives that make up these modules include the common curricular elements and best practices, and address the curricular gaps identified by the WG in one standardized Joint curriculum—the first of its kind in the Military Health System. The Joint ARSC curriculum was approved by the Committee on Surgical Combat Casualty Care and published in July of 2024 and is available for free on the Deployed Medicine website.
The course curriculum that emerged from the efforts of the ARSC WG is the Joint Expeditionary Trauma Training Course (JETT). The JTS continues to push service and defense health agency leadership to support a joint collective training requirement for ARSC, and really all Role 2 surgical teams as the future operating environment will require these teams to work jointly.
