Volume 1 Issue 2, November 2015, pp. 71-76

The nature of the current and future battlespace will require adaptive solutions to provide troops with timely damage-control surgery and resuscitation. A light surgical module, the Mobile Surgical Resuscitation Team (MSRT), was developed to meet this need for Canadian Special Operations Forces. The team is composed of six Canadian Health Services Group clinicians specialized in the delivery of trauma care in remote environments. In addition to care delivery, the MSRT can provide simulation training to allied nations and presents an ideal platform for the introduction of emerging science and technology to the field environment.

Les espaces de combats actuels et futurs nécessitent des solutions dynamiques qui permettent d’offrir aux soldats des services de chirurgie et de réanimation dans les délais essentiels. Un petit groupe, l’équipe de réanimation et de chirurgie mobile, a été créé pour venir en aide au Commandement des Forces d’opérations spéciales du Canada. Le groupe est composé de six clinicien(ne)s du groupe des Services de santé des Forces armées canadiennes qui se spécialisent dans le domaine du trauma chirurgical dans les régions isolées. En plus de fournir des soins, l’équipe de réanimation et de chirurgie mobile peut être responsable de la formation des pays alliés et peut aussi devenir la plateforme idéale pour l’introduction des nouvelles sciences et technologies dans l’environnement.

In this era of persistent conflict, Special Operations Forces (SOF) have proved essential to defeating global threats.1 The economy of force, cost-effectiveness, and versatility inherent to SOF make them ideal for neutralizing a broad range of emerging enemies.2 Consequently, the use of SOF by Western countries, including Canada, has seen rapid growth since 9/11.3 Special operations are often carried out in austere environments with fewer personnel and a smaller logistical footprint than conventional operations, resulting in the need for medical support specifically designed for these conditions.

Trauma care during the wars in Afghanistan and Iraq relied on a sophisticated multi-echelon trauma system that resulted in rates of survival comparable to those of victims of motor vehicle accidents in North America.4 This standard for trauma care has become expected in armed conflicts involving Western nations.5 Such outcomes can only be achieved with the uninterrupted delivery of expert combat casualty care from the point of injury to the surgical facility and beyond. The rapidly evolving nature of the current security environment makes it likely that future operations will be conducted in conflict zones without the benefit of an established theatre trauma system.5 Specifically, the evacuation time to a surgical facility can be expected to be much greater in immature theatres of war. To bridge this gap, specific solutions had to be designed to optimize the medical support provided to Canadian SOF (CANSOF) deployed to austere environments.

The first element designed to provide such support was a program of enhanced academic, clinical, and tactical medicine training for CANSOF medical technicians. The Special Operations Medical Technician Course was started in 2010 to provide an expanded scope of practice for CANSOF medical technicians. The second element was the creation of the Mobile Surgical Resuscitation Team (MSRT), a Canadian Forces Health Services Group (CF H Svcs Gp) asset that was developed to provide a surgical force package to augment a Special Operations Task Force (SOTF) during specific high-risk operations. This capability is consistent with the aspiration to deploy self-sufficient Canadian SOTFs.1 A surgical module makes Canadian SOTFs more autonomous and enhances their “relative value in coalition operations.”6 This article describes the medical and operational rationale behind the MSRT and makes suggestions for its future.

Most deaths sustained in combat occur on the battlefield, before patients reach surgical care, as a result of devastating injuries that are considered non-survivable regardless of the level of medical care available.7 Approximately one quarter of battlefield deaths are considered potentially preventable, most of which (90%) are the result of haemorrhage.7 The most common anatomic sites of bleeding are the extremities, the trunk (thorax and abdomen), and the so-called “transitional zones,” the axilla and the groin. Each type of haemorrhage is managed differently in the pre-hospital setting.

Bleeding from extremity injuries (“compressible haemorrhage”) is managed by direct pressure or a tourniquet. In recent conflicts, the liberal use of tourniquets combined with systematic tactical medicine training for medical technicians and soldiers has significantly decreased the risk of death from extremity injuries.8 Non-compressible haemorrhage has been defined as bleeding from large vessels in the chest or abdomen, from solid organ or lung injuries, or a from pelvic fracture in the presence of haemorrhagic shock.9 At present, aside from rapid transport to a surgical facility for definitive control of haemorrhage, little can be offered to these patients in the pre-hospital environment. Unfortunately, as many as 75% of patients with non-compressible haemorrhage die before reaching a medical treatment facility.10 Finally, transitional injuries are wounds to the groin or axilla that are not amenable to haemorrhage control by a tourniquet. These injuries can be extremely complex and difficult to manage in the pre-hospital environment. Transitional injuries, like non-compressible haemorrhage, will also benefit from immediate transport to a surgical facility.

A study of deaths in US SOF from 2001 to 2004 found that 85% had non-survivable injuries.11 Non-compressible haemorrhage was responsible, in whole or in part, for 8 of 12 potentially preventable deaths. Faster transport to a surgical facility could have changed the outcome for these patients.11 A similar study of Canadian deaths in Afghanistan from January 2006 to April 2008 found that 23 of 63 Canadian Armed Forces members died from torso or junctional haemorrhage.12 The researchers recognized that these deaths are currently not preventable by medics and recommended faster transport to surgery as a potential solution. It is important to note that these injuries are severe, and even rapid transport to a surgical facility will not ensure survival.

Damage-control surgery (DCS) refers to abbreviated surgical procedures aimed at rapidly controlling bleeding and contamination while minimizing additional surgical trauma. It is appropriate for unstable patients who are nearing physiologic exhaustion.13 The most classic example is the damage-control laparotomy in which bleeding is stopped, contamination (from bowel content spillage) is controlled, and the abdomen is left open to prevent the physiologic complications from intra-abdominal edema.13 Extremity injuries, the most common type of injury in armed conflict, may also benefit from DCS.14 A typical extremity procedure might include the debridement of nonviable tissue, temporary reperfusion of the extremity, and external fixation of long bone fractures.15 In combat, such a procedure allows timely removal of tourniquets, haemorrhage control, and extremity revascularization, thereby improving the chances of extremity salvage. These abbreviated surgical procedures include only essential surgical manoeuvres that will allow the patient to survive to receive ongoing resuscitation in an intensive care unit. Subsequently, staged procedures will be performed for the definitive treatment of the injuries.

Damage-control resuscitation (DCR) refers to a group of practices intended to minimize post-traumatic coagulopathy, a condition that leads to diffuse bleeding in severely injured patients.16 Recent conflicts have been a major driver of research in this area, resulting in constant refinement of DCR. Hemostatic resuscitation, one of the key practices of DCR, involves the transfusion of blood products (packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets) in proportions approximating those of whole blood.16 Evidence suggests that this resuscitation strategy increases survival of combat casualties.17 The consequence of this paradigm is the need for a robust cold chain to sustain DCR capability, because blood products need to be either frozen or refrigerated continuously.

DCS and DCR are the raison d’être of the MSRT. These two specialized capabilities bridge the gap between SOFCOM medics and the higher echelons of care at which comprehensive surgery and critical care are possible. Projecting these capabilities far forward will increase the chance of survival for severely injured casualties and improve secondary outcomes, such as limb salvage. There is currently broad agreement within NATO that both DCR and DCS should be accessible as soon as possible after wounding, but no later than 1 hour and 2 hours, respectively.18 The MSRT allows compliance with these guidelines in the dynamic environment of special operations.

Figure 1 Mobile Surgical Resuscitation Team members performing surgery.

The preceding sections have established the need for early access to surgery and resuscitation for combat casualties, ideally within 1 hour. The MSRT was created to provide this capability in the specific context of a SOTF. This surgical force package can provide advanced care while having sufficient mobility and versatility to integrate seamlessly into a SOTF. The need to minimize its logistical burden had to be balanced with the requirement to provide a relevant patient-care capacity. The current force package is felt to be optimal in this regard. MSRT personnel consist of six CF H Svcs Gp clinicians: an operating room technician, critical care nursing officer, emergency physician, anaesthesiologist, general surgeon, and orthopaedic surgeon (see Figure 1). These personnel are all actively involved in clinical practice, most often embedded in academic trauma centers as part of CF H Svcs Gp’s maintenance-of-clinical-readiness program. This program allows clinicians to practice in high-acuity centers to maintain their acute-care medical and nursing skills.

The equipment fits on one aircraft pallet (approximately 1,632 kg, or 3,600 lb) and is powered by a small (7.5-kW) generator. Several minimalistic sets of pre-sterilized surgical instruments are also included, each intended for surgery in a specific anatomic area. The MSRT can become operational within 1 hour of arriving on location. The equipment also includes 20 units of packed red blood cells and 20 units of fresh frozen plasma, which are kept in thermostabilizers at 4°C and −18°C, respectively. These blood products allow damage control resuscitation to be performed according to the current best-practice paradigm. The cold chain constitutes the MSRT’s greatest logistical burden.

Defining the MSRT’s patient capacity is an imprecise endeavour. The limiting factors will probably vary according to the pattern of injuries encountered. For example, injuries resulting from dismounted improvised explosive device blasts often result in devastating wounds and massive requirements for blood product.19 A single dismounted complex blast injury could be expected to deplete the entire stock of blood products.20 Alternatively, some patterns of extremity injury, specifically those resulting from blunt trauma, can require much fewer resources.

On the basis of experience with civilian and military injuries, the current estimate is that the MSRT can manage two critically ill patients and, in optimal circumstances, perform up to four extremity and four thoraco-abdominal surgeries. This capacity is felt to be sufficient for the majority of scenarios encountered by a SOTF.21 The holding capacity for critically ill patients is at most 24 hours, which implies the rapid need for Critical Care Air Evacuation (CCAE). Integral to the team are CCAE-qualified anaesthetists and critical care nurses who can perform patient evacuation on an aircraft of opportunity. The emergency physician and critical care nurse can also be deployed forward to provide en route care for critically ill patients coming to the MSRT. Physician-led resuscitation of combat casualties during helicopter transport to the surgical facility has been shown to improve patient survival.22 However, the decision to forward deploy some elements of the MSRT must be balanced against the tactical risks as well as those of having an incomplete team at the base location, which could result in the loss of its intended surgical capability.

The MSRT has other roles that broaden its effect in the battlespace. First, non-trauma emergency care can be performed, improving patient outcomes and preserving the SOTF’s fighting strength. Probable situations include non-surgical emergency care, orthopaedic injuries, and surgical procedures for non-trauma conditions, such as appendicitis. Critical care of a non-trauma patient can be provided for brief periods until evacuation can be arranged. Second, team members can provide training to medical providers from partner nations. Most team members are extensively involved in medical education and simulation in Canada, which allows for impromptu or planned training of partner nation clinicians. This training can be of immense value in building relationships with allied militaries and can have a major impact on combat casualty care in partner nations.

The MSRT should be considered for deliberate, high-risk, short-duration deployments in locations in which access to a surgical facility will exceed 1 hour. In these situations, the MSRT will effectively extend the SOTF’s strategic reach and decrease mission risk. In one such instance, the MSRT was deployed to the Canadian Arctic in 2012 in support of an exercise with a high risk of blunt trauma. Staged in Churchill, Manitoba, the location was more than 1,000 km from the nearest trauma centre. A kinetic mission in a similarly isolated location would make the requirement for the MSRT even stronger. Arctic and maritime operations are the two situations in which the MSRT can be most useful domestically.

The MSRT personnel, kit, and blood products are limited resources that should be saved for appropriate indications. Specifically, the MSRT does not have appropriate capability for large deployments, humanitarian operations, routine care of host nation populations, or medical outreach missions. Domestic urban operations will generally be better served by direct transfer to a civilian trauma centre. Given its limited capacity, the MSRT’s usefulness outside of Special Operations deployments may be limited.

Since its inception, the MSRT has demonstrated its ability to work in fixed land-based structures in three operations. Although intended to perform on multiple platforms, this land-based structure arrangement is expected to be the most commonly used for MSRT deployments. Nevertheless, the team’s mobility should evolve to provide operational planners with more options to allow its positioning within 1 hour of any high-risk tactical action. The highest priority is integration with Royal Canadian Navy frigates and Royal Canadian Air Force C-130s and CH-47s. These platforms are the ones most likely to be used by the MSRT to conduct mobile operations and patient evacuation. MSRT members are mostly regular force personnel embedded in civilian hospitals, which limits their availability for training. This limitation should be viewed positively; by being clinically active, team members are constantly refining the unique skills they can bring to a SOTF. Military training necessary for an expanded mission set needs to be balanced with the other duties of CF H Svcs Gp personnel, for whom this is one of many specialized operational tasks. Many team members are involved in other high-readiness activities, such as CCAE.

Because of the limited number of physicians and critical care nurses, multiple parallel duties will remain the norm. Surgery and resuscitation are the core skills of SOF surgical team members.21 Accordingly, tactical and environmental training needs to be streamlined as much as possible. This delicate balance between medical and tactical skills has also been described by other SOF surgical teams.21 Members should also be encouraged to expand their clinical skills beyond their base specialty to offset the limited number of care providers on the team. Finally, the MSRT’s small size, experienced clinicians, and projected operational tempo make it an ideal platform to introduce new technology to the field. Advanced point-of-care ultrasound and transfusion medicine are two areas of active research within the CF H Svcs Gp with the potential to improve far-forward care.

The MSRT is a CF H Svcs Gp asset designed to support Special Operations. Its key function is the surgical management of non-compressible haemorrhage, the most frequent cause of preventable battlefield death, in austere conditions. Expansion of the MSRT’s ability to perform this role in the maritime, air, and Arctic environments would be necessary to allow coverage of SOF’s full mission set. The MSRT contributes to the deployment of more autonomous Canadian SOFTs, which is highly desirable when contributing to multinational operations.1, 23 We hope this article will stimulate further discussion and collaboration, leading to continuous improvement in the delivery of far-forward surgical care.

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None declared.

All authors participated in conceiving the design of the study, conducting the literature search, selecting the research questions and data set, analyzing the results, drafting the manuscript, and editing and revising the manuscript. All authors approved the final version submitted for publication.

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None declared.

This article has been peer reviewed.