OPERATIONAL INFLUENCES ON CLINICAL DECISION MAKING

Expert clinical decision-making in the austere environment is the most important asset the ARSC provides. It is multifactorial and may differ from traditional Role 2 and Role 3 settings based on the operational context and the time and distance to the next role of care. Availability of resources, personnel, blood products, sterility, anticipation of further casualties, evacuation capability,15,16 security, mobility, and patient holding capacity must all be considered. Additionally, the dynamic nature of the tactical environment may result in frequent changes and constant situational awareness is required. Assumptions on duration of transport and time to intervention at next level of care may increase the risk for the patient, the team, and the mission. Therefore, in the majority of cases damage control surgery should be done prior to transport of a casualty. A patient should never be transported from this environment with any question of instability if there is any uncertainly of the transport timeline.

Surgeons are responsible to communicate real-time clinical risk assessments regarding tactical conditions, operational constraints and potential impact on patient outcomes. However, surgeons must recognize that the operational commander retains legal decision-making authority to assume risk and to decide when operational objectives and tactical mission requirements supersede the recommended clinical course of action. Priorities may be weighed against the current threat situation, necessity for tactical maneuver, opportunities to accomplish mission objectives, etc. ARSC team integration in operational planning phases not only determines the medical plan but clarifies the overall tactical intent and the Operational Commander’s desired end state. This allows the Operational Command and ARSC team to make timely decisions to accomplish objectives and maximize critical care capabilities.