Expertise in trauma care is the cornerstone for ARSC teams and trauma training to achieve and sustain clinical expertise of all team members is foundational. Historic abbreviated ‘just-in-time’ training for trauma care is highly discouraged. Combat trauma patients already present the most demanding challenges to an experienced trauma team in the unconstrained environment. ARSC team members should be selected to possess a mission-first mindset, perform well under duress, work effectively as part of a team, and demonstrate resilience to periods of sustained levels of stress. Individual members should be proficient in TCCC and their respective specialties of resuscitative, surgical, and post-op care of critically-ill trauma patients. Ideally, ARSC teams will achieve expertise by working routinely as a team in high volume, high quality trauma centers in order to develop trust, fluid team dynamics, and to cross train on key roles and tasks in order to maximize use of limited available hands.

It has been well recognized that certain teams supporting these missions may not maintain the appropriate clinical volume for skill sustainment. This fact emphasizes two elements of the current trauma system in the DoD: (1) maintaining surgical trauma skills while not deployed (2) keeping deployments short for individuals with life-saving critical skills that have been demonstrated to be perishable. It is important that deployed clinical and operational leadership recognize the value of personnel flexibility (intra-theater rotations) to ensure that providers get clinical exposure during deployments.

ARSC teams should be prepared to function outside of the boundaries of forward operating bases; therefore, success relies on proper integration with the operational mission. The ability to balance resuscitative trauma care within the tactical mission requirements and constraints is the greatest challenge. ARSC teams should undergo training to function in tactical environments, including training in survival, evasion, resistance, and escape, and be proficient in tactical communications and weapons management. Specific guidance from the supported ground force should guide the training requirements. Personnel must have the ability to defend themselves and their patients. Teams require expeditionary maneuverability with a compact resuscitative surgical package that is rapidly deployable and collapsible. Pre-mission tactical training for the team should be supported by hospital and ground force leaders and include technical skills and knowledge, team training, and professional development.

Employing ad hoc teams without specialized equipment or more intensive, sustained pre-deployment and team-centric training specific for this mission presents both a risk-to-mission and risk-to-force, and is highly discouraged.3,13,14 Being an asset in the operational environment, and not a liability, requires that ARSC team members have sufficient training to integrate with the supported operational force and throughout the entire en route chain of care. The smaller the ARSC team, the more technical and clinical expertise is required for all team members. Likewise, the farther forward the ARSC team deploys, the more tactical and clinical proficiency the team requires.

Mission planning is essential to effective employment of the ARSC team and begins well before deployment. Surgeon involvement with ARSC leadership is essential. ARSC leadership elements include: the officer in charge (OIC), senior surgeon, and senior enlisted member –they should be involved in all phases of the Joint Operations Planning Process. Communicate early and often with the line command in order to establish mutual trust and shared realistic expectations of the ARSC team’s capabilities, limitations, and requirements for each individual mission while deployed. The Operational Command must be advised by the OIC and/or senior surgeon of the decreased capability (as compared to a conventional Role 2) that ARSCs can deliver, and accept the increased risk to their forces. The Command must be aware of the number of critically injured casualties that can be managed before personnel are overwhelmed or resources exhausted. Dedicated security from anticipated threats must be provided when the ARSC team is decisively engaged in patient care. Successful integration of resuscitative trauma care within the operational environment begins before the first patient contact.