Packing for ARSC missions can be framed usefully by the Ruck-Truck-House model developed by SOF medics,82 which is a modular approach to mission planning based on cube and weight constraints. As building blocks, each phase of this supply model builds upon itself, with Ruck capabilities intrinsic to Truck, and Truck capabilities intrinsic to House. The term Ruck-Truck-House refers to the cube and weight of the mission equipment and not necessarily to the mobility platform. For example, ‘Ruck’ missions may be performed from a truck, and ‘Truck’ missions are often conducted via rotary wing platforms.

Specific team member composition of each team is based on multiple variables, and specific staffing recommendations are outside the scope of this practice guideline. Generally, ARSC teams should be prepared to scale their team size according to mission requirements dictated by the Operational Command. A Ruck team may be the smallest number of personnel of any given ARSC team that still provides a minimal, functional capability, while a House team may be the maximum number of personnel with maximal capability. Limitations of scaled teams must be clearly articulated to the Operational Command in order to accurately communicate inherent risk.

RUCK

The Ruck model is the most mobile pack out, as supplies and equipment are limited to what can be carried on each team member’s back. It is well understood, that this is not the ideal environment for surgical care; however, mission requirements occasionally dictate this capability. When it comes to surgical intervention, or no intervention and likely casualty death, this substandard option becomes a mission requirement. Due to its inherent limitations on resources, the Ruck model requires the highest levels of clinical skill, tactical proficiency, and teamwork, and personnel must be highly trained in all above areas for mission success. Medical planners and the surgeon must clearly communicate the clinical and other limitations to mission planners and the supported Operational Command in order to conduct appropriate risk mitigation. The Ruck model fits onto most transportation platforms. Although emergency surgery may be performed with this model, it is generally capable of providing temporary support for only one critical patient with no capacity to hold critically ill patients for any length of time. Blood products are extremely limited and the lack of power and electricity prevents use of blood storage and cooling, blood warming, and electronic patient warming devices. As a result of these limitations, rapid patient evacuation to the next level of care is vital and urgent resupply must occur in order to continue the mission. Alternatively, the plan may include performance of en route care and return to base upon mission completion. Additionally, communications are limited to personal radios and team security must be provided by the supported unit during clinical care.

TRUCK

The Truck model is also very mobile, capable of set up or collapse within minutes, and can be transported to a fixed location. Although this model may have greater capability than the Ruck model, its limitations must be carefully considered and communicated to planners and commanders in order not to fail expectations placed upon it. It includes each team members’ ruck and as many additional supplies and equipment that can fit onto the mission’s mobility platforms, depending on the mission need. This model may be able to treat and sustain more patients but is also limited by power and electricity, blood storage, and fluid volume. Although supplies are increased, it is still dependent upon a rapid evacuation and resupply chain if heavy casualties are encountered or it is intended to perform a static mission.

HOUSE

The House model is far less mobile, as it refers to a fixed location where the full equipment loadout of an ARSC team can be established and is only feasible to be maintained at a team house, firebase, or other mission support site. This model provides the highest level of care organic to the team and has a greater patient capacity. Continuous operations may be sustainable with casualty evacuation and resupply of blood and other Class VIII. Additional requirements for full operational capability include power and electricity for blood cooling and storage, blood warming and infusion, patient warming, water for steam sterilization and hygiene, and other requirements. Open communication of requirements, capabilities and limitations to planners and commanders will enable mission success.

In all three models, challenges are magnified with supply and resupply limitations, blood availability, and prolonged hold time, transport time to next level of care, personnel available to help, and more. It is understood that this is not the ideal environment to care for surgical patients and that certain severe injuries will not be survivable. As emphasized above, the limited capabilities of these teams have to be understood by mission planners and operational commanders. Clinical experts including the senior surgeon should be involved in medical planning of mission support in order to ensure that critical supply requirements and limitations are addressed, clearly articulated, and solutions are developed within mission constraints. Involve planners and the Operational Command early and often in mission planning to understand command requirements, mitigate risks, and shape expectations for success. See Appendix A for sample packing lists for each model.

Many mission variables impact what is ultimately packed into the finite cube and weight requirements for each model. See Table 2 below for some of the variables to consider when planning for logistical support of ARSC missions.

Table 2: Variables to consider when planning logistical support for ARSC missions