Redefining SOF Surgical Support to Meet Joint Force Demand

From Combat and Casualty Care, Spring 2018 Issue

United States Special Operations Command (USSOCOM) missions have maintained global distribution into many isolated areas of the world. The regions that these missions are conducted in often have little to no infrastructure to support requirements for Damage Control Surgery (DCS) or Damage Control Resuscitation (DCR).

By CAPT Scott A. Cota, Command Surgeon, USSOCOM

In certain areas of the world evacuation times can be delayed as competing missions and limited resources push casualty evacuation beyond the “Golden Hour”. The operational expectation that is often recognized by commanders who have experience in Iraq, Afghanistan or the Central Command Theatre is the “Golden Hour”. Increasing missions into minimally supported or previously unsupported areas of the globe may often necessitate risk mitigation and a strategy to minimize the risk. The strategy to minimize risk often includes requesting DCS or DCR for global SOF operations to support to USSOCOM missions. The increased use and reliance on sustained Special Operations Force (SOF) missions naturally increased the global requirements for surgical support and has increased proportionately to expanding SOF operations.

Increased Field Surgical Need in Wartime

As early as 2015, the request for DCS and DCR support to SOF operations far outpaced the inherent capacity of embedded SOF surgical teams such as the Air Force Special Operations Command (AFSOC) Special Operations Surgical Teams (SOST), so the Services filled the SOF support request with General Purpose Force individual augmentation or ad hoc surgical teams. By 2016, the rising requirement for DCS and DCR pushed a continuous demand signal on the Services conventional force medical departments to support global SOF. I believe this increasing demand signal helped to influence the Services to look for solutions. Demanding support for USSOCOM units taxed the services with those early requests and were supported by USSOCOM Commanders, the Joint Staff Surgeon, and not wavering in the scope or breadth of the high risk missions. The services were familiar with the SOST capability and its training, equipping and manning solutions and were synchronized with AFSOC to review the SOST.

U.S. Army Medical Command (MEDCOM) responded with innovations to expand a modular capability by breaking up the larger field surgical team units and assembling smaller DCS and DCR teams. Navy and Marine Corps developed capability that was limited to the maritime environment. Mostly, the early service response was often to provide ad hoc individual augmentation teams that had none or minimal experience in supporting SOF operations. The requirement that USSOCOM missions needed Modular, Mobile, Minimally Dependent, and Tactically Aware DCS/DCR support was often validated but unfilled because a standardized general purpose force solution set did not exist. Depending on which Service was requested to fill the mission of DCS or DCR, the response often times expected by USSOCOM units was sorry we don’t have that capability or that is not our mission. Most of the early versions of conventional surgical support provided to SOF missions were the repackaging of larger capability that existed with splitting of teams or piece-meal individual augmentation of joint teams. These teams were successful in their primary medical mission, but lacked maneuverability, were not under command and control of the SOF units and often complained of skill degradation. The DCS or DCR support to USSOCOM units appeared to be a task that was at times ignored or caused angst due to the perceived over requesting of support.

By 2017, it was well known that the requirement could not be overlooked since USSOCOM operations increased into very isolated, unsupported parts of the world. In an additional effort to find support, many of the Theatre Special Operations Commands (TSOCS) networked with partner nations to understand or build additional capability with force provision from the partner nation. The United States military services looked at internal solutions and hoped to standardize with surgical teams similar to the train, man, equip plan that AFSOC provided to their Special Operations Surgical Teams (SOSTs).

Networking a Joint Solution

The continued demand signal for non-SOF DCS support for SOF missions drove change and allowed the SOCOM Surgeon to network with the services and share a joint solution to provide surgical teams. The joint effort was intended to deliver real solutions to support SOF missions with DCS and DCR at any location on the globe. During this joint effort, Transportation Command Surgeon (TRANSCOM) played a key role to relieve the DCS support requirements by increasing capacity for casualty evacuation to areas with minimal support such as U.S. Africa Command (AFRICOM). In an attempt to control requests, planning estimates and risk management strategies advocated for stewardship of resources by the Joint Staff and USSOCOM Surgeons. This approach demonstrated to the services that SOF planners were attempting to push for support at times where support was truly required.

The Joint Staff Surgeon hosted capabilities-based assessments (CBAs) focused on defining the requirements of the Defense Trauma Enterprise, Prolonged Field Care and Field Resuscitation, so that the larger joint planning and requirements process could help drive change. The CBA focus areas along with the 2017 National Defense Authorizations Act (NDAA) recommending a Joint Trauma System pushed the focus on a DoD wide effort to provide DCS and DCR capability in a standard package. USSOCOM Surgeon advocated that DCS and DCR teams should broadly be SOF familiar and the USSOCOM Medical enterprise should look for opportunities to exercise with those general purpose force teams. In additional response to the 2017 NDAA, the Committee on Surgical Combat Casualty Care was stood up and modeled after the undeniable success of the Tactical Combat Casualty Care Committee and enabled a platform for SOF Surgical Teams to share their after-action reports, develop clinical guidelines, brief their capabilities and provide an opportunity to influence the direction of the Defense Trauma Enterprise.

In 2018, the move of the Defense Health Agency (DHA) to assume a combat support agency role and establish the structure of the Defense Trauma Enterprise will provide a catalyst toward the scaled down surgical support that USSOCOM missions expect. These missions vary from direct combat support, foreign internal defense, to unconventional warfare as Special Operations units carry out their 10 core tasks. The backbone of support to these missions is still the USSOCOM combat medic, but as resources and DCS/DCR teams are guided by DHA and stood up by the Services it is expected that the medic will obtain some relief from expanding capability expectations and very real prolonged field care situations. Since a system, the Defense Trauma Enterprise will recommend SOF familiarization the personnel in support of SOF missions will be more knowledgeable of SOF forces, have the appropriate subject matter expertise to support SOF missions and of course will be clear on limited infrastructure and prolonged CASEVAC.

Re-Thinking from a Training Focus

Many of the discussions with the Joint Services, and even internal to USSOCOM medical, revolve around development of a pathway or pipeline to keep knowledge, skills, and training up to date and current for surgical teams supporting USSOCOM missions. The training requirement is a dichotomy in that current surgical training is primarily minimally invasive and most combat wounds are complex and require open procedures. In addition, the trauma training required to treat combat injured is not easily obtained in the current Department of Defense medical facilities. So the AFSOC SOST model of obtaining training at civilian institutions was shared with the services and articulated to senior service medical decision makers. The ability to develop expanded telemedicine capability and push more procedures to medics and non-surgeon providers is being developed by USASOC. The proposal to embed surgical teams into SOF units and guide the training pipelines of DCS teams supporting SOF missions has been forwarded from JSOC to USSOCOM leadership for consideration.

The push to train in partner nation civilian trauma centers for SOF familiar surgical teams and the ability to formulate status of forces agreements with partner nations to train in foreign countries has to be expanded. It is recommended that this direction be explored by the Services as they stand up their modular surgical capability. USSOCOM medical enterprise support to educate and familiarize the SOF mission to general purpose force surgical teams could include expanding country agreements, cultural training, standardized tactical skills, weapons familiarization, expectation management for skill degradation and familiarity to Joint, Global Health Engagement, Medical Training and Foreign Internal Defense (FID) opportunities. Expanding the core tasks of surgical teams to include Guerrilla Warfare and Unconventional Warfare when feasible, to train partner Countries in DCS and DCR capability, and learn the collection methods to report and document area capability. These tasks should be solicited, evaluated, validated and supported during SOF exercises. SOF exercises employing DCS and DCR capability should include full mission profile surgical team training, observation and where feasible the expansion of MEDIC Capabilities with enhanced telemedicine support. During these exercises communication networks have to include interoperable methods to communicate with partner nations and partner nation facilities. Overseas Medical Facilities should be included in DCS and DCR training OCONUS when the MTF is geographically positioned to support more than one GCC. The techniques, tactics and procedures of patient movement, logistics support and equipment maintenance should also be exercised.

Visualizing the Challenges Ahead

Fast forward into the future. The DTE and the Trauma committees will improve the system of combat trauma care and I believe will lead to the standardized joint approach to mission support. Continuing to look at care at the point of injury (POI), prolonged field care and DCS/DCR outcomes will improve the quality of care and should include a broad range of educational and training experiences. USSOCOM will continue its efforts of collaboration with groups like JTAPIC to develop tactical context to injury reports, data analysis of injury patterns and the sharing of reports within the USSOCOM Medical Enterprise. Improving documentation and expanding tactical context to clinical outcomes will support resource requirements and prioritization of mission support. SOF operations will require Forecasting Medical Risk down to the POI and should continue development of life-saving capability with the expansion of autonomous blood delivery, rapid logistics support, 3D printing capability and Unmanned CASEVAC.

Surgical support to SOF missions has expanded to include an improved effort and response by the Services and really all of DoD medicine. There are still gaps that will require continued vigor and attention toward a modular, mobile, tactically aware and independent surgical capability that meets the expectation of USSOCOM operational support.




Combat & Casualty Care recently spoke with Command Surgeons from a number of U.S. Special Operations Command (USSOCOM) component commands regarding lessons learned in field surgical practice during recent decades of U.S. combat commitment. As war efforts in Iraq and Afghanistan have contracted and expanded, U.S. military services and USSOCOM have adapted their forces to provide damage control resuscitation (DCR) and damage control surgery (DCS) capabilities far forward on the battlefield.

The views expressed are the personal views of the writers and do not necessarily represent the views of DoD or its Components.

Roundtable Participants:
SOCCENT Surgeon COL David D. Haight
AFSOC Surgeon Col. Rudolph Cachuela
SOCAF Surgeon COL Ramey L. Wilson
528th Surgeon COL Jay Baker
JSOC Surgeon COL Robert L. Mabry


Wartime Role Re-evaluation

According to Joint U.S. Department of Defense Doctrine, combat medical support forces have traditionally been organized and equipped to provide health service support in a tri-echelon order of point of injury care (Role I), primary care (Role II), and theater level (Role III) care, with the addition of definitive care at United States or overseas medical treatment facilities (Role IV).
According to Joint Publication 4-02: Joint Health Services Doctrine, current doctrine now views notional Roles of Medical Care as based on:

Role I: First Responder
Role II: Forward Resuscitative Care
Role III: Theater Hospitalization
Role IV: Definitive Care

In line with NATO forces view of Role II care, forward surgical/resuscitative capability has taken center stage as the key determinant of Role II level care. As joint doctrine has evolved, so has the manner in which Special Operations Force (SOF) Components have taken on the challenge of providing early resuscitative surgery for SOF.

Recent decades of combat medicine have highlighted challenges in providing care in counterinsurgency operations and on the noncontiguous battlefield, especially damage control surgery (DCS). Special Operations Forces (SOF) operations, in particular, have been challenged to enable operations with DCS, especially in Afghanistan and Iraq where planning requirements stipulated that DCS would be provided within the “Golden Hour,” and as SOF operations were often far from the conventional medical assets providing support.

As a result, several different variations of expeditionary surgical capability were developed to meet the needs of the SOF commanders. Some of these solutions took existing surgical units and reorganized them to support SOF operations, other solutions started with a new approach and completely redesigned their units to become more expeditionary. As each force provider adapted and shaped the development of these units to include DCS to non-SOF forces, there has been a confusing litany of various names and compositions for DCS capabilities.

Joint SOF/Conventional Interoperability

During Operation Enduring Freedom, U.S. Special Operations Forces medics in Afghanistan used Army Forward Surgical Teams (FSTs), which were never designed to operate independently, and carved them up in small expeditionary teams and named them Golden Hour Offset Surgical Trauma (GHOST) teams. Traditional FSTs were a 20-person unit with 3 general surgeons, one orthopedist, 3 RNs, 2 certified registered nurse anesthetists (CRNAs), 1 administrative officer, 1 detachment sergeant, 3 licensed practical nurses (LPN)’s, 3 surgical techs and 3 medics. The FST was designed to operate as a complete unit but have the ability to do split operations if needed. The U.S. Army is now in the process of converting all of their FSTs into Forward Resuscitation and Surgical Teams (FRSTs) which will be more mobile, modular and expeditionary.

The U.S. Air Force’s previous surgical teams, Mobile Forward Surgical Teams (MFST), comprised of a general surgeon, orthopedic surgeon, anesthesiologist, emergency medicine physician, and surgical technician (previously an OR nurse) were re-organized in November 2017, and re-named Ground Surgical Team (GST). The GST now includes a general surgeon, anesthesiologist, critical care nurse, emergency medicine physician, surgical technician, and a medical operations officer. Similar to the FSTs, these teams were designed to augment expeditionary medical units in a modular fashion, but the Air Force units are also designed to operate independently.

The U.S. Navy has an Expeditionary Resuscitative Surgical System (ERSS), a 9 man surgical team meant for USN SOF support. The Navy also has a 36-man Navy Expeditionary Medical Unit (EMU), that is neither expeditionary, nor mobile, and provides services from a fixed location.

The U.S. Marine Corps designates a Surgical Company to provide surgical care for Marine Expeditionary Force (MEF) personnel with one Surgical Company per Infantry Regiment. Doctrinally, the Surgical Company consists of 4 Forward Resuscitative Surgical Systems (FRSS), 4 shock trauma platoons, and 4 en route care teams. Marine Corps FRSS is an 8-person team with 2 surgeons and an anesthesiologist.

And finally, U.S. Air Force Special Operations Command (AFSOC) has developed and fielded the Special Operations Surgical Team (SOST) and the U.S. Army has the Special Operations Resuscitation Teams (SORTs). There are currently no expeditionary surgical teams within U.S. Marine Special Operations Command nor U.S. Naval Special Warfare (NAVSPECWARFARE) Command.

Myriad Options Challenge Need Targeting

In the current Iraq, Syria, and Afghanistan conflicts, the U.S. Central Command (CENTCOM) Commander and staff have a dizzying array of GSTs, FSTs, SOSTs, SORTs, EMUs, and Expeditionary Medical Support (EMEDs) distributed across the battlefield. What is clear is that the multiple different surgical capabilities make for a difficult task for the medical personnel determining best distribution of medical resources to support a largely Special Operations Force on the ground. What is needed is a common surgical team construct across the Services that is mobile, highly capable and can be utilized across all theaters.

“The various surgical teams across services have different capabilities and limitations,” noted COL Dave Haight, U.S. Special Operations-Central Command (SOCCENT) Surgeon. “Newer SOF surgical teams such as the SOST and SORT are better able to perform the missions required to support SOF missions, as they are more modular, mobile, and trained to work supporting SOF mission sets. An FST can provide exceptional care in a specific location but cannot move as readily as the SOST/SORT.”

The Air Force’s SOST is one team that has gained great notoriety of late for their mobility, capability, and actions. “We created SOST shortly after 9-11 to meet the U.S. Special Operations Command (SOCOM) requirement for a rapidly deployable forward resuscitation damage control surgery capability that could operate outside the wire in austere conditions,” said COL Rudolph “Rudy” Cachuela, AFSOC Surgeon. “We also wanted to include a tactical patient movement capability into this package. We initially did this by taking the Air Force Medical Service (AFMS) Mobile Forward Surgical Team (MFST) and the Critical Care Air Transport Team (CCATT) packages from the conventional force and began to adopt them for AFSOC.” This included modernizing their equipment packages to make them lighter, more mobile, and also adapting their training to make them more tactically competent. The packages became the first SOST and Special Operations Critical Care Evacuation Teams (SOCCET). “As we began deploying these teams, we realized that the members of these teams needed to be clinically outstanding since they were working outside of the expeditionary military treatment facilities (MTFs) in less than ideal conditions,” Cachuela added. “In order to ensure this, we began embedding the SOST/SOCCET into civilian level one trauma centers. In 2010, we located our teams at University of Alabama Birmingham (UAB) and St. Louis University (SLU). Currently, our teams are working out of UAB, University Medical Center in Las Vegas, and University of Miami/Ryder Trauma Center.”

“We also realized that these teams needed to be tactically competent. They needed to be able to move, shoot, communicate, if required, to be able to operate with the Joint SOF warfighter and placed these teams into the 24th Special Operations Wing which is our Special Tactics unit and allowed the 24 SOW to organize, train, and equip these teams in the area of tactics,” Cachuela emphasized.

“We continue to modernize these teams to include taking advantage of commercial off-the-shelf (COTS) technology to reduce their footprint and increase their mobility. We do this through our own SOF specific medical combat development division that works with both AF research labs, the SOF enterprise, academic, and private industry to continue to modernize our capabilities. Having our own modernization division allows us to rapidly acquire new technology to include testing and then quickly fielding these technologies. Closely reviewing AARs from deployments and JTS data allows us to continue to identify requirements and improve our capabilities,” he noted.

Today’s SOST meets the requirement for a mobile, rapidly deployable forward resuscitation/damage control surgery/tactical critical care transport capability that is clinically outstanding/tactically competent and can operate in austere environments. Current SOST members undergo a formal accession and selection process to include evaluating their clinical skills and physical skills. They are also assessed by an operational psychologist,” Cachuela indicated. “We have recently stood up a Reserve SOST capability and are in the process of standing up a SOST capability within the Guard force.”

Improving Modularity for Flexible Response

Modernization efforts continue to include ongoing equipment and supply testing and acquisition to make our teams even lighter while maintaining or increasing their capabilities. “We are also modernizing SOST Techniques, Tactics and Procedures (TTPs) to include the ability to operate in a chemical, biological, radiological, nuclear (CBRN) environment to include medical management of CBRN casualties,” noted Cachuela. “Modularity of our SOST equipment packages is key here so that our teams can just take what they need to support the SOF mission across the full spectrum of mission sets. We continue to review After Action Reviews (AARs) and Joint Trauma System (JTS) data to ensure we are adapting to a constantly changing environment, and work closely with our operators as we plan for future conflicts.” “We also look for opportunities to integrate ourselves into the entire Joint Trauma System and SOF enterprise to include training with our sister Service and coalition partners, other AFSOC expeditionary capabilities to include Special Operations Forces Medical Element (SOFME), SOFME augmentation packages, and AFMS conventional expeditionary medical capabilities,” Cachuela added.

In a similar fashion, U.S. Army Special Operations Command (USASOC) developed a SORT concept and currently possesses three SORTs within the 528th Sustainment Brigade (SO) (A) of 1st Special Forces Command. “SORT comprises the following personnel: Flight Physician (61N), Critical Care Nurse, 3x Special Operations Combat Medics, and ancillary support staff with specialization in radiology, laboratory, and patient administration,” noted COL Jay Baker, Command Surgeon, 528th Sustainment Brigade. “These teams currently provide expeditionary medical care in austere locations with limited resources and support. The skill sets that the SORT brings include but are not limited to: point of injury care; triage, emergency and critical care; damage control resuscitation; prolonged field care; critical care transport; integration with surgical assets; and technical rescue. In addition to their medical skill sets, SORTs constantly train to be tactically proficient,” Baker added.

Since their creation in 2008, SORTs have deployed in support of SOF operations in Afghanistan, Africa, Syria and Iraq. “Actual implementation of the SORT is variable and dependent on the needs of the ground commander, with flexible manning, equipping and ability to support diverse mission requirements,” Baker emphasized. “The SORT is frequently employed as smaller sub-teams or even as individual Special Operations Combat Medics (SOCMs) to augment the organic medical capabilities of SOF teams. The ability to be flexible in their employment has been key to the SORT’s success on the contemporary battlefield,” he iterated.

With the recent recognition that the majority of potentially survivable injuries on the battlefield are due to non-compressible truncal hemorrhage, organic surgical capability was recognized as a critical capability in the U.S. Army Special Operations Forces (ARSOF) 2022 strategy. A force design update is currently pending approval by the Pentagon, which will transform the SORTs into ARSOF Forward Resuscitative Surgical Teams (FRSTs), beginning with a similar construct to the conventional Army FRST. Key personnel changes from SORT to ARSOF FRST include the following: Each team will add a general surgeon (61J) and CRNA; the flight physician (61N) billet will become an emergency physician (62A); an emergency nurse will be added to the critical care nurse; SOCMs will be substituted for the LPN and OR tech. “We are currently looking to substitute a surgical PA for the orthopedic surgeon, with anticipation that they will be the team leader,” Baker indicated.

ARSOF FRSTs will be manned, equipped, and trained in order to preserve the ability of the SORT to provide flexible medical augmentation to ground commanders depending on mission requirements. In accordance with NDAA 17, USASOC plans to embed ARSOF FRSTs in high quality, high volume civilian Level I trauma centers at Grady Hospital in Atlanta, GA, and Carolinas Medical Center in Charlotte, NC. Demanding tactical training will continue to take place at Fort Bragg in order to sustain the high levels of the tactical proficiency that have set apart SORT capability from its inception.

Command Coordination for Enhanced Patient Mobility

COL Ramey Wilson, Command Surgeon for Special Operations Command – Africa (SOCAFRICA), and previous Command Surgeon for Joint Special Operations Task Force (JSOTF)-Afghanistan, noted that “Army and Air Force teams have different capabilities. The Air Force teams, for example, have a medical planner (but no orthopedic capability), while the Expeditionary Resuscitation and Surgical Teams (ERST) provided by the Army (an ad-hoc capability designed to meet a specific capability requirement) has an orthopedic provider but no planner.” “The small expeditionary nature of these teams shifts the risk for patient care. While it provides damage control surgery (DCS) closer to potential injury, their small size challenges their ability to hold patients post-operatively,” Wilson emphasized.

As a consequence, SOCAFRICA has worked deliberately with U.S. Transportation Command to expedite out of theater movement of patients in order to move the patients and allow the surgical teams to reset and prepare for their next mission or patients. “While the surgical teams help enable operations, the geographical and political challenges of Africa, challenge the ability to provide DCS in a timely manner and evacuate the patient to Germany for follow-on care,”
Wilson noted. “These factors challenge blood resupply and medical maintenance, as well.”

Wilson also notes that “the lack of an enterprise-wide medical documentation system to support DCS and critical care evacuation in immature theaters is a major issue. There is currently no fielded medical documentation system equipped to meet the challenges of austere, small-footprint care that requires multiple patient handoffs. While forces have been criticized for a lack of documentation, the reality is that they are sending their documentation with the patients, but it is never arriving at its final destination to be scanned into the electronic medical record,” he added. “We are not operating in Afghanistan or Iraq where it is one leg of evacuation to a Role 3 hospital. We have almost zero success of our written documentation making it back to Landstuhl Regional Medical Center (LRMC), our closest Role 3 facility. That being said, the surgical teams that currently support SOCAFRICA operations are much better prepared than the FSTs previously used as GHOST teams in Afghanistan, as at least the current teams are equipped and trained for their expeditionary missions with SOF.”

There was universal agreement among the group that what is needed is improved standardization among the force providers on the composition, capabilities, equipment and training by the various force providers to provide better interoperability among the DCS capabilities. “We feel that the services, under the direction/supervision of the Joint Staff, should establish core principles, policies and procedures to decrease the friction created by these various flavors of DCS,” Wilson said. “Across the board, component surgeons are concerned about skills maintenance and skill maintenance for these teams while deployed is a continual concern for force providers. While Africa, for example, is a lower risk area in terms of kinetic operations, the lack of adequate medical infrastructure in their partner nations and the tyranny of distance and transportation mandate the need for DCS capabilities. Skill degradation during deployments is an enterprise-wide problem and while services are now looking at how they sustain wartime surgical skills while in the garrison environment, a lot of effort has not been put into exploring ways to sustain skill levels while deploying in a low-patient volume environment.” Dr. Wilson also suggests that SOF medicine needs to continue to capture and publish the experiences and the lessons learned from these small teams into the peer-reviewed literature.

Continuing to Adapt to Changing Need

It is clear that expeditionary, small, mobile surgical teams are the way of the future to support SOF. Split FSTs, SOSTs, and SORTs have proven their ability to provide exceptional damage control on the battlefield. “We need to continue to refine our processes and constructs to develop the right answer to a more maneuverable surgical capability in support of SOF operations,” said Haight. “The way forward is a joint solution, but regardless of the direction taken with surgical support on the battlefield,“ said COL Bob Mabry, U.S. Joint Special Operations Command (JSOC) Surgeon. Mabry cautions that the smaller these teams are, the more “expert” they need to be. “Otherwise we are putting something out there that will likely fail when put to the test,” Mabry noted. “With a small team, you have no backup, you have no one to ask for help or advice. With just one severely injured casualty everyone on a small team will quickly become task saturated. If just one of the team is marginal in best of conditions, the team will fail when stressed. All on this team need to be ‘A game players’ and meet the National Academy of Medicine’s definition of trauma “experts” with trauma fellowship training and years of experience at a busy, top-quality trauma center.”