Reducing Risk — Training Surgical Teams to Survive
Written by MAJ Jacob Kotzian and CPT Brian Lee
For almost a decade, Active and Reserve conventional Army Forward Surgical Teams (FST) have supported special operations missions in Afghanistan as the Golden Hour Offset Surgical Team (GHOST). Under the operational control of Special Operations Task Force — Afghanistan (SOTF-A), the GHOST conducts expeditionary damage control resuscitation (DCR) and damage control surgery (DCS) to provide freedom of maneuver in time and space for Special Operations Forces (SOF) operations while reducing medical risk to force. The purpose is to provide scalable packages to reduce time to surgery for operations that are outside of the support of fixed Role 2s or to support casualties during prolonged evacuation through aggressive resuscitation.
While each FST performing the GHOST mission has inevitably risen to the challenge of supporting SOF, they deserve to arrive in theater fully trained in the tactical skills necessary to accompany SOF operators. After Action Reviews on GHOST performance have consistently reflected the lack of pre-deployment tactical weapons training, equipment familiarization, and tailored assessments to ensure competency to conduct expeditionary surgery in austere environments. Based on lessons learned with SOTF72 in Operation Freedom’s Sentinel (OFS) X, 7th Special Forces Group (SFG) (Airborne) contacted the Army Reserve FST assigned the GHOST mission during SOTF73’s deployment to integrate with SOF Pre-Mission Training (PMT). The authors do not know of any previous instance where a deploying FST has directly trained with the supported Special Forces (SF) Battalion assuming the SOTF-A mission. This article provides the reader a framework for training FSTs in survivability and reducing risk to mission.
Employment Methodology
Unlike other Role 2s in Afghanistan, the GHOST is expected to encounter enemy forces, potentially in direct combat. The GHOST’s smallest unit of action is the Damage Control Resuscitative Team (DCRT), a four (4) man element comprised of 1x General Surgeon, 1x Critical Care Nurse, 1x Certified Registered Nurse Anesthetist (CRNA), and 1x Combat Medic. The DCRT’s primary mission is to provide resuscitative stabilization at the Casualty Collection Point (CCP) and often conducts tactical ground movement with the supported SOF element over a period of days. If resuscitative interventions fail, the DCRT provides minor surgical intervention at the discretion of the General Surgeon. Prior to assuming the mission, GHOST members chosen for the DCRT undergo weapons and maneuver training with the supported Special Forces Operational Detachment Alpha (SFODA). Weapons proficiency is critical. Members of the DCRT have employed weapons systems in defense of casualties during past operations. Physical fitness is also critical, as the 4-man element must carry all equipment necessary to perform resuscitation, including six (6) units or more of whole blood.
Other variations of the GHOST include the GHOST Mobile, GHOST Light, GHOST Light+, and GHOST Heavy. The GHOST Mobile is comprised of 1–2x Surgeons (General/Orthopedic), 1x Critical Care Nurse, 1x Operating Room Nurse, 1x CRNA, and 1–2x Combat Medics. Designed to operate from a CH-47, CV-22, or C-130, the GHOST Mobile converts CASEVAC platforms into a static operating room or mobile resuscitative platform. The GHOST Mobile does not perform in-flight surgery.
The GHOST Light is the same package as the GHOST Mobile but operates out of buildings of opportunity, usually at an SFODA’s Mission Support Site (MSS). All equipment for the GHOST Mobile/Light fits on one litter. The GHOST Light+ adds a Polaris MRZR that carries additional supplies, 1x 3kw generator, and doubles as a CASEVAC vehicle when not carrying equipment. The GHOST Heavy is equipped with two MRZRs, 1x 5kw generator, doubles the personnel of the GHOST Light+, and carries up to 30 units of whole blood. At peak capacity, the GHOST has throughput of up to six (6) surgical casualties and can stabilize up to twelve (12) resuscitative casualties. Attached Infantry or SFODA personnel at the CCP or MSS provide GHOST security. With proper planning and support, the GHOST is not limited by length of mission. Furthermore, the GHOST mission is expeditionary. In Afghanistan, SOTF-A FSTs have requirements to support fixed locations that would otherwise have no means of health service support. Teams supporting these fixed locations, while configured GHOST-like, are not inherently GHOST.
Pre-Mission Training (PMT)
Historically, the FST received the bulk of GHOST training during Relief-In-Place (RIP) from the outgoing FST. While the result is FST units of action that can perform GHOST functions, the onus of designing training fell to the outgoing FST. This creates a variation in expectation management and an FST without pre-deployment SOF input for mission readiness. To ensure tactical competency and to socialize members of the FST with the supported SOF operators, 7th SFG(A) invited the 911th FST to conduct PMT.
One of the biggest challenges for an FST is familiarization with the MRZR. When utilized, the MRZR carries all of the supplies necessary for patient care and GHOST sustainment. In austere environments, knowing how to effectively operate the MRZR and conduct preventive maintenance is critical to mission success. Furthermore, trained and licensed MRZR operators ensure utilization within design parameters, increases safety through load considerations, and standardizes familiarization for other members of the FST. For a one-week period in May 2019, members of the 911th FST traveled to Eglin Air Force Base, Florida to conduct MRZR and ATV training. From classroom instruction to hands on Preventive Maintenance Checks and Services (PMCS) to multiple days of driving in rough terrain, the 911th FST gained confidence in a training environment without the pressures of RIP. The SF Battalion and the FST members socialized and relayed expectations and concerns with regards to the MRZRs. This pays dividends in that the Battalion’s mobility section is fully aware of the support required for the FST, and the FST knows who to request assistance from in the event of MRZR issues.
Twenty-four members of the 911th FST conducted two-week PMTs with SFODAs in the fall of 2019 near Fort Bliss, Texas. FST members embedded with SFODAs to train on heavy weapons, movement and maneuver, IED lane, and Key Leader Engagement (KLE). At the conclusion of each KLE a casualty scenario occurred using human patient simulators. Air MEDEVAC and ground CASEVAC were incorporated into the scenario. An anatomy lab culminated the KLE, with a general surgeon from William Beaumont Army Medical Center, the 7th SFG(A) Group Dentist, and trauma/general surgeons and CRNAs from the FST leading a course of instruction for the SFODA on dental blocks, dental extraction, lateral canthotomy, endotracheal tube placement, chest tube, cricothyrotomy, eviscerations, sternal/external IO, field amputations, pelvic bleeds, pelvic fracture, nerve blocks, needle decompression, and prolonged field care. After training with the SFODA, the FST conducted one day of CH-47 familiarization and cold load training with the 501st General Support Aviation Battalion.
The FST concluded their training by planning a Full Mission Profile (FMP) night raid with a Special Forces Advanced Operating Base (AOB) and up to four (4) SFODAs. The FST functioned as a GHOST in direct support of the raid in a captured building of opportunity. Seven (7) casualties incurred during the raid were stabilized by Special Forces Medical Sergeants (18Ds), ground CASEVAC to the MSS, and received by the GHOST as a mass casualty (MASCAL) event.
Throughout the training, FST, AOB, and SFODA personnel gradually understood operating parameters, built esprit de corps, enhanced medical skills, and increased survivability. The FST departed training having achieved interoperability with their supported elements and increased their tactical weapons proficiency. Once deployed, the GHOST will decrease their liability as enablers on missions, thereby reducing the overall mission risk.
Conclusion
The scale, scope, and cost of the medical portion of PMT required early BN and Group Commander’s buy-in. Much like the 75th Ranger Regiment, “survive” is a cornerstone of the Annual Commander’s Training Guidance and one of the Group’s top priorities. AOB Commanders were similarly vested in straining their medical capability during training to ensure competence on the battlefield. In an era where most casualties in Afghanistan are incurred during SOF operations, “survive” is of paramount importance.
Incorporating the FST in SOF PMT does not replace other training requirements necessary to ensure a ready medical force. Instead, FST participation in PMT should be viewed strictly as a means to increase interoperability with special operations units. In planning health service support for both conventional and special operations missions, the tactical proficiency of medical personnel should ideally not be the limiting factor in whether or not a mission is executable. FSTs must be tactically ready in order to provide the Ground Force Commander (GFC) with medical capabilities able to reduce the medical risk to mission.
The training conducted by 7th SFG(A) and 911th FST is but a first-step in an enterprise effort to standardize FST training in support of SOF. Special Operations Command Central (SOCCENT), as the Theater Special Operations Command (TSOC) overseeing SOF-operations in the Central Command area of operations, should develop a critical task list that SFG Group Medical staff can utilize for GHOST-validation. FSTs and SFGs need to normalize communications and begin aggressive incorporation into all aspects of training to create a conventionally supported, SOF-validated expeditionary surgical capability.
Key contributors:
SGM Steven McDavid, 3rd BN, 7th SFG(A) Operations Sergeant Major
MAJ Jelaun Newsome, 3rd BN, 7th SFG(A) Surgeon
CPT Nicholas Chaput, 3rd BN, 7th SFG(A) Physician Assistant
SFC Matthew Samlick, 3rd BN, 7th SFG(A) Senior Enlisted Medical Advisor
MAJ Christopher Brooks, 7th SFG(A) Group Surgeon
Authors:
MAJ Jacob Kotzian is the Commander of the 911th Forward Surgical Team. He deployed with the 945th Forward Surgical Team in support of SOTF72 during RSM X.
CPT(P) Brian Lee is the Medical Operations Officer for 7th Special Forces Group (Airborne). He deployed with SOTF72 in support of RSM X and will deploy with SOTF73 in support of RSM XIII.
The views expressed in this article are the authors’ alone and do not reflect the official position of the Army Medical Department, United States Army Special Operations Command, or the Department of Defense.
