April 7, 2022 • 54 mins
Dr. Dan Brillhart and Army Nurse Erick Thronson discuss our experiences integrating a 2 person Damage Control Resuscitation (DCR) Team into the manuever element Special Operations Forces (SOF) in austere environments in Africa. This DCR Team moved with the lead ground element on operations lasting from several hours to several weeks and provided advanced resuscitative care as the initial treatment to dozens of casualties at point of injury. We describe how this model worked for us and advocate for expansion of similar programs both within SOF and conventional units.
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Episode Transcript
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Dan Brillhart (00:00):
Hello GSACEP. And thank you for joining us for our
talk regarding the DCR teamconcept. dcr. Core stands for
damage control resuscitation,which I think of as sort of all
of the trauma management thatoccurs in tactical combat
casualty care prior to thepatient receiving surgical care.
(00:20):
The DCR team concept that wewant to tell you about is our
proposal to bring more advancedand sort of nuanced DCR care
farther forward on thebattlefield, as far forward as
possible. Ideally, I'm but I'mgetting a little bit ahead of
myself, who are we? And why arewe talking about this? I'm Dan
Bernhardt. I'm an Army 62 Alphaemergency physician, my
(00:43):
colleague, Eric Johnson, is anarmy 66 tango, emergency trauma
nurse, Eric and I have beendeployed together for about five
years now, most recently withthe earth mission supporting
Special Operations CommandAfrica. And throughout those
five years, we've been refiningand testing a set of TTPs that
(01:04):
evolved into this concept thatwe refer to just simply as a DCR
team. And the intent, the intentof those teams is to accomplish
the thing that we're mostpassionate about. And that is
bring high quality emergencydepartment level resuscitative
care as close to the point ofinjury as possible for our
warfighters.
(01:24):
So these disclaimer slides,we've all seen it a million
times. But in this case, Ireally do mean it. The views
here that we're talking aboutreally are not policy, or even
widely held beliefs within theDOD. But Eric, and I think they
should be. And if we're reallyserious about reducing
preventable deaths on thebattlefield, we think employing
(01:47):
emergency medicineprofessionals, doctors and
nurses in the manner we'redescribing could have a
significant impact. But none ofthis is doctrine. None of this
is policy. And none of this is asort of accepted dogma at this
point. So the purpose of whatwe're talking about is number
one, to tell the story of whatwe've been doing, share our
(02:08):
successes, our failures, and thehope to be that some of you can
take this sort of initial effortand move forward with it and
create something bigger andbetter and more effective.
Because we believe that thisconcept should expand outside of
the Special Operations communitywhere it's currently being used,
(02:30):
and sort of being employedacross the force where
appropriate to deliver the bestcare that we can for our service
members. So what exactly is ourstory? What did we do? Well, as
part of the the earth program,in our East Africa area, we took
an emergency physician andemergency trauma nurse, and we
(02:52):
embedded them with a maneuverelement. And augmented are for
Special Operations medics, andyou can see there's our medical
treatment team here. And we wentout on Grand ground combat
missions lasting anywhere from afew hours to a few weeks. And
augmented the the medicalcapability of that team with
(03:16):
again, emergency departmentlevel resuscitative, sort of
knowledge, skill, equipment, andput it not only at the point of
injury, but at the time ofinjury as well, which I think is
an important distinction becausewe can throw advanced
resuscitation teams on toaircraft and fly them out to the
(03:37):
point of injury to pick apatient up. But you've already
lost some time at that point.
And those minutes may becritical, especially for the
types of advanced resuscitativecapabilities that we're
advocating for things likeadvanced airway, reboa,
emergency resuscitative,thoracotomy, more robust use of
blood products, all those thingshave a very finite window of
(03:58):
minutes really, where they canpotentially make a difference.
And so having the people toprovide those procedures, those
sort of augmented skill setsthere when the damage happens,
we think is important.
Erick Thronson (04:18):
So the idea of putting Advanced Care forward
isn't necessarily a new idea. Ithink military medicine is
always trying to balance therisk of getting physicians and
advanced medical care as closeto the casualty and the point of
injury as possible. With youknow, the the life saving
benefits that they they provide.
So there's always a kind of arisk benefit analysis that goes
(04:39):
into that.
But using small, highly mobileteams like this is is something
that has been done acrossvarious organizations, both in
the United States andinternationally for for several
years. I'm particularly insupport of special operations.
(05:03):
And they have been verysuccessful doing so. But those
teams are few and far between.
and, and they're in high demand.
So they can't be everywhere allthe time. And that is just one
(05:23):
or a few. A team concepts andconstructs that have been
created that aren't necessarilythe right thing for all
environments. So you have to beable to look at where you're
going to be in the kind ofmission you're going to support
in order to create the best sortof team to support those kinds
(05:44):
of operations. So in EastAfrica, that was born out of the
need for sort of this farforward, highly mobile flexible
team that was able to travelfrom place to place in the
resource limited environment ofEast Africa. And so the medical
military medical community inEast Africa identified that
there were no existing oravailable teams that were going
(06:06):
to be able to fill that gap atthat time. And the conventional
teams, we're not necessarilygoing to be able to work in that
space either. You know, thetheater in East Africa is, is
also complicated, not just bytime and distance. But
(06:27):
logistically, it's a far moreimmature theater, and certainly
more mature than the theaterthat we know, that exists in
CENTCOM or has existed in thelast several years, there are
far fewer troops, far fewerresources with much smaller
footprints. They're supporting amuch larger area of operations.
And in particular, there aremuch fewer Air Mobility assets
(06:50):
and air evacuation assets. Andtheir capabilities and their
capacities may vary from placeto place as well.
Dan Brillhart (06:59):
And so out of that sort of identified need. In
East Africa, the concept forerst was born the emergency
resuscitative surgical teamsAfrica, were first fielded in
2016 to support these veryaustere environments, and be
mobile able to go where theywere needed, with limited
(07:23):
support, and perhaps without anyaeromedical evacuation assets to
augment them. And initially,when these teams were created,
the the focus was on mobilityand proximity to the troops who
were at risk of being injured.
Over capability, we sacrificesort of what the normal
(07:44):
capability of a surgical team inCENTCOM over the last decade had
been, in order to get thosesurgical assets closer to the
troops who might need them. Butas happens over time, that
theater did slightly mature, thefootprint slightly increased,
and things sort of progressedand matured.
Erick Thronson (08:14):
One thing we do want to point out is that irst,
not just flexible and mobile,but is a highly modular team. So
when we talk about our DCRconcept, that is one subset of
the Earth, so irst consisted ofDCR team, which was an ER
physician and an ER nurse, adamage control surgery team, and
(08:37):
then another CSET, or criticalcare and road transport element.
And each of these three subsetsare able to operate
independently of each other, sothe DCR team can break away and
do their mission, DCS can stayin a position and still do
surgery. CSET can go off andtransport all by themselves
(09:01):
independently of the otherteams. And each element is able
to provide some redundantcapability. DCs can still
provide resuscitation CSET canstill provide resuscitative care
DCR can can provide transport ifneeded. And so can DCS. So
(09:21):
there, there's someinterchangeability there. In
addition, the personnel couldalso change. So Dan could have
broken away and jumped on to acritical care, transport and
flown a patient if you needed tothe same for me. Our ICU nurse
(09:41):
could have taken him on positionif needed to and that's a
product of of cross trainingreally, and and others
understanding the expectationthat you might need to step into
a role that is outside ofoutside of your norm. In
addition, so DCR we couldoperate independently, meaning
(10:05):
we could be our own standalonemedical asset, we could provide
point of injury care and enrollcare from the point of injury to
the rule two, all by ourselves,or we could augment organic
medical assets on the ground, sosoft medics, or we could augment
the aeromedical. Flightparamedics as well, if they if
they had those. So you need tobe we were really concerned with
(10:30):
being flexible andinteroperable.
Dan Brillhart (10:36):
So, so progress have been in quotation marks for
for a reason. You see in thenext slide, that this is the
sort of where the earth conceptstarted was a mobile operating
room set up on litter stands onthe leeward side of an armored
vehicle. And over time, thatsort of progressed, you know, we
(10:58):
went from these litter standsto, you know, thrown up a small
surgical tent. As you can see onthe next slide, men, that tent
became more robust and filled inwithin some HESCO barriers and
you know, some protective wirearound it. And then eventually,
we ended up in this purposebuilt, see hut that was designed
(11:22):
to be an operating room and withthat facility came more stuff
and X ray machine autoclavesterilization, plasma thar for
blood products. We even had PCRCOVID testing on our last
iteration. And those thingsincreased the capabilities. But
(11:42):
it flipped that paradigm thaterstes had initially been
founded on where I said, youknow, flexibility and proximity
were prioritized overcapability. Once we had those
capabilities, essentiallyfunction to anchor the surgical
team to this fixed location, itbecomes difficult to leave
(12:05):
behind all those extracapabilities and move forward.
So that modularity of DCR teamDCS team CSAT team that sort of
degraded over time is reallyjust span of a few years to
where we started to feel tied toa this to this fixed sight to
(12:28):
this outstation.
Erick Thronson (12:31):
You know, as time went on, and the theater
matured, and we became more of afixed facility asset, our
ability to be close to thatpoint of injury really
decreased. So, as we said, whenyou have an O bar, you want to
use the or you want to use allthe stuff that's an O R, because
(12:51):
it provides such a greatcapability to the patient. But
when all you have is a backpack,then operating in that backpack
seems second nature, becausethat's all you have. And being
able to do that in a far forwardlocation. Seems pretty
straightforward. So ultimately,you have a trade off there. And
(13:15):
so we saw, you know, over time,we really stopped becoming what
irst had originally beenintended for. So our DCR
concept, we, if the team iscontinually static, and anchored
(13:36):
to a fixed location all the timethat has a lot of capability,
then where is that capabilitygap that a conventional role to
couldn't fill? What is thedifference between this special
operations team that was puttogether and conventional FST?
Could they not also just sitthere just as well as you could?
What sets you apart from fromthose conventional teams. And so
(13:59):
we we think that the DCR in thissort of soft medical team should
be designed to accompany theground force, as far forward as
the objective right as farforward as the acts and to be
able to provide advancedresuscitative care as early and
casualties course of care aspossible and as tactically
(14:22):
feasible. So there isn't alwaysa role for providing very
advanced resuscitative care atthe point of injury, just
because that would that wouldpresent a tactical liability.
That doesn't make sense. Butthere could be certainly a lot
(14:42):
of circumstances where you dohave the time and you do have
the security to provide thosekinds of advanced resuscitative
techniques that they casuallymight need in a very time
sensitive manner. Especiallywhen you're so far removed
Medical Evacuation assets andyou're so far from a DCS role
(15:04):
to. But you also don't, youdon't want to be a tactical
liability on the battlefield. Sowe're all medical providers,
we're not soft operators. But ifyou're going to operate this far
forward, and you're going tosupport these kinds of teams,
you need to know how to movelike they do, you need to know
(15:25):
how to be highly mobile, youneed to know more than just the
medicine piece, you have to beable to, to work seamlessly and
integrate seamlessly into thoseteams. In addition, you know,
the, the soft medic is veryhighly trained, and they're very
(15:45):
good at what they do. The DCRteam, however, provides not just
advanced capabilities that theDCR medic, or that the soft
medic is never going to be ableto do. But we also provide a
great deal of experience thatthe soft medic doesn't
necessarily have. So, you know,we we do trauma care and
(16:08):
resuscitation all day, everyday, that's all we do. So if we
can take that and we can adaptthat to the austere environment,
I think we can, we can reallymake a difference, especially
when you're talking about thattyranny of distance, where you,
you might potentially have tosit at a patient for quite some
time. Either because evacuationis not available, or because it
(16:32):
is not technically feasible. Sothis is this is us, this is us
going back to kind of what Earthwas originally envisioned to be
the universe, if you will. Sothese are some patients that
were involved in an IED blastfar forward on an operation. And
(16:59):
as it turned out, these patientswere not able to be evacuated
immediately from thebattlefield. And so we did have
to sit on these patients for forsome time, there were multiple
patients. And we were able toemploy kind of our advanced or
sensitive techniques, not andnot just procedures and skill
sets, but also diagnosticcapability and experience to be
(17:24):
able to manage these highlycomplex multi system trauma
patients for an extended periodof time on the battlefield.
So, you know, you saw onprevious slides, we had our sort
of CCP set up in a purpose Billswamp hut, inside of a HESCO
(17:48):
barrier behind sea wire. This isan example of, you know, a
hastily built CCP that we set upimmediately following contact
with the enemy, where we wereable to, you know, take those
those fixed facility concepts,and put them here into into a
(18:11):
far forward you know, tacticalsituation. So this is a really
far cry from where we had beenat Arista a couple of years ago.
And, and so here we are in a CCPon the side of a partially
filled HESCO barrier,immediately following an attack
and, and our ability to, to bethere on the battlefield, that
(18:33):
far forward, ease the burden, orsome of the burden from those
soft operators, who functionedas soft medics as well, in that
situation, so that they couldfocus less on the medicine and
focus more on getting themission completed. And we could
worry about sort of the medicinepiece at that particular time.
Dan Brillhart (18:53):
And I think that's an important, you know,
thing to point out is that our,our combat medics, whether soft
medics or conventional medics,most of them were a dual hat,
where they are expected to bewarfighters and medical
providers. And so when you'reoperating with with a small
team, you know, platoon sized orsmaller element, and you can
(19:18):
offload that medical requirementoff of those dual hatted medics
and allow them to be warfighterswhen necessary, and you handle
the medical treatment. I thinkthat is a big plus for the the
ground force commander. So whatwhat do you you offer as a DCR
(19:39):
team, you know, you know,advanced skill sets are sort of
what what we push is that ourcombat medics, especially our
soft medics are are phenomenaland can do amazing things, but
there are, there's a limit totheir capabilities, there's a
limit to the amount of trainingtime They can dedicate to their
(20:02):
medical tasks versus theirwarfighter tasks. And there's a
limit to the amount ofexperience that they had.
Generally, the the medic who isout there, providing care point
of injury is relatively junior.
And especially compared to a lotof our emergency physicians,
(20:22):
emergency nurses that are outthere who have years of
experience, that makes a hugedifference. And you can go to
the next slide. These these aresome of the specific
capabilities that we providedwith our damage or solicitation
(20:43):
team. And these are things thatwe felt it was important to be
able to lay out to the groundforce commanders that we were
working for to say, Look, theseare the things that we can do,
that your medics can't, can'tnecessarily do. And we'll go
into sort of these in a coupleof subsequent slides. But that
(21:06):
last bullet is the biggest one.
I mean, it's really aboutexperience trauma experience
experience with transportingpatients experience with mass
casualty incidents is it's it'sit doesn't matter how robustly
your medics are trained, many ofthem, most of them over the
(21:29):
course of a career, we'll seefewer critically ill patients
and manage fewer critically illpatients then, you know, senior
emergency medicine resident doesin a year or, you know, a new ER
nurse does in a year, and sothat that level of experience
just can't be replicated easily.
And so that's one of the maincapabilities that we think we
(21:53):
add. You know, advanced airway.
This is one patient, you see,you know, we're working under
under lights outside with a safeto transport vent, but this
guy's orally intubated. If we goto the next slide, this is
(22:15):
another patient who this is backat the fixed role to about to
undergo surgery. But thispatient as well was oral
drakeley, intubated by by ourDCR team. And that's not sort of
standard TC three airwaymanagement. Had we not had a DCR
(22:36):
team there, both of thesepatients would have received
cricothyrotomy say almostcertainly. And so we can have an
academic discussion about theyou know, the risk benefit pros
cons of cricothyrotomy versusSupraglottic, airway versus RSI,
but the fact is, there's atleast a subset of patients who
(22:58):
could receive or trachealintubation on the battlefield
and for these two guys, atleast, it resulted in one less
war wound that they needed torecover from. And so we think
that advanced airway is is of isdefinitely something to weigh in
the risk benefit of employingthese DCR teams.
Erick Thronson (23:23):
Another big piece is blood blood is always a
huge logistical concern whereveryou go. So the teams that we
support primarily relied on alimited amount of fresh old
blood that they could carryforward in Golden Hour boxes.
(23:45):
However, you know, as I said,they carried only a few units
and outside of that they reliedon sort of a Rolo ask or fresh
whole blood buddy transfusionscheme. And, and that's fine.
And we absolutely need to employimplement those strategies.
(24:12):
Those are critical. Being ableto carry cold stored whole blood
Ford is an excellent option thatis certainly much more
economical in terms of time andtactics. Having golden hour
boxes that you can take forwardis perfect, except when you need
(24:35):
to do a mission that lasts morethan a couple of days. And in
that case, you need some otherbetter option. Our DCR team was
able to take our equipment anddevice you know a couple of
novel solutions in order to tostore and transport a couple
(24:58):
dozen Cold storage units withthe ground force and be able to
use it whenever we needed and infact, did use it. And it was
immediately available. So youknow, it might take you it's
gonna take you at least 20minutes probably to get a year
(25:19):
of whole blood using a Roll Upprogram. And in some instances,
it might take you equally aslong 20 minutes, 40 minutes, an
hour, an hour and a half orlonger depending on the tactical
situation to get blood flown in,if you don't otherwise have it
available. So being able to takethese this many units as far
(25:40):
forward and store themsustainably was was key. And
these teams would not have beenable to, to do this without our
support. In addition to having aDCR team on the ground, and one
that you can integrateseamlessly with with the ground
(26:02):
force and with the theevacuation asset provides a
pretty key capability of beingable to have seamless continuity
of care. So this is a casualtywho is being offloaded from a
Kazakh asset. The DCR team wasable to provide care for that
(26:24):
casualty on the ground at thepoint of injury, moments after
injury. resuscitate that patienton the ground, continue care in
the air, augmenting the flightparamedics, handoff care to our
own DCS team and then continuecare with that DCS team at the
(26:46):
fix role to facility. So beingable to provide insight into
this casualties, both injuries,mechanism of injuries course of
care that they received on theground and trending that
patient's status throughouttheir continuum of care through
surgery and, and possibly evenpost surgery is pretty huge. And
(27:11):
frankly, probably a lot saferthan the sort of hand off
shuffle that we often see tryingto provide care to the patient
doing a hasty handoff on to therotor wash to a flight medic
that, you know, some thingsmight get left out or be
unknown. And then depending onthe tactical situation, that
(27:32):
flight medic might also get ahasty handoff out of the rotor
wash to some provider while thatcable is being offloaded so they
can go back and fly pick up morecasualties.
Dan Brillhart (27:46):
Um, so this is a specific example of this general
principle of you know, advancedmedical care and it's not
necessarily all combat trauma.
There are a lot of things that aDCR team as we envision it is
more capable and equipped totreat than our our combat medic
(28:10):
contingent. This is Eric at ajuvenile Black Mamba that, that
we killed in a area where wewere operating troops were
sleeping nearby. And so thepoint of this picture is that we
were able to carry bring forwardanti venom capability. For in we
(28:35):
worked in an area operationsthat had some of the most
venomous snakes in the world.
And the flight time to bring apatient who was snake bitten
back to the fixed facility wasless than the amount of time
that it typically takes a blackmamba to kill an adult human.
(28:56):
And so we were able to bringthat anti venom capability and
the knowledge and experiencerequired to use it because it's
a pretty dangerous drug reallyto administer, we're able to
bring those with us to theobjective to the point of
potential risk to our ouroperators. And, you know, this
(29:19):
is an example, I think, similarto reboa. Where could we teach
our medics to do this? Yes. Howmuch effort is required to teach
that medical expertise to anoperator versus how much effort
(29:41):
does it take to teach thetechnical expertise necessary to
bring a medical professional tothis point, becomes becomes what
we have to balance in thescales. Other advanced
diagnostic sort of scenarios,you know, bring ultrasonography
forward Is is helpful this is,you know, one of us diagnosing a
(30:06):
nerve injury after a penetratingwound in one of our host nation,
partner force patients, that'ssomething that again, it would
be very difficult to impart thatskill set to a combat medic. And
then the next slide, I think ispotentially the sexiest
(30:30):
capability add that a DCR teambrings, I'm not sure that it is
the most important one, however,but I'm not sure if he can
really even make it out in thisslide. But down there in the red
circle, you can see a reboacatheter emerging from the the
groin of this patient who'sbeing dropped off from
(30:51):
evacuation from point of injury,or DCR team was able to bring
Ebola to point of injury at timeof injury, and, as far as we
know, is the first instance ofemploying it. And there's, you
know, the case reports, inprocess and be pending. So don't
bother going to the details ofthe scenario. But the real point
(31:14):
here is that we need to be ableto talk to our ground force
commanders about whatcapabilities can be added in
terms that they're able tounderstand and process and use
in a risk benefit analysis ofwhether it makes sense in a
given scenario for a givenmission with a given unit to
(31:34):
bring these DCR teams forward ornot.
And, you know, there is someadditional medical training that
that I think is necessary, Idon't think that you can pluck a
hospital based emergencymedicine provider out and say,
Well, you have everything thatyou need to know to go out and
(31:55):
work on your knees in the dirtin this sort of scenario, and I
guess this would be my sort ofshort list of recommendations,
you know, Recommendation NumberOne, two, and three are our
nursing skills. You know, wethink of sort of traditional
nursing skills for me as an ERphysician, those were some of
the the that was the steepestlearning curve for me was
(32:17):
medication administrationgetting better at IV starts
doing sort of patient caretasks, those things that sort of
bleed into prolonged field care,all of those things need to be
within your skill set and withinwithin your purview.
Additionally, aeromedicalevacuation if you're going to be
(32:39):
at point of injury, as Eric wassaying earlier, earlier, one of
the greatest benefits is thatbeing at point of injury, you're
able to accompany the patientthrough evacuation to the next
level of care. And so you needto be able to jump on that
helicopter and provide care. Andthe jack the joint in route
(33:01):
critical care course, issomething I would highly
recommend for anyone who's goingto be on one of these DCR type
missions. And then, you know,understanding the TC three sort
of specific equipment, you know,we all are fairly comfortable
with our hospital basedventilators and monitors and
title co2 detectors andeverything but making sure that
(33:23):
you're you know, facile withwhichever you know, save bands,
or the the impact bands orwhatever it is that you are
equipped with is anotherspecific training thing that I
would certainly encourage you toundergo. I think to
Erick Thronson (33:43):
still speaking on the slide. So tests, you know
that that first bullet, allthose nursing skills are
probably important for, for thephysicians, you don't
necessarily do those every day.
I think in the type of settingthat we're talking about as
well. If you're going to takesomebody who is not a physician,
(34:05):
if you're going to take anemergency nurse, perhaps or
you're going to take specialoperations combat medic with
you. That provider, thatclinician also needs additional
medical training to fill some ofthose gaps in these type of
settings, all of us, no matterkind of what your role is medica
(34:29):
physician and nurse operate atthe greatest extent of our scope
of practice. So that means thatI for instance, might be doing
something in these kind ofsettings that I'm not normally
going to be doing in theemergency department, or I
typically work. I think that wesometimes don't give a lot of
(34:55):
credence that But being able tobe facile with some of those
skills, some of those advancedskills that we might not
necessarily be doing. It can bepretty critical. lifesaving in
some instances, and you need toknow how to do that. And you
need to train the people thatare going to be with you how to
(35:17):
either also do those skills thatyou do or how to help you
accomplish some of thoseadvanced tasks. So what are some
of the trade offs of having aDCR team that's, that's far far
we like that. One, we don't haveany surgeons with us right? In
this particular permutation of ateam that's going to go far
(35:42):
forward with a soft yet. Solimited surgical capability,
right, we can do some surgicalthings. Dan can obviously can do
a thoracotomy if we have thetools available to us. But
that's about it, where we're notopening valets, we're not fixing
vascular injuries surgically.
(36:06):
And as a medical team, whenyou're that far forward, you
incur a greater risk ofexposure, you're not
unnecessarily in a protectedlocation. At a base, although we
should also recognize that beingat an MSS or FOB doesn't make
(36:29):
you immune from injury fromenemy attack, but you certainly
if you're going to go outsidethe wire, and you're going to
operate, where some of theseunits are operating, you're
going to incur the same, orpretty similar amounts of risk
that that those operators arealso incurring, that has to go
into your calculus, as well asthe calculus, the ground force
(36:50):
commander, about the kind ofrisks that you all are willing
to incur based off of themission that that is in front of
you. Also, if if, if there's aDCR team that goes forward, they
require seats, right, you haveto be able to put them on a seat
to get them with to travel withyou to get them onto the x,
(37:11):
which means that there arepotentially fewer seats for
First off operators. Again, aswe've highlighted, this is a
very limited environment. It'snot like we have an unlimited
number of vehicles, or aircraftto take us places, there are a
limited number of seats. So youhave to decide who is going to
(37:33):
fill that particular seat. Is itworth it to the ground force
commander to give those seats toyou, versus giving them to
somebody else. Also, what goesinto that, that calculus as well
is that, you know, as medicalproviders, we're not soft
(37:54):
hoppers. I think, as we've said,several times during this talk,
we're not Green Berets, andwe're not seals, we're doctors
and nurses, and we have limitedformal training in those kind of
tactical and operational tasks.
That doesn't mean that thoseskills are beyond you. But it
does mean that as part of yourtraining pipeline, you didn't
(38:17):
necessarily learn how to shootfrom behind a barricade or
operate a cross system, orrecover a stuck vehicle or learn
the nuances of passage of linesin the dark during patrol base
operations. But you can learnthose skills that's just not
(38:39):
necessarily in your wheelhouse.
We're considered non combatants.
And we are also as such,typically we don't carry operate
offensive weapons, and wereafforded certain protections
under the Geneva Convention.
(39:01):
That status is not a permanentstatus that can change you can
become a combatant, depending onthe particular situation that
you're in. For instance, if youare not exclusively providing
humanitarian aid, or exclusivelyproviding medical care, you may
(39:23):
lose your protected status andmay go from non combatant to a
legal combatant. Those are legalquestions that you will have to
to seek, seek counsel for inyour specific set of
(39:44):
circumstances but that issomething that should be
considered by yourself by theground force commander and by a
higher headquarters
Dan Brillhart (40:01):
And so there are a lot of benefits the DCR teams
want to be very upfront aboutwhat what the limitations are, I
mean, the biggest limitation forany of this time to become
proficient in the technicaltasks that we're talking about
requires time time for training,to truly integrate with the
(40:24):
team's, the maneuver elementsthat you're supporting requires
time time to familiarize time totrain time to integrate. And,
you know, far forward advanceddamage control resuscitation is
not a panacea, you're not goingto save every patient by being
out there. And so how does thatconvey? How does that play with
(40:51):
the maneuver elements thatyou're working with? And then
it's critical, we all know thatsurgery is what fixes trauma,
and so resuscitation, bloodproduct product resuscitation
can sort of prolong the timethat a patient can tolerate
(41:13):
surgery. But having a DCR teamwithout damage control surgical
plan to back it up, isirrational and obviously going
to be ineffectual. So we'vetalked a little bit about this
conversation, this theoreticalconversation with the Ground
(41:37):
Force Commander about, hey,here's a DCR team, they can
support your operations, hereare the capabilities that they
add, here are their limitationshere, the things that they're
gonna need. But this is, Ithink, a very critical thing.
And this is just a genericexample of what Eric and I used,
we provided basically a menu toour ground force commander and
(42:00):
says, These are the differentpackages that we can do. And
there's a very light packages, avery robust package. And you can
figure out the duration based onthe number of days of operations
that you can support or thenumber of casualties that that
you can treat. But you've got tocome up with something that
(42:21):
says, Hey, these are our packageoptions. And this is the waiting
cube that it requires. Becausethat's what you really come down
to how many seats have you takenup? How much of our cargo space
do we need to give away in orderto bring you out there, and then
that Notes section of what areyou adding, if I've just bring
one guy out there with hisrucksack, I'm going to add
(42:42):
advanced airway. If I add in,you know, another turn 50 pounds
and a second DCR team member, Ican give you a bow, a
thoracotomy, blood transfusion,etc. And so you want to have
some type of menu of options forthese DCR teams if you're going
to offer them to a to a groundelement. And so the other things
(43:07):
that I will say are we need tomitigate our limitations and
mitigate our risks as much aspossible. And so self
sufficiency, I think, is theoverarching critical one, you
know, in regards to security,life, sport needs, weight, and
cute everything you want to beas minimal a burden on the
maneuver element as possible.
field craft is what a lot ofthis comes down to. And then
(43:31):
weapons proficiency, crosstraining, making sure that you
can fill needs and voids withinthe maneuver unit, and then
rehearsals as much as possiblein as as deep as possible,
rehearsing all of the varioustasks that you're going to need
to accomplish. And this issomething that helps you also
(43:54):
build credibility with themaneuver unit is you engage in
their tactical rehearsals andwork through the sort of, you
know, tactical tasks that theyrehearse over and over again,
but then there's always amedical piece that comes into
rehearsals, and you can bringmore fidelity and force them to
sort of train that task to ahigher level than they probably
(44:19):
do when you're not there. Andthat can help you instill
confidence with that maneuverunit that you really are, you're
the real deal. You are bringingsomething to the table. And then
integration and planning isimportant, just for the sake of
making sure that theexpectations are realistic and
(44:39):
being able to be there and say,you know, just cuz you bring me
out there and drop me in themiddle of a swamp. I'm not
necessarily going to be able tosave everybody's life no matter
what happens, you know, so ifyou're not there at the table,
when the planning is ongoing,sometimes things can get
Erick Thronson (44:58):
a little bit askew
Dan Brillhart (45:01):
And these next couple slides just you know,
some some pictures like go outthere, train with the guys that
you're going to work with, dothe things that they're doing.
Show them that you arecompetent, capable and willing
to get your hands dirty. We dida lot of weapons training. And
we did a lot of hoist trainingwith our both our evac team and
(45:28):
our soft medics, and just madesure that they knew, hey, we're
here, we're willing to do thesame stuff that you guys are
doing. And then that helped usto integrate. And then this next
slide is a recycle of the firstpicture that we loaded up there.
You know, this is me, Eric andour four seal medics. And
(45:51):
there's a distinction betweenposing as an operator, looking
cool, trying to play a role, andsuccessfully integrating with
the people that you'resupporting, living working with
on a day in day out basis. Itisn't about you know, hyping
(46:13):
yourself up it is about beingable to speak the same language,
walk the walk and look the lookof the guys you're there with.
Because if you stick out like asore thumb, nobody's nobody's
really gonna trust you out in afar forward tactical environment
like this. And you know, Ithink, in emergency medicine,
(46:35):
we're pretty good at this, inbalancing those two things. You
know, if if I've got a ifthere's a baby that needs to be
delivered in the ER, I'm notgoing to deliver that baby. If
there's an OBGYN standing nextto me, I'm ready to go.
Similarly, I'm not going to mana machine gun when there's a
navy steel Navy SEAL standing byready to do the job. But in
(46:56):
either one of those situations,I'm I'm ready, I'm able to be
the second best option if thosepeople can't be there. And it's,
it's just being realistic andrecognizing your limit your
limitations and yourcapabilities, and being honest
about those with with everyone.
Erick Thronson (47:18):
Alright, so kind of our conclusions about our DCS
concept is that an adequatelyprepared and motivated DCR team
really can bring something tothe table in this environment,
you can augment and enhance thecapabilities of the organic
medical assets of whichevermaneuver element you happen to
(47:41):
be supporting. And you canprovide elements and you can
provide opportunities tomitigate the risk of being so
far forward with so fewresources, you can enhance the
kind of care that thosecasualties are going to receive
at the point of injury, andpotentially save lives. I think
(48:02):
it's important to note that, asDan mentioned previously, DCR
far forward is not the end allbe all isn't a panacea. We can't
solve all the problems, we'renot going to save every life on
the battlefield. And it mightnot be appropriate to put a DCR
(48:23):
element forward in everycircumstance. Those are specific
questions. And that's an answerto a specific problem. So there,
there is a time and place andthere is a role in the correct
circumstance. And if you prepareyourself, and you're able to
(48:46):
successfully integrate, and intothe unit that you're supporting,
on, you really can make adifference, literally on the
battlefield. So in 2019, the JTSpublished CPG on on austere,
resuscitative, surgical care,which really laid out a lot of
(49:12):
those key concepts that wentinto the creation of irst. And
described in detail, kind ofwhat are the requirements for
being able to do the kind ofresuscitative and surgical care
that's required in those typesof settings and sort of what
(49:34):
what sets you apart from thesort of conventional medical
surgical asset that you mighttypically take, and that that
CBG was really designed to helpprepare conventional surgical
units to be able to take onthese kinds of missions. But
(49:55):
that really provide does providethe opportunity to doctrinal
eyes Some of the those conceptsand and I think lays the
foundation for not justconventional assets, but also
some more permanent, specialoperations, surgical assets, as
(50:18):
well.
Dan Brillhart (50:22):
And so what our recommendations for all of this,
you know, our experience, beinga DCR team providing highly
advanced very far forward,damage control a state of care
to sort of the tip of the spearwas mostly successful and
(50:47):
rewarding for us and for the thepeople that we supported. And,
you know, we operated in aspecial operations sort of
context. But I personallybelieve that this is something
that could be expanded toconventional forces as well, in
a sort of conventional warfareenvironment, putting a DCR team
(51:13):
on every mission makes no senseand isn't sustainable and
requires far too much risk andfar too many resources. But
certainly, there are higher riskmissions, where it does make
sense. And I think the, thebridge to get to that point is,
you know, within the virtualroom of this conference, it's
(51:38):
the people within ourorganization who can advocate
for the capabilities that we canadd and provide and the
willingness of us to providethem that can sort of augment
and enhance and take fartherforward these concepts of
damage, control, resuscitationand make things better for the
(52:01):
people who are out theredefending our nation. You know,
one, one way of thinking of forme is that, you know, every
every infantry platoon in the USArmy doesn't need a damage
control resuscitation team, butmaybe every division does, and
the, you know, highest riskmissions, it's an asset that can
(52:23):
be requested and support amaneuver element. I mean, that's
just me spitballing it pie inthe sky doctrine. But I do, I do
think that there is a role forthis, and it needs to be
expanded and developed. Soreally, thank you all for
listening. And I look forward toyour questions in the live q&a
(52:46):
session that's going toimmediately follow this recorded
lecture. Thank you all. Thanks,Eric.
Hello GSACEP. And thank you for joining us for our
talk regarding the DCR teamconcept. dcr. Core stands for
damage control resuscitation,which I think of as sort of all
of the trauma management thatoccurs in tactical combat
casualty care prior to thepatient receiving surgical care.
(00:20):
The DCR team concept that wewant to tell you about is our
proposal to bring more advancedand sort of nuanced DCR care
farther forward on thebattlefield, as far forward as
possible. Ideally, I'm but I'mgetting a little bit ahead of
myself, who are we? And why arewe talking about this? I'm Dan
Bernhardt. I'm an Army 62 Alphaemergency physician, my
(00:43):
colleague, Eric Johnson, is anarmy 66 tango, emergency trauma
nurse, Eric and I have beendeployed together for about five
years now, most recently withthe earth mission supporting
Special Operations CommandAfrica. And throughout those
five years, we've been refiningand testing a set of TTPs that
(01:04):
evolved into this concept thatwe refer to just simply as a DCR
team. And the intent, the intentof those teams is to accomplish
the thing that we're mostpassionate about. And that is
bring high quality emergencydepartment level resuscitative
care as close to the point ofinjury as possible for our
warfighters.
(01:24):
So these disclaimer slides,we've all seen it a million
times. But in this case, Ireally do mean it. The views
here that we're talking aboutreally are not policy, or even
widely held beliefs within theDOD. But Eric, and I think they
should be. And if we're reallyserious about reducing
preventable deaths on thebattlefield, we think employing
(01:47):
emergency medicineprofessionals, doctors and
nurses in the manner we'redescribing could have a
significant impact. But none ofthis is doctrine. None of this
is policy. And none of this is asort of accepted dogma at this
point. So the purpose of whatwe're talking about is number
one, to tell the story of whatwe've been doing, share our
(02:08):
successes, our failures, and thehope to be that some of you can
take this sort of initial effortand move forward with it and
create something bigger andbetter and more effective.
Because we believe that thisconcept should expand outside of
the Special Operations communitywhere it's currently being used,
(02:30):
and sort of being employedacross the force where
appropriate to deliver the bestcare that we can for our service
members. So what exactly is ourstory? What did we do? Well, as
part of the the earth program,in our East Africa area, we took
an emergency physician andemergency trauma nurse, and we
(02:52):
embedded them with a maneuverelement. And augmented are for
Special Operations medics, andyou can see there's our medical
treatment team here. And we wentout on Grand ground combat
missions lasting anywhere from afew hours to a few weeks. And
augmented the the medicalcapability of that team with
(03:16):
again, emergency departmentlevel resuscitative, sort of
knowledge, skill, equipment, andput it not only at the point of
injury, but at the time ofinjury as well, which I think is
an important distinction becausewe can throw advanced
resuscitation teams on toaircraft and fly them out to the
(03:37):
point of injury to pick apatient up. But you've already
lost some time at that point.
And those minutes may becritical, especially for the
types of advanced resuscitativecapabilities that we're
advocating for things likeadvanced airway, reboa,
emergency resuscitative,thoracotomy, more robust use of
blood products, all those thingshave a very finite window of
(03:58):
minutes really, where they canpotentially make a difference.
And so having the people toprovide those procedures, those
sort of augmented skill setsthere when the damage happens,
we think is important.
Erick Thronson (04:18):
So the idea of putting Advanced Care forward
isn't necessarily a new idea. Ithink military medicine is
always trying to balance therisk of getting physicians and
advanced medical care as closeto the casualty and the point of
injury as possible. With youknow, the the life saving
benefits that they they provide.
So there's always a kind of arisk benefit analysis that goes
(04:39):
into that.
But using small, highly mobileteams like this is is something
that has been done acrossvarious organizations, both in
the United States andinternationally for for several
years. I'm particularly insupport of special operations.
(05:03):
And they have been verysuccessful doing so. But those
teams are few and far between.
and, and they're in high demand.
So they can't be everywhere allthe time. And that is just one
(05:23):
or a few. A team concepts andconstructs that have been
created that aren't necessarilythe right thing for all
environments. So you have to beable to look at where you're
going to be in the kind ofmission you're going to support
in order to create the best sortof team to support those kinds
(05:44):
of operations. So in EastAfrica, that was born out of the
need for sort of this farforward, highly mobile flexible
team that was able to travelfrom place to place in the
resource limited environment ofEast Africa. And so the medical
military medical community inEast Africa identified that
there were no existing oravailable teams that were going
(06:06):
to be able to fill that gap atthat time. And the conventional
teams, we're not necessarilygoing to be able to work in that
space either. You know, thetheater in East Africa is, is
also complicated, not just bytime and distance. But
(06:27):
logistically, it's a far moreimmature theater, and certainly
more mature than the theaterthat we know, that exists in
CENTCOM or has existed in thelast several years, there are
far fewer troops, far fewerresources with much smaller
footprints. They're supporting amuch larger area of operations.
And in particular, there aremuch fewer Air Mobility assets
(06:50):
and air evacuation assets. Andtheir capabilities and their
capacities may vary from placeto place as well.
Dan Brillhart (06:59):
And so out of that sort of identified need. In
East Africa, the concept forerst was born the emergency
resuscitative surgical teamsAfrica, were first fielded in
2016 to support these veryaustere environments, and be
mobile able to go where theywere needed, with limited
(07:23):
support, and perhaps without anyaeromedical evacuation assets to
augment them. And initially,when these teams were created,
the the focus was on mobilityand proximity to the troops who
were at risk of being injured.
Over capability, we sacrificesort of what the normal
(07:44):
capability of a surgical team inCENTCOM over the last decade had
been, in order to get thosesurgical assets closer to the
troops who might need them. Butas happens over time, that
theater did slightly mature, thefootprint slightly increased,
and things sort of progressedand matured.
Erick Thronson (08:14):
One thing we do want to point out is that irst,
not just flexible and mobile,but is a highly modular team. So
when we talk about our DCRconcept, that is one subset of
the Earth, so irst consisted ofDCR team, which was an ER
physician and an ER nurse, adamage control surgery team, and
(08:37):
then another CSET, or criticalcare and road transport element.
And each of these three subsetsare able to operate
independently of each other, sothe DCR team can break away and
do their mission, DCS can stayin a position and still do
surgery. CSET can go off andtransport all by themselves
(09:01):
independently of the otherteams. And each element is able
to provide some redundantcapability. DCs can still
provide resuscitation CSET canstill provide resuscitative care
DCR can can provide transport ifneeded. And so can DCS. So
(09:21):
there, there's someinterchangeability there. In
addition, the personnel couldalso change. So Dan could have
broken away and jumped on to acritical care, transport and
flown a patient if you needed tothe same for me. Our ICU nurse
(09:41):
could have taken him on positionif needed to and that's a
product of of cross trainingreally, and and others
understanding the expectationthat you might need to step into
a role that is outside ofoutside of your norm. In
addition, so DCR we couldoperate independently, meaning
(10:05):
we could be our own standalonemedical asset, we could provide
point of injury care and enrollcare from the point of injury to
the rule two, all by ourselves,or we could augment organic
medical assets on the ground, sosoft medics, or we could augment
the aeromedical. Flightparamedics as well, if they if
they had those. So you need tobe we were really concerned with
(10:30):
being flexible andinteroperable.
Dan Brillhart (10:36):
So, so progress have been in quotation marks for
for a reason. You see in thenext slide, that this is the
sort of where the earth conceptstarted was a mobile operating
room set up on litter stands onthe leeward side of an armored
vehicle. And over time, thatsort of progressed, you know, we
(10:58):
went from these litter standsto, you know, thrown up a small
surgical tent. As you can see onthe next slide, men, that tent
became more robust and filled inwithin some HESCO barriers and
you know, some protective wirearound it. And then eventually,
we ended up in this purposebuilt, see hut that was designed
(11:22):
to be an operating room and withthat facility came more stuff
and X ray machine autoclavesterilization, plasma thar for
blood products. We even had PCRCOVID testing on our last
iteration. And those thingsincreased the capabilities. But
(11:42):
it flipped that paradigm thaterstes had initially been
founded on where I said, youknow, flexibility and proximity
were prioritized overcapability. Once we had those
capabilities, essentiallyfunction to anchor the surgical
team to this fixed location, itbecomes difficult to leave
(12:05):
behind all those extracapabilities and move forward.
So that modularity of DCR teamDCS team CSAT team that sort of
degraded over time is reallyjust span of a few years to
where we started to feel tied toa this to this fixed sight to
(12:28):
this outstation.
Erick Thronson (12:31):
You know, as time went on, and the theater
matured, and we became more of afixed facility asset, our
ability to be close to thatpoint of injury really
decreased. So, as we said, whenyou have an O bar, you want to
use the or you want to use allthe stuff that's an O R, because
(12:51):
it provides such a greatcapability to the patient. But
when all you have is a backpack,then operating in that backpack
seems second nature, becausethat's all you have. And being
able to do that in a far forwardlocation. Seems pretty
straightforward. So ultimately,you have a trade off there. And
(13:15):
so we saw, you know, over time,we really stopped becoming what
irst had originally beenintended for. So our DCR
concept, we, if the team iscontinually static, and anchored
(13:36):
to a fixed location all the timethat has a lot of capability,
then where is that capabilitygap that a conventional role to
couldn't fill? What is thedifference between this special
operations team that was puttogether and conventional FST?
Could they not also just sitthere just as well as you could?
What sets you apart from fromthose conventional teams. And so
(13:59):
we we think that the DCR in thissort of soft medical team should
be designed to accompany theground force, as far forward as
the objective right as farforward as the acts and to be
able to provide advancedresuscitative care as early and
casualties course of care aspossible and as tactically
(14:22):
feasible. So there isn't alwaysa role for providing very
advanced resuscitative care atthe point of injury, just
because that would that wouldpresent a tactical liability.
That doesn't make sense. Butthere could be certainly a lot
(14:42):
of circumstances where you dohave the time and you do have
the security to provide thosekinds of advanced resuscitative
techniques that they casuallymight need in a very time
sensitive manner. Especiallywhen you're so far removed
Medical Evacuation assets andyou're so far from a DCS role
(15:04):
to. But you also don't, youdon't want to be a tactical
liability on the battlefield. Sowe're all medical providers,
we're not soft operators. But ifyou're going to operate this far
forward, and you're going tosupport these kinds of teams,
you need to know how to movelike they do, you need to know
(15:25):
how to be highly mobile, youneed to know more than just the
medicine piece, you have to beable to, to work seamlessly and
integrate seamlessly into thoseteams. In addition, you know,
the, the soft medic is veryhighly trained, and they're very
(15:45):
good at what they do. The DCRteam, however, provides not just
advanced capabilities that theDCR medic, or that the soft
medic is never going to be ableto do. But we also provide a
great deal of experience thatthe soft medic doesn't
necessarily have. So, you know,we we do trauma care and
(16:08):
resuscitation all day, everyday, that's all we do. So if we
can take that and we can adaptthat to the austere environment,
I think we can, we can reallymake a difference, especially
when you're talking about thattyranny of distance, where you,
you might potentially have tosit at a patient for quite some
time. Either because evacuationis not available, or because it
(16:32):
is not technically feasible. Sothis is this is us, this is us
going back to kind of what Earthwas originally envisioned to be
the universe, if you will. Sothese are some patients that
were involved in an IED blastfar forward on an operation. And
(16:59):
as it turned out, these patientswere not able to be evacuated
immediately from thebattlefield. And so we did have
to sit on these patients for forsome time, there were multiple
patients. And we were able toemploy kind of our advanced or
sensitive techniques, not andnot just procedures and skill
sets, but also diagnosticcapability and experience to be
(17:24):
able to manage these highlycomplex multi system trauma
patients for an extended periodof time on the battlefield.
So, you know, you saw onprevious slides, we had our sort
of CCP set up in a purpose Billswamp hut, inside of a HESCO
(17:48):
barrier behind sea wire. This isan example of, you know, a
hastily built CCP that we set upimmediately following contact
with the enemy, where we wereable to, you know, take those
those fixed facility concepts,and put them here into into a
(18:11):
far forward you know, tacticalsituation. So this is a really
far cry from where we had beenat Arista a couple of years ago.
And, and so here we are in a CCPon the side of a partially
filled HESCO barrier,immediately following an attack
and, and our ability to, to bethere on the battlefield, that
(18:33):
far forward, ease the burden, orsome of the burden from those
soft operators, who functionedas soft medics as well, in that
situation, so that they couldfocus less on the medicine and
focus more on getting themission completed. And we could
worry about sort of the medicinepiece at that particular time.
Dan Brillhart (18:53):
And I think that's an important, you know,
thing to point out is that our,our combat medics, whether soft
medics or conventional medics,most of them were a dual hat,
where they are expected to bewarfighters and medical
providers. And so when you'reoperating with with a small
team, you know, platoon sized orsmaller element, and you can
(19:18):
offload that medical requirementoff of those dual hatted medics
and allow them to be warfighterswhen necessary, and you handle
the medical treatment. I thinkthat is a big plus for the the
ground force commander. So whatwhat do you you offer as a DCR
(19:39):
team, you know, you know,advanced skill sets are sort of
what what we push is that ourcombat medics, especially our
soft medics are are phenomenaland can do amazing things, but
there are, there's a limit totheir capabilities, there's a
limit to the amount of trainingtime They can dedicate to their
(20:02):
medical tasks versus theirwarfighter tasks. And there's a
limit to the amount ofexperience that they had.
Generally, the the medic who isout there, providing care point
of injury is relatively junior.
And especially compared to a lotof our emergency physicians,
(20:22):
emergency nurses that are outthere who have years of
experience, that makes a hugedifference. And you can go to
the next slide. These these aresome of the specific
capabilities that we providedwith our damage or solicitation
(20:43):
team. And these are things thatwe felt it was important to be
able to lay out to the groundforce commanders that we were
working for to say, Look, theseare the things that we can do,
that your medics can't, can'tnecessarily do. And we'll go
into sort of these in a coupleof subsequent slides. But that
(21:06):
last bullet is the biggest one.
I mean, it's really aboutexperience trauma experience
experience with transportingpatients experience with mass
casualty incidents is it's it'sit doesn't matter how robustly
your medics are trained, many ofthem, most of them over the
(21:29):
course of a career, we'll seefewer critically ill patients
and manage fewer critically illpatients then, you know, senior
emergency medicine resident doesin a year or, you know, a new ER
nurse does in a year, and sothat that level of experience
just can't be replicated easily.
And so that's one of the maincapabilities that we think we
(21:53):
add. You know, advanced airway.
This is one patient, you see,you know, we're working under
under lights outside with a safeto transport vent, but this
guy's orally intubated. If we goto the next slide, this is
(22:15):
another patient who this is backat the fixed role to about to
undergo surgery. But thispatient as well was oral
drakeley, intubated by by ourDCR team. And that's not sort of
standard TC three airwaymanagement. Had we not had a DCR
(22:36):
team there, both of thesepatients would have received
cricothyrotomy say almostcertainly. And so we can have an
academic discussion about theyou know, the risk benefit pros
cons of cricothyrotomy versusSupraglottic, airway versus RSI,
but the fact is, there's atleast a subset of patients who
(22:58):
could receive or trachealintubation on the battlefield
and for these two guys, atleast, it resulted in one less
war wound that they needed torecover from. And so we think
that advanced airway is is of isdefinitely something to weigh in
the risk benefit of employingthese DCR teams.
Erick Thronson (23:23):
Another big piece is blood blood is always a
huge logistical concern whereveryou go. So the teams that we
support primarily relied on alimited amount of fresh old
blood that they could carryforward in Golden Hour boxes.
(23:45):
However, you know, as I said,they carried only a few units
and outside of that they reliedon sort of a Rolo ask or fresh
whole blood buddy transfusionscheme. And, and that's fine.
And we absolutely need to employimplement those strategies.
(24:12):
Those are critical. Being ableto carry cold stored whole blood
Ford is an excellent option thatis certainly much more
economical in terms of time andtactics. Having golden hour
boxes that you can take forwardis perfect, except when you need
(24:35):
to do a mission that lasts morethan a couple of days. And in
that case, you need some otherbetter option. Our DCR team was
able to take our equipment anddevice you know a couple of
novel solutions in order to tostore and transport a couple
(24:58):
dozen Cold storage units withthe ground force and be able to
use it whenever we needed and infact, did use it. And it was
immediately available. So youknow, it might take you it's
gonna take you at least 20minutes probably to get a year
(25:19):
of whole blood using a Roll Upprogram. And in some instances,
it might take you equally aslong 20 minutes, 40 minutes, an
hour, an hour and a half orlonger depending on the tactical
situation to get blood flown in,if you don't otherwise have it
available. So being able to takethese this many units as far
(25:40):
forward and store themsustainably was was key. And
these teams would not have beenable to, to do this without our
support. In addition to having aDCR team on the ground, and one
that you can integrateseamlessly with with the ground
(26:02):
force and with the theevacuation asset provides a
pretty key capability of beingable to have seamless continuity
of care. So this is a casualtywho is being offloaded from a
Kazakh asset. The DCR team wasable to provide care for that
(26:24):
casualty on the ground at thepoint of injury, moments after
injury. resuscitate that patienton the ground, continue care in
the air, augmenting the flightparamedics, handoff care to our
own DCS team and then continuecare with that DCS team at the
(26:46):
fix role to facility. So beingable to provide insight into
this casualties, both injuries,mechanism of injuries course of
care that they received on theground and trending that
patient's status throughouttheir continuum of care through
surgery and, and possibly evenpost surgery is pretty huge. And
(27:11):
frankly, probably a lot saferthan the sort of hand off
shuffle that we often see tryingto provide care to the patient
doing a hasty handoff on to therotor wash to a flight medic
that, you know, some thingsmight get left out or be
unknown. And then depending onthe tactical situation, that
(27:32):
flight medic might also get ahasty handoff out of the rotor
wash to some provider while thatcable is being offloaded so they
can go back and fly pick up morecasualties.
Dan Brillhart (27:46):
Um, so this is a specific example of this general
principle of you know, advancedmedical care and it's not
necessarily all combat trauma.
There are a lot of things that aDCR team as we envision it is
more capable and equipped totreat than our our combat medic
(28:10):
contingent. This is Eric at ajuvenile Black Mamba that, that
we killed in a area where wewere operating troops were
sleeping nearby. And so thepoint of this picture is that we
were able to carry bring forwardanti venom capability. For in we
(28:35):
worked in an area operationsthat had some of the most
venomous snakes in the world.
And the flight time to bring apatient who was snake bitten
back to the fixed facility wasless than the amount of time
that it typically takes a blackmamba to kill an adult human.
(28:56):
And so we were able to bringthat anti venom capability and
the knowledge and experiencerequired to use it because it's
a pretty dangerous drug reallyto administer, we're able to
bring those with us to theobjective to the point of
potential risk to our ouroperators. And, you know, this
(29:19):
is an example, I think, similarto reboa. Where could we teach
our medics to do this? Yes. Howmuch effort is required to teach
that medical expertise to anoperator versus how much effort
(29:41):
does it take to teach thetechnical expertise necessary to
bring a medical professional tothis point, becomes becomes what
we have to balance in thescales. Other advanced
diagnostic sort of scenarios,you know, bring ultrasonography
forward Is is helpful this is,you know, one of us diagnosing a
(30:06):
nerve injury after a penetratingwound in one of our host nation,
partner force patients, that'ssomething that again, it would
be very difficult to impart thatskill set to a combat medic. And
then the next slide, I think ispotentially the sexiest
(30:30):
capability add that a DCR teambrings, I'm not sure that it is
the most important one, however,but I'm not sure if he can
really even make it out in thisslide. But down there in the red
circle, you can see a reboacatheter emerging from the the
groin of this patient who'sbeing dropped off from
(30:51):
evacuation from point of injury,or DCR team was able to bring
Ebola to point of injury at timeof injury, and, as far as we
know, is the first instance ofemploying it. And there's, you
know, the case reports, inprocess and be pending. So don't
bother going to the details ofthe scenario. But the real point
(31:14):
here is that we need to be ableto talk to our ground force
commanders about whatcapabilities can be added in
terms that they're able tounderstand and process and use
in a risk benefit analysis ofwhether it makes sense in a
given scenario for a givenmission with a given unit to
(31:34):
bring these DCR teams forward ornot.
And, you know, there is someadditional medical training that
that I think is necessary, Idon't think that you can pluck a
hospital based emergencymedicine provider out and say,
Well, you have everything thatyou need to know to go out and
(31:55):
work on your knees in the dirtin this sort of scenario, and I
guess this would be my sort ofshort list of recommendations,
you know, Recommendation NumberOne, two, and three are our
nursing skills. You know, wethink of sort of traditional
nursing skills for me as an ERphysician, those were some of
the the that was the steepestlearning curve for me was
(32:17):
medication administrationgetting better at IV starts
doing sort of patient caretasks, those things that sort of
bleed into prolonged field care,all of those things need to be
within your skill set and withinwithin your purview.
Additionally, aeromedicalevacuation if you're going to be
(32:39):
at point of injury, as Eric wassaying earlier, earlier, one of
the greatest benefits is thatbeing at point of injury, you're
able to accompany the patientthrough evacuation to the next
level of care. And so you needto be able to jump on that
helicopter and provide care. Andthe jack the joint in route
(33:01):
critical care course, issomething I would highly
recommend for anyone who's goingto be on one of these DCR type
missions. And then, you know,understanding the TC three sort
of specific equipment, you know,we all are fairly comfortable
with our hospital basedventilators and monitors and
title co2 detectors andeverything but making sure that
(33:23):
you're you know, facile withwhichever you know, save bands,
or the the impact bands orwhatever it is that you are
equipped with is anotherspecific training thing that I
would certainly encourage you toundergo. I think to
Erick Thronson (33:43):
still speaking on the slide. So tests, you know
that that first bullet, allthose nursing skills are
probably important for, for thephysicians, you don't
necessarily do those every day.
I think in the type of settingthat we're talking about as
well. If you're going to takesomebody who is not a physician,
(34:05):
if you're going to take anemergency nurse, perhaps or
you're going to take specialoperations combat medic with
you. That provider, thatclinician also needs additional
medical training to fill some ofthose gaps in these type of
settings, all of us, no matterkind of what your role is medica
(34:29):
physician and nurse operate atthe greatest extent of our scope
of practice. So that means thatI for instance, might be doing
something in these kind ofsettings that I'm not normally
going to be doing in theemergency department, or I
typically work. I think that wesometimes don't give a lot of
(34:55):
credence that But being able tobe facile with some of those
skills, some of those advancedskills that we might not
necessarily be doing. It can bepretty critical. lifesaving in
some instances, and you need toknow how to do that. And you
need to train the people thatare going to be with you how to
(35:17):
either also do those skills thatyou do or how to help you
accomplish some of thoseadvanced tasks. So what are some
of the trade offs of having aDCR team that's, that's far far
we like that. One, we don't haveany surgeons with us right? In
this particular permutation of ateam that's going to go far
(35:42):
forward with a soft yet. Solimited surgical capability,
right, we can do some surgicalthings. Dan can obviously can do
a thoracotomy if we have thetools available to us. But
that's about it, where we're notopening valets, we're not fixing
vascular injuries surgically.
(36:06):
And as a medical team, whenyou're that far forward, you
incur a greater risk ofexposure, you're not
unnecessarily in a protectedlocation. At a base, although we
should also recognize that beingat an MSS or FOB doesn't make
(36:29):
you immune from injury fromenemy attack, but you certainly
if you're going to go outsidethe wire, and you're going to
operate, where some of theseunits are operating, you're
going to incur the same, orpretty similar amounts of risk
that that those operators arealso incurring, that has to go
into your calculus, as well asthe calculus, the ground force
(36:50):
commander, about the kind ofrisks that you all are willing
to incur based off of themission that that is in front of
you. Also, if if, if there's aDCR team that goes forward, they
require seats, right, you haveto be able to put them on a seat
to get them with to travel withyou to get them onto the x,
(37:11):
which means that there arepotentially fewer seats for
First off operators. Again, aswe've highlighted, this is a
very limited environment. It'snot like we have an unlimited
number of vehicles, or aircraftto take us places, there are a
limited number of seats. So youhave to decide who is going to
(37:33):
fill that particular seat. Is itworth it to the ground force
commander to give those seats toyou, versus giving them to
somebody else. Also, what goesinto that, that calculus as well
is that, you know, as medicalproviders, we're not soft
(37:54):
hoppers. I think, as we've said,several times during this talk,
we're not Green Berets, andwe're not seals, we're doctors
and nurses, and we have limitedformal training in those kind of
tactical and operational tasks.
That doesn't mean that thoseskills are beyond you. But it
does mean that as part of yourtraining pipeline, you didn't
(38:17):
necessarily learn how to shootfrom behind a barricade or
operate a cross system, orrecover a stuck vehicle or learn
the nuances of passage of linesin the dark during patrol base
operations. But you can learnthose skills that's just not
(38:39):
necessarily in your wheelhouse.
We're considered non combatants.
And we are also as such,typically we don't carry operate
offensive weapons, and wereafforded certain protections
under the Geneva Convention.
(39:01):
That status is not a permanentstatus that can change you can
become a combatant, depending onthe particular situation that
you're in. For instance, if youare not exclusively providing
humanitarian aid, or exclusivelyproviding medical care, you may
(39:23):
lose your protected status andmay go from non combatant to a
legal combatant. Those are legalquestions that you will have to
to seek, seek counsel for inyour specific set of
(39:44):
circumstances but that issomething that should be
considered by yourself by theground force commander and by a
higher headquarters
Dan Brillhart (40:01):
And so there are a lot of benefits the DCR teams
want to be very upfront aboutwhat what the limitations are, I
mean, the biggest limitation forany of this time to become
proficient in the technicaltasks that we're talking about
requires time time for training,to truly integrate with the
(40:24):
team's, the maneuver elementsthat you're supporting requires
time time to familiarize time totrain time to integrate. And,
you know, far forward advanceddamage control resuscitation is
not a panacea, you're not goingto save every patient by being
out there. And so how does thatconvey? How does that play with
(40:51):
the maneuver elements thatyou're working with? And then
it's critical, we all know thatsurgery is what fixes trauma,
and so resuscitation, bloodproduct product resuscitation
can sort of prolong the timethat a patient can tolerate
(41:13):
surgery. But having a DCR teamwithout damage control surgical
plan to back it up, isirrational and obviously going
to be ineffectual. So we'vetalked a little bit about this
conversation, this theoreticalconversation with the Ground
(41:37):
Force Commander about, hey,here's a DCR team, they can
support your operations, hereare the capabilities that they
add, here are their limitationshere, the things that they're
gonna need. But this is, Ithink, a very critical thing.
And this is just a genericexample of what Eric and I used,
we provided basically a menu toour ground force commander and
(42:00):
says, These are the differentpackages that we can do. And
there's a very light packages, avery robust package. And you can
figure out the duration based onthe number of days of operations
that you can support or thenumber of casualties that that
you can treat. But you've got tocome up with something that
(42:21):
says, Hey, these are our packageoptions. And this is the waiting
cube that it requires. Becausethat's what you really come down
to how many seats have you takenup? How much of our cargo space
do we need to give away in orderto bring you out there, and then
that Notes section of what areyou adding, if I've just bring
one guy out there with hisrucksack, I'm going to add
(42:42):
advanced airway. If I add in,you know, another turn 50 pounds
and a second DCR team member, Ican give you a bow, a
thoracotomy, blood transfusion,etc. And so you want to have
some type of menu of options forthese DCR teams if you're going
to offer them to a to a groundelement. And so the other things
(43:07):
that I will say are we need tomitigate our limitations and
mitigate our risks as much aspossible. And so self
sufficiency, I think, is theoverarching critical one, you
know, in regards to security,life, sport needs, weight, and
cute everything you want to beas minimal a burden on the
maneuver element as possible.
field craft is what a lot ofthis comes down to. And then
(43:31):
weapons proficiency, crosstraining, making sure that you
can fill needs and voids withinthe maneuver unit, and then
rehearsals as much as possiblein as as deep as possible,
rehearsing all of the varioustasks that you're going to need
to accomplish. And this issomething that helps you also
(43:54):
build credibility with themaneuver unit is you engage in
their tactical rehearsals andwork through the sort of, you
know, tactical tasks that theyrehearse over and over again,
but then there's always amedical piece that comes into
rehearsals, and you can bringmore fidelity and force them to
sort of train that task to ahigher level than they probably
(44:19):
do when you're not there. Andthat can help you instill
confidence with that maneuverunit that you really are, you're
the real deal. You are bringingsomething to the table. And then
integration and planning isimportant, just for the sake of
making sure that theexpectations are realistic and
(44:39):
being able to be there and say,you know, just cuz you bring me
out there and drop me in themiddle of a swamp. I'm not
necessarily going to be able tosave everybody's life no matter
what happens, you know, so ifyou're not there at the table,
when the planning is ongoing,sometimes things can get
Erick Thronson (44:58):
a little bit askew
Dan Brillhart (45:01):
And these next couple slides just you know,
some some pictures like go outthere, train with the guys that
you're going to work with, dothe things that they're doing.
Show them that you arecompetent, capable and willing
to get your hands dirty. We dida lot of weapons training. And
we did a lot of hoist trainingwith our both our evac team and
(45:28):
our soft medics, and just madesure that they knew, hey, we're
here, we're willing to do thesame stuff that you guys are
doing. And then that helped usto integrate. And then this next
slide is a recycle of the firstpicture that we loaded up there.
You know, this is me, Eric andour four seal medics. And
(45:51):
there's a distinction betweenposing as an operator, looking
cool, trying to play a role, andsuccessfully integrating with
the people that you'resupporting, living working with
on a day in day out basis. Itisn't about you know, hyping
(46:13):
yourself up it is about beingable to speak the same language,
walk the walk and look the lookof the guys you're there with.
Because if you stick out like asore thumb, nobody's nobody's
really gonna trust you out in afar forward tactical environment
like this. And you know, Ithink, in emergency medicine,
(46:35):
we're pretty good at this, inbalancing those two things. You
know, if if I've got a ifthere's a baby that needs to be
delivered in the ER, I'm notgoing to deliver that baby. If
there's an OBGYN standing nextto me, I'm ready to go.
Similarly, I'm not going to mana machine gun when there's a
navy steel Navy SEAL standing byready to do the job. But in
(46:56):
either one of those situations,I'm I'm ready, I'm able to be
the second best option if thosepeople can't be there. And it's,
it's just being realistic andrecognizing your limit your
limitations and yourcapabilities, and being honest
about those with with everyone.
Erick Thronson (47:18):
Alright, so kind of our conclusions about our DCS
concept is that an adequatelyprepared and motivated DCR team
really can bring something tothe table in this environment,
you can augment and enhance thecapabilities of the organic
medical assets of whichevermaneuver element you happen to
(47:41):
be supporting. And you canprovide elements and you can
provide opportunities tomitigate the risk of being so
far forward with so fewresources, you can enhance the
kind of care that thosecasualties are going to receive
at the point of injury, andpotentially save lives. I think
(48:02):
it's important to note that, asDan mentioned previously, DCR
far forward is not the end allbe all isn't a panacea. We can't
solve all the problems, we'renot going to save every life on
the battlefield. And it mightnot be appropriate to put a DCR
(48:23):
element forward in everycircumstance. Those are specific
questions. And that's an answerto a specific problem. So there,
there is a time and place andthere is a role in the correct
circumstance. And if you prepareyourself, and you're able to
(48:46):
successfully integrate, and intothe unit that you're supporting,
on, you really can make adifference, literally on the
battlefield. So in 2019, the JTSpublished CPG on on austere,
resuscitative, surgical care,which really laid out a lot of
(49:12):
those key concepts that wentinto the creation of irst. And
described in detail, kind ofwhat are the requirements for
being able to do the kind ofresuscitative and surgical care
that's required in those typesof settings and sort of what
(49:34):
what sets you apart from thesort of conventional medical
surgical asset that you mighttypically take, and that that
CBG was really designed to helpprepare conventional surgical
units to be able to take onthese kinds of missions. But
(49:55):
that really provide does providethe opportunity to doctrinal
eyes Some of the those conceptsand and I think lays the
foundation for not justconventional assets, but also
some more permanent, specialoperations, surgical assets, as
(50:18):
well.
Dan Brillhart (50:22):
And so what our recommendations for all of this,
you know, our experience, beinga DCR team providing highly
advanced very far forward,damage control a state of care
to sort of the tip of the spearwas mostly successful and
(50:47):
rewarding for us and for the thepeople that we supported. And,
you know, we operated in aspecial operations sort of
context. But I personallybelieve that this is something
that could be expanded toconventional forces as well, in
a sort of conventional warfareenvironment, putting a DCR team
(51:13):
on every mission makes no senseand isn't sustainable and
requires far too much risk andfar too many resources. But
certainly, there are higher riskmissions, where it does make
sense. And I think the, thebridge to get to that point is,
you know, within the virtualroom of this conference, it's
(51:38):
the people within ourorganization who can advocate
for the capabilities that we canadd and provide and the
willingness of us to providethem that can sort of augment
and enhance and take fartherforward these concepts of
damage, control, resuscitationand make things better for the
(52:01):
people who are out theredefending our nation. You know,
one, one way of thinking of forme is that, you know, every
every infantry platoon in the USArmy doesn't need a damage
control resuscitation team, butmaybe every division does, and
the, you know, highest riskmissions, it's an asset that can
(52:23):
be requested and support amaneuver element. I mean, that's
just me spitballing it pie inthe sky doctrine. But I do, I do
think that there is a role forthis, and it needs to be
expanded and developed. Soreally, thank you all for
listening. And I look forward toyour questions in the live q&a
(52:46):
session that's going toimmediately follow this recorded
lecture. Thank you all. Thanks,Eric.
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