GSACEP Lecture Series: The Damage Control Resuscitation Team Concept

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.

Watch the full episode at https://gsacep.tradewing.com/event/oeysmjqADcdsp4v7w

Transcript

Dan Brillhart: 1:01

Hello GSACEP. And thank you for joining us for our talk regarding the DCR team concept. dcr. Core stands for damage control resuscitation, which I think of as sort of all of the trauma management that occurs in tactical combat casualty care prior to the patient receiving surgical care. The DCR team concept that we want to tell you about is our proposal to bring more advanced and sort of nuanced DCR care farther forward on the battlefield, as far forward as possible. Ideally, I'm but I'm getting a little bit ahead of myself, who are we? And why are we talking about this? I'm Dan Bernhardt. I'm an Army 62 Alpha emergency physician, my colleague, Eric Johnson, is an army 66 tango, emergency trauma nurse, Eric and I have been deployed together for about five years now, most recently with the earth mission supporting Special Operations Command Africa. And throughout those five years, we've been refining and testing a set of TTPs that evolved into this concept that we refer to just simply as a DCR team. And the intent, the intent of those teams is to accomplish the thing that we're most passionate about. And that is bring high quality emergency department level resuscitative care as close to the point of injury as possible for our warfighters. So these disclaimer slides, we've all seen it a million times. But in this case, I really do mean it. The views here that we're talking about really are not policy, or even widely held beliefs within the DOD. But Eric, and I think they should be. And if we're really serious about reducing preventable deaths on the battlefield, we think employing emergency medicine professionals, doctors and nurses in the manner we're describing could have a significant impact. But none of this is doctrine. None of this is policy. And none of this is a sort of accepted dogma at this point. So the purpose of what we're talking about is number one, to tell the story of what we've been doing, share our successes, our failures, and the hope to be that some of you can take this sort of initial effort and move forward with it and create something bigger and better and more effective. Because we believe that this concept should expand outside of the Special Operations community where it's currently being used, and sort of being employed across the force where appropriate to deliver the best care that we can for our service members. So what exactly is our story? What did we do? Well, as part of the the earth program, in our East Africa area, we took an emergency physician and emergency trauma nurse, and we embedded them with a maneuver element. And augmented are for Special Operations medics, and you can see there's our medical treatment team here. And we went out on Grand ground combat missions lasting anywhere from a few hours to a few weeks. And augmented the the medical capability of that team with again, emergency department level resuscitative, sort of knowledge, skill, equipment, and put it not only at the point of injury, but at the time of injury as well, which I think is an important distinction because we can throw advanced resuscitation teams on to aircraft and fly them out to the point of injury to pick a patient up. But you've already lost some time at that point. And those minutes may be critical, especially for the types of advanced resuscitative capabilities that we're advocating for things like advanced airway, reboa, emergency resuscitative, thoracotomy, more robust use of blood products, all those things have a very finite window of minutes really, where they can potentially make a difference. And so having the people to provide those procedures, those sort of augmented skill sets there when the damage happens, we think is important.

Erick Thronson: 5:19

So the idea of putting Advanced Care forward isn't necessarily a new idea. I think military medicine is always trying to balance the risk of getting physicians and advanced medical care as close to the casualty and the point of injury as possible. With you know, the the life saving benefits that they they provide. So there's always a kind of a risk benefit analysis that goes into that. But using small, highly mobile teams like this is is something that has been done across various organizations, both in the United States and internationally for for several years. I'm particularly in support of special operations. And they have been very successful doing so. But those teams are few and far between. and, and they're in high demand. So they can't be everywhere all the time. And that is just one or a few. A team concepts and constructs that have been created that aren't necessarily the right thing for all environments. So you have to be able to look at where you're going to be in the kind of mission you're going to support in order to create the best sort of team to support those kinds of operations. So in East Africa, that was born out of the need for sort of this far forward, highly mobile flexible team that was able to travel from place to place in the resource limited environment of East Africa. And so the medical military medical community in East Africa identified that there were no existing or available teams that were going to be able to fill that gap at that time. And the conventional teams, we're not necessarily going to be able to work in that space either. You know, the theater in East Africa is, is also complicated, not just by time and distance. But logistically, it's a far more immature theater, and certainly more mature than the theater that we know, that exists in CENTCOM or has existed in the last several years, there are far fewer troops, far fewer resources with much smaller footprints. They're supporting a much larger area of operations. And in particular, there are much fewer Air Mobility assets and air evacuation assets. And their capabilities and their capacities may vary from place to place as well.

Dan Brillhart: 8:00

And so out of that sort of identified need. In East Africa, the concept for erst was born the emergency resuscitative surgical teams Africa, were first fielded in 2016 to support these very austere environments, and be mobile able to go where they were needed, with limited support, and perhaps without any aeromedical evacuation assets to augment them. And initially, when these teams were created, the the focus was on mobility and proximity to the troops who were at risk of being injured. Over capability, we sacrifice sort of what the normal capability of a surgical team in CENTCOM over the last decade had been, in order to get those surgical assets closer to the troops who might need them. But as happens over time, that theater did slightly mature, the footprint slightly increased, and things sort of progressed and matured.

Erick Thronson: 9:15

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 DCR concept, that is one subset of the Earth, so irst consisted of DCR team, which was an ER physician and an ER nurse, a damage control surgery team, and then another CSET, or critical care and road transport element. And each of these three subsets are able to operate independently of each other, so the DCR team can break away and do their mission, DCS can stay in a position and still do surgery. CSET can go off and transport all by themselves independently of the other teams. And each element is able to provide some redundant capability. DCs can still provide resuscitation CSET can still provide resuscitative care DCR can can provide transport if needed. And so can DCS. So there, there's some interchangeability there. In addition, the personnel could also change. So Dan could have broken away and jumped on to a critical care, transport and flown a patient if you needed to the same for me. Our ICU nurse could have taken him on position if needed to and that's a product of of cross training really, and and others understanding the expectation that you might need to step into a role that is outside of outside of your norm. In addition, so DCR we could operate independently, meaning we could be our own standalone medical asset, we could provide point of injury care and enroll care from the point of injury to the rule two, all by ourselves, or we could augment organic medical assets on the ground, so soft medics, or we could augment the aeromedical. Flight paramedics as well, if they if they had those. So you need to be we were really concerned with being flexible and interoperable.

Dan Brillhart: 11:38

So, so progress have been in quotation marks for for a reason. You see in the next slide, that this is the sort of where the earth concept started was a mobile operating room set up on litter stands on the leeward side of an armored vehicle. And over time, that sort of progressed, you know, we went from these litter stands to, you know, thrown up a small surgical tent. As you can see on the next slide, men, that tent became more robust and filled in within some HESCO barriers and you know, some protective wire around it. And then eventually, we ended up in this purpose built, see hut that was designed to be an operating room and with that facility came more stuff and X ray machine autoclave sterilization, plasma thar for blood products. We even had PCR COVID testing on our last iteration. And those things increased the capabilities. But it flipped that paradigm that erstes had initially been founded on where I said, you know, flexibility and proximity were prioritized over capability. Once we had those capabilities, essentially function to anchor the surgical team to this fixed location, it becomes difficult to leave behind all those extra capabilities and move forward. So that modularity of DCR team DCS team CSAT team that sort of degraded over time is really just span of a few years to where we started to feel tied to a this to this fixed sight to this outstation.

Erick Thronson: 13:32

You know, as time went on, and the theater matured, and we became more of a fixed facility asset, our ability to be close to that point of injury really decreased. So, as we said, when you have an O bar, you want to use the or you want to use all the stuff that's an O R, because it provides such a great capability to the patient. But when all you have is a backpack, then operating in that backpack seems second nature, because that's all you have. And being able to do that in a far forward location. Seems pretty straightforward. So ultimately, you have a trade off there. And so we saw, you know, over time, we really stopped becoming what irst had originally been intended for. So our DCR concept, we, if the team is continually static, and anchored to a fixed location all the time that has a lot of capability, then where is that capability gap that a conventional role to couldn't fill? What is the difference between this special operations team that was put together and conventional FST? Could they not also just sit there just as well as you could? What sets you apart from from those conventional teams. And so we we think that the DCR in this sort of soft medical team should be designed to accompany the ground force, as far forward as the objective right as far forward as the acts and to be able to provide advanced resuscitative care as early and casualties course of care as possible and as tactically feasible. So there isn't always a role for providing very advanced resuscitative care at the point of injury, just because that would that would present a tactical liability. That doesn't make sense. But there could be certainly a lot of circumstances where you do have the time and you do have the security to provide those kinds of advanced resuscitative techniques that they casually might need in a very time sensitive manner. Especially when you're so far removed Medical Evacuation assets and you're so far from a DCS role to. But you also don't, you don't want to be a tactical liability on the battlefield. So we're all medical providers, we're not soft operators. But if you're going to operate this far forward, and you're going to support these kinds of teams, you need to know how to move like they do, you need to know how to be highly mobile, you need to know more than just the medicine piece, you have to be able to, to work seamlessly and integrate seamlessly into those teams. In addition, you know, the, the soft medic is very highly trained, and they're very good at what they do. The DCR team, however, provides not just advanced capabilities that the DCR medic, or that the soft medic is never going to be able to do. But we also provide a great deal of experience that the soft medic doesn't necessarily have. So, you know, we we do trauma care and resuscitation all day, every day, that's all we do. So if we can take that and we can adapt that to the austere environment, I think we can, we can really make a difference, especially when you're talking about that tyranny of distance, where you, you might potentially have to sit at a patient for quite some time. Either because evacuation is not available, or because it is not technically feasible. So this is this is us, this is us going back to kind of what Earth was originally envisioned to be the universe, if you will. So these are some patients that were involved in an IED blast far forward on an operation. And as it turned out, these patients were not able to be evacuated immediately from the battlefield. And so we did have to sit on these patients for for some time, there were multiple patients. And we were able to employ kind of our advanced or sensitive techniques, not and not just procedures and skill sets, but also diagnostic capability and experience to be able to manage these highly complex multi system trauma patients for an extended period of time on the battlefield. So, you know, you saw on previous slides, we had our sort of CCP set up in a purpose Bill swamp hut, inside of a HESCO barrier behind sea wire. This is an example of, you know, a hastily built CCP that we set up immediately following contact with the enemy, where we were able to, you know, take those those fixed facility concepts, and put them here into into a far forward you know, tactical situation. So this is a really far cry from where we had been at Arista a couple of years ago. And, and so here we are in a CCP on the side of a partially filled HESCO barrier, immediately following an attack and, and our ability to, to be there on the battlefield, that far forward, ease the burden, or some of the burden from those soft operators, who functioned as soft medics as well, in that situation, so that they could focus less on the medicine and focus more on getting the mission completed. And we could worry about sort of the medicine piece at that particular time.

Dan Brillhart: 19:54

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 be warfighters and medical providers. And so when you're operating with with a small team, you know, platoon sized or smaller element, and you can offload that medical requirement off of those dual hatted medics and allow them to be warfighters when necessary, and you handle the medical treatment. I think that is a big plus for the the ground force commander. So what what do you you offer as a DCR team, you know, you know, advanced skill sets are sort of what what we push is that our combat medics, especially our soft medics are are phenomenal and can do amazing things, but there are, there's a limit to their capabilities, there's a limit to the amount of training time They can dedicate to their medical tasks versus their warfighter tasks. And there's a limit to the amount of experience that they had. Generally, the the medic who is out there, providing care point of injury is relatively junior. And especially compared to a lot of our emergency physicians, emergency nurses that are out there who have years of experience, that makes a huge difference. And you can go to the next slide. These these are some of the specific capabilities that we provided with our damage or solicitation team. And these are things that we felt it was important to be able to lay out to the ground force commanders that we were working for to say, Look, these are the things that we can do, that your medics can't, can't necessarily do. And we'll go into sort of these in a couple of subsequent slides. But that last bullet is the biggest one. I mean, it's really about experience trauma experience experience with transporting patients experience with mass casualty incidents is it's it's it doesn't matter how robustly your medics are trained, many of them, most of them over the course of a career, we'll see fewer critically ill patients and manage fewer critically ill patients then, you know, senior emergency medicine resident does in a year or, you know, a new ER nurse does in a year, and so that that level of experience just can't be replicated easily. And so that's one of the main capabilities that we think we add. You know, advanced airway. This is one patient, you see, you know, we're working under under lights outside with a safe to transport vent, but this guy's orally intubated. If we go to the next slide, this is another patient who this is back at the fixed role to about to undergo surgery. But this patient as well was oral drakeley, intubated by by our DCR team. And that's not sort of standard TC three airway management. Had we not had a DCR team there, both of these patients would have received cricothyrotomy say almost certainly. And so we can have an academic discussion about the you know, the risk benefit pros cons of cricothyrotomy versus Supraglottic, airway versus RSI, but the fact is, there's at least a subset of patients who could receive or tracheal intubation on the battlefield and for these two guys, at least, it resulted in one less war wound that they needed to recover from. And so we think that advanced airway is is of is definitely something to weigh in the risk benefit of employing these DCR teams.

Erick Thronson: 24:24

Another big piece is blood blood is always a huge logistical concern wherever you go. So the teams that we support primarily relied on a limited amount of fresh old blood that they could carry forward in Golden Hour boxes. However, you know, as I said, they carried only a few units and outside of that they relied on sort of a Rolo ask or fresh whole blood buddy transfusion scheme. And, and that's fine. And we absolutely need to employ implement those strategies. Those are critical. Being able to carry cold stored whole blood Ford is an excellent option that is certainly much more economical in terms of time and tactics. Having golden hour boxes that you can take forward is perfect, except when you need to do a mission that lasts more than a couple of days. And in that case, you need some other better option. Our DCR team was able to take our equipment and device you know a couple of novel solutions in order to to store and transport a couple dozen Cold storage units with the ground force and be able to use it whenever we needed and in fact, did use it. And it was immediately available. So you know, it might take you it's gonna take you at least 20 minutes probably to get a year of whole blood using a Roll Up program. And in some instances, it might take you equally as long 20 minutes, 40 minutes, an hour, an hour and a half or longer depending on the tactical situation to get blood flown in, if you don't otherwise have it available. So being able to take these this many units as far forward and store them sustainably was was key. And these teams would not have been able to, to do this without our support. In addition to having a DCR team on the ground, and one that you can integrate seamlessly with with the ground force and with the the evacuation asset provides a pretty key capability of being able to have seamless continuity of care. So this is a casualty who is being offloaded from a Kazakh asset. The DCR team was able to provide care for that casualty on the ground at the point of injury, moments after injury. resuscitate that patient on the ground, continue care in the air, augmenting the flight paramedics, handoff care to our own DCS team and then continue care with that DCS team at the fix role to facility. So being able to provide insight into this casualties, both injuries, mechanism of injuries course of care that they received on the ground and trending that patient's status throughout their continuum of care through surgery and, and possibly even post surgery is pretty huge. And frankly, probably a lot safer than the sort of hand off shuffle that we often see trying to provide care to the patient doing a hasty handoff on to the rotor wash to a flight medic that, you know, some things might get left out or be unknown. And then depending on the tactical situation, that flight medic might also get a hasty handoff out of the rotor wash to some provider while that cable is being offloaded so they can go back and fly pick up more casualties.

Dan Brillhart: 28:48

Um, so this is a specific example of this general principle of you know, advanced medical care and it's not necessarily all combat trauma. There are a lot of things that a DCR team as we envision it is more capable and equipped to treat than our our combat medic contingent. This is Eric at a juvenile Black Mamba that, that we killed in a area where we were operating troops were sleeping nearby. And so the point of this picture is that we were able to carry bring forward anti venom capability. For in we worked in an area operations that had some of the most venomous snakes in the world. And the flight time to bring a patient who was snake bitten back to the fixed facility was less than the amount of time that it typically takes a black mamba to kill an adult human. And so we were able to bring that anti venom capability and the knowledge and experience required to use it because it's a pretty dangerous drug really to administer, we're able to bring those with us to the objective to the point of potential risk to our our operators. And, you know, this is an example, I think, similar to reboa. Where could we teach our medics to do this? Yes. How much effort is required to teach that medical expertise to an operator versus how much effort does it take to teach the technical expertise necessary to bring a medical professional to this point, becomes becomes what we have to balance in the scales. Other advanced diagnostic sort of scenarios, you know, bring ultrasonography forward Is is helpful this is, you know, one of us diagnosing a nerve injury after a penetrating wound in one of our host nation, partner force patients, that's something that again, it would be very difficult to impart that skill set to a combat medic. And then the next slide, I think is potentially the sexiest capability add that a DCR team brings, 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 this slide. But down there in the red circle, you can see a reboa catheter emerging from the the groin of this patient who's being dropped off from evacuation from point of injury, or DCR team was able to bring Ebola to point of injury at time of injury, and, as far as we know, is the first instance of employing it. And there's, you know, the case reports, in process and be pending. So don't bother going to the details of the scenario. But the real point here is that we need to be able to talk to our ground force commanders about what capabilities can be added in terms that they're able to understand and process and use in a risk benefit analysis of whether it makes sense in a given scenario for a given mission with a given unit to bring these DCR teams forward or not. And, you know, there is some additional medical training that that I think is necessary, I don't think that you can pluck a hospital based emergency medicine provider out and say, Well, you have everything that you need to know to go out and work on your knees in the dirt in this sort of scenario, and I guess this would be my sort of short list of recommendations, you know, Recommendation Number One, two, and three are our nursing skills. You know, we think of sort of traditional nursing skills for me as an ER physician, those were some of the the that was the steepest learning curve for me was medication administration getting better at IV starts doing sort of patient care tasks, those things that sort of bleed into prolonged field care, all of those things need to be within your skill set and within within your purview. Additionally, aeromedical evacuation if you're going to be at point of injury, as Eric was saying earlier, earlier, one of the greatest benefits is that being at point of injury, you're able to accompany the patient through evacuation to the next level of care. And so you need to be able to jump on that helicopter and provide care. And the jack the joint in route critical care course, is something I would highly recommend for anyone who's going to 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 based ventilators and monitors and title co2 detectors and everything but making sure that you're you know, facile with whichever you know, save bands, or the the impact bands or whatever it is that you are equipped with is another specific training thing that I would certainly encourage you to undergo. I think to

Erick Thronson: 34:45

still speaking on the slide. So tests, you know that that first bullet, all those nursing skills are probably important for, for the physicians, you don't necessarily do those every day. I think in the type of setting that we're talking about as well. If you're going to take somebody who is not a physician, if you're going to take an emergency nurse, perhaps or you're going to take special operations combat medic with you. That provider, that clinician also needs additional medical training to fill some of those gaps in these type of settings, all of us, no matter kind of what your role is medica physician and nurse operate at the greatest extent of our scope of practice. So that means that I for instance, might be doing something in these kind of settings that I'm not normally going to be doing in the emergency department, or I typically work. I think that we sometimes don't give a lot of credence that But being able to be facile with some of those skills, some of those advanced skills that we might not necessarily be doing. It can be pretty critical. lifesaving in some instances, and you need to know how to do that. And you need to train the people that are going to be with you how to either also do those skills that you do or how to help you accomplish some of those advanced tasks. So what are some of the trade offs of having a DCR team that's, that's far far we like that. One, we don't have any surgeons with us right? In this particular permutation of a team that's going to go far forward with a soft yet. So limited surgical capability, right, we can do some surgical things. Dan can obviously can do a thoracotomy if we have the tools available to us. But that's about it, where we're not opening valets, we're not fixing vascular injuries surgically. And as a medical team, when you're that far forward, you incur a greater risk of exposure, you're not unnecessarily in a protected location. At a base, although we should also recognize that being at an MSS or FOB doesn't make you immune from injury from enemy attack, but you certainly if you're going to go outside the wire, and you're going to operate, where some of these units are operating, you're going to incur the same, or pretty similar amounts of risk that that those operators are also incurring, that has to go into your calculus, as well as the calculus, the ground force commander, about the kind of risks that you all are willing to incur based off of the mission that that is in front of you. Also, if if, if there's a DCR team that goes forward, they require seats, right, you have to be able to put them on a seat to get them with to travel with you to get them onto the x, which means that there are potentially fewer seats for First off operators. Again, as we've highlighted, this is a very limited environment. It's not like we have an unlimited number of vehicles, or aircraft to take us places, there are a limited number of seats. So you have to decide who is going to fill that particular seat. Is it worth it to the ground force commander to give those seats to you, versus giving them to somebody else. Also, what goes into that, that calculus as well is that, you know, as medical providers, we're not soft hoppers. I think, as we've said, several times during this talk, we're not Green Berets, and we're not seals, we're doctors and nurses, and we have limited formal training in those kind of tactical and operational tasks. That doesn't mean that those skills are beyond you. But it does mean that as part of your training pipeline, you didn't necessarily learn how to shoot from behind a barricade or operate a cross system, or recover a stuck vehicle or learn the nuances of passage of lines in the dark during patrol base operations. But you can learn those skills that's just not necessarily in your wheelhouse. We're considered non combatants. And we are also as such, typically we don't carry operate offensive weapons, and were afforded certain protections under the Geneva Convention. That status is not a permanent status that can change you can become a combatant, depending on the particular situation that you're in. For instance, if you are not exclusively providing humanitarian aid, or exclusively providing medical care, you may lose your protected status and may go from non combatant to a legal combatant. Those are legal questions that you will have to to seek, seek counsel for in your specific set of circumstances but that is something that should be considered by yourself by the ground force commander and by a higher headquarters

Dan Brillhart: 41:02

And so there are a lot of benefits the DCR teams want to be very upfront about what what the limitations are, I mean, the biggest limitation for any of this time to become proficient in the technical tasks that we're talking about requires time time for training, to truly integrate with the team's, the maneuver elements that you're supporting requires time time to familiarize time to train time to integrate. And, you know, far forward advanced damage control resuscitation is not a panacea, you're not going to save every patient by being out there. And so how does that convey? How does that play with the maneuver elements that you're working with? And then it's critical, we all know that surgery is what fixes trauma, and so resuscitation, blood product product resuscitation can sort of prolong the time that a patient can tolerate surgery. But having a DCR team without damage control surgical plan to back it up, is irrational and obviously going to be ineffectual. So we've talked a little bit about this conversation, this theoretical conversation with the Ground Force Commander about, hey, here's a DCR team, they can support your operations, here are the capabilities that they add, here are their limitations here, the things that they're gonna need. But this is, I think, a very critical thing. And this is just a generic example of what Eric and I used, we provided basically a menu to our ground force commander and says, These are the different packages that we can do. And there's a very light packages, a very robust package. And you can figure out the duration based on the number of days of operations that you can support or the number of casualties that that you can treat. But you've got to come up with something that says, Hey, these are our package options. And this is the waiting cube that it requires. Because that's what you really come down to how many seats have you taken up? How much of our cargo space do we need to give away in order to bring you out there, and then that Notes section of what are you adding, if I've just bring one guy out there with his rucksack, I'm going to add advanced airway. If I add in, you know, another turn 50 pounds and a second DCR team member, I can give you a bow, a thoracotomy, blood transfusion, etc. And so you want to have some type of menu of options for these DCR teams if you're going to offer them to a to a ground element. And so the other things that I will say are we need to mitigate our limitations and mitigate our risks as much as possible. And so self sufficiency, I think, is the overarching critical one, you know, in regards to security, life, sport needs, weight, and cute everything you want to be as minimal a burden on the maneuver element as possible. field craft is what a lot of this comes down to. And then weapons proficiency, cross training, making sure that you can fill needs and voids within the maneuver unit, and then rehearsals as much as possible in as as deep as possible, rehearsing all of the various tasks that you're going to need to accomplish. And this is something that helps you also build credibility with the maneuver unit is you engage in their tactical rehearsals and work through the sort of, you know, tactical tasks that they rehearse over and over again, but then there's always a medical piece that comes into rehearsals, and you can bring more fidelity and force them to sort of train that task to a higher level than they probably do when you're not there. And that can help you instill confidence with that maneuver unit that you really are, you're the real deal. You are bringing something to the table. And then integration and planning is important, just for the sake of making sure that the expectations are realistic and being able to be there and say, you know, just cuz you bring me out there and drop me in the middle of a swamp. I'm not necessarily going to be able to save everybody's life no matter what happens, you know, so if you're not there at the table, when the planning is ongoing, sometimes things can get

Erick Thronson: 46:00

a little bit askew

Dan Brillhart: 46:03

And these next couple slides just you know, some some pictures like go out there, train with the guys that you're going to work with, do the things that they're doing. Show them that you are competent, capable and willing to get your hands dirty. We did a lot of weapons training. And we did a lot of hoist training with our both our evac team and our soft medics, and just made sure that they knew, hey, we're here, we're willing to do the same stuff that you guys are doing. And then that helped us to integrate. And then this next slide is a recycle of the first picture that we loaded up there. You know, this is me, Eric and our four seal medics. And there's a distinction between posing as an operator, looking cool, trying to play a role, and successfully integrating with the people that you're supporting, living working with on a day in day out basis. It isn't about you know, hyping yourself up it is about being able to speak the same language, walk the walk and look the look of the guys you're there with. Because if you stick out like a sore thumb, nobody's nobody's really gonna trust you out in a far forward tactical environment like this. And you know, I think, in emergency medicine, we're pretty good at this, in balancing those two things. You know, if if I've got a if there's a baby that needs to be delivered in the ER, I'm not going to deliver that baby. If there's an OBGYN standing next to me, I'm ready to go. Similarly, I'm not going to man a machine gun when there's a navy steel Navy SEAL standing by ready to do the job. But in either one of those situations, I'm I'm ready, I'm able to be the second best option if those people can't be there. And it's, it's just being realistic and recognizing your limit your limitations and your capabilities, and being honest about those with with everyone.

Erick Thronson: 48:20

Alright, so kind of our conclusions about our DCS concept is that an adequately prepared and motivated DCR team really can bring something to the table in this environment, you can augment and enhance the capabilities of the organic medical assets of whichever maneuver element you happen to be supporting. And you can provide elements and you can provide opportunities to mitigate the risk of being so far forward with so few resources, you can enhance the kind of care that those casualties are going to receive at the point of injury, and potentially save lives. I think it's important to note that, as Dan mentioned previously, DCR far forward is not the end all be all isn't a panacea. We can't solve all the problems, we're not going to save every life on the battlefield. And it might not be appropriate to put a DCR element forward in every circumstance. Those are specific questions. And that's an answer to a specific problem. So there, there is a time and place and there is a role in the correct circumstance. And if you prepare yourself, and you're able to successfully integrate, and into the unit that you're supporting, on, you really can make a difference, literally on the battlefield. So in 2019, the JTS published CPG on on austere, resuscitative, surgical care, which really laid out a lot of those key concepts that went into the creation of irst. And described in detail, kind of what are the requirements for being able to do the kind of resuscitative and surgical care that's required in those types of settings and sort of what what sets you apart from the sort of conventional medical surgical asset that you might typically take, and that that CBG was really designed to help prepare conventional surgical units to be able to take on these kinds of missions. But that really provide does provide the opportunity to doctrinal eyes Some of the those concepts and and I think lays the foundation for not just conventional assets, but also some more permanent, special operations, surgical assets, as well.

Dan Brillhart: 51:23

And so what our recommendations for all of this, you know, our experience, being a DCR team providing highly advanced very far forward, damage control a state of care to sort of the tip of the spear was mostly successful and rewarding for us and for the the people that we supported. And, you know, we operated in a special operations sort of context. But I personally believe that this is something that could be expanded to conventional forces as well, in a sort of conventional warfare environment, putting a DCR team on every mission makes no sense and isn't sustainable and requires far too much risk and far too many resources. But certainly, there are higher risk missions, where it does make sense. And I think the, the bridge to get to that point is, you know, within the virtual room of this conference, it's the people within our organization who can advocate for the capabilities that we can add and provide and the willingness of us to provide them that can sort of augment and enhance and take farther forward these concepts of damage, control, resuscitation and make things better for the people who are out there defending our nation. You know, one, one way of thinking of for me is that, you know, every every infantry platoon in the US Army doesn't need a damage control resuscitation team, but maybe every division does, and the, you know, highest risk missions, it's an asset that can be requested and support a maneuver element. I mean, that's just me spitballing it pie in the sky doctrine. But I do, I do think that there is a role for this, and it needs to be expanded and developed. So really, thank you all for listening. And I look forward to your questions in the live q&a session that's going to immediately follow this recorded lecture. Thank you all. Thanks, Eric.