The concept of the FST has been in the Army’s medical playbook since at least World War II, if not earlier. The contemporary FST doctrine and organization as we know it today was established in the 1990s, as a small mobile surgical element designed to support the maneuver brigade in conventional warfare. While the personnel and equipment assigned to FSTs have changed over the years, the general concepts remain. Current FST doctrine includes a 20-person team composed of two general surgeons, one orthopedic surgeon, two surgical technicians, one OR nurse, two critical care nurses, several medics, and the Commander and Detachment Sergeant. Often, the Commander is also a surgeon, permitting two surgeons per OR table. These teams are frequently augmented with additional personnel once deployed, such as a second orthopedic surgeon, primary care provider, or additional surgical support personnel. The FST is designed to be composed of two identical teams, capable of split operations if required. Ideally, an even number of personnel and equipment for each team would be included, but this does not always happen. If split operations are expected, it is strongly advised that the command element and providers discuss the best plan for distribution of personnel and equipment based upon mission requirements and personnel experience.

The deployed FST may or may not have all of its organic assigned equipment, to include vehicles, trailers, tents, and storage containers (Fig. 50.1). More than likely, the unit living and medical equipment will be crammed into a number of shipping containers and you will fall in on it, in theater, or you will inventory and assume the equipment of the unit you are replacing. Equipment inventory is a time-honored tradition of misery and loathing for enlisted personnel; in the FST, everyone works during inventory. If you choose to do something else, and subsequently find your special instrument set is not to be found, you have no one to blame but yourself. Officers, surgeons, enlisted – everyone participates in the daily duties and maintenance requirements for this small unit to function and succeed.

The FST typically occupies a tent or building and its general organization includes a receiving or triage area, operating room, and recovery ward or possibly ICU. If space allows, separate areas for sensitive medical issues or exams, patient waiting, sick call, and administrative section are ideal. When establishing or taking over an FST, think about patient arrival and flow through the facility. What will the area look like in a Mass Casualty event (MASCAL)? Where will you conduct a walking blood drive? Where will you store bodies temporarily? If you are establishing the site, you have a relatively blank slate to work with. If you are taking over for a prior FST, it is ok to reassess and change things up. The FST is not intended or capable of standing alone, for security, logistic, or medical purposes. By doctrine, the FST is meant to be colocated with an Area or Forward Support Medical Company to allow enhanced patient holding, primary care, and additional non-surgical treatment capacity, and modest radiologic, lab, and dental support. In current deployments, the FST may or may not be colocated with these units, but is likely to have some equipment and personnel augmentation.

Some key predeployment and deployment considerations for the surgeon assigned to an FST or any of the surgical units in this chapter are listed in Table 50.1. The role of the FST is to perform damage control surgery (DCS) and damage control resuscitation (DCR) . Definitive surgical care is rarely indicated at an FST, and often only with local nationals, if approved by the Commander and in line with the medical rules of engagement. The FST is frequently utilized in a split fashion, allowing a damage control surgical capability to be available across a greater geographic area. As the team breaks down into smaller elements, holding capacity and the ability to care for more than one or two patients at a time becomes limited. A single critical surgical patient will likely consume the resources of a split FST element, and two critical patients may overwhelm a whole FST. Therefore, it is essential to have ongoing communications with the medical planners, and to ensure early resupply and timely coordination with ground force commanders reagarding surgical availability.