Over the last 2 years, 2nd Surgical Company (2 SURG) has focused its time and effort to plan, develop, and generate the Role 2 Basic (R2B); a highly capable, logistically deployable, and versatile surgical capability.
The origins of our efforts were largely nested within the most recent strategic guidance; smaller, more dispersed health effects located closer to the Point of Injury (POI) are required for both survival and to be effective in our likely operating environments in the context of a strategy of denial. This is a significant change for health support from our recent experiences in the Middle East area of operations and requires us to embrace a change in mindset from clinical best practice to military medicine.
A large surgical facility that meets Australian standards is irrelevant if casualties cannot survive to reach it. A general feeling that we had ‘priced ourselves out of the market’ for current operations by being too large and cumbersome created an imperative for us to focus on being logistically smaller. We wanted something that a non-health Joint Operations Command (JOC) planner could easily understand and assess that it could be easily deployed via multiple methods.
However, it also had to remain highly capable. A surgical facility that cannot hold patients rapidly culminates, and without the ability to do the things that a Treatment Team normally would (primary health care, low dependency holding, evacuation), has limited versatility. We also took significant effort in our planning to understand how our allies and partners operate so it could be easily integrated into coalition operations.
The Role 2 Basic nomenclature comes from NATO doctrine. In theory, a Canadian Armed Forces staff officer speaking to a UK staff officer in a time-sensitive and pressurised coalition Casualty Regulation Cell, would be able to rapidly understand what capabilities an ADF R2B can generate in order to enable good decision making.
Our end result was a surgical effect that can be deployed via multiple means in 2 x 20ft containers and be ready for surgical patients in less than two hours. It can conduct nine types of damage-control surgeries – procedures that enable us to buy time prior to definitive care being provided at a higher level facility.
The R2B can manage resuscitation for two simultaneous priority one casualties, has one Operating Table that can provide 12 hours of surgery every 24 hours (which is about five surgical cases), has two Intensive Care Unit beds and five low-dependency beds. It also has an imaging capability, primary health care, diagnostics to support forward blood, and sterilisation to remain sustainable in the field.
In terms of personnel, the R2B encompasses a team of 29. Again, to remain logistically deployable everyone needs to double-hat and work as a team; there is no room for niche within the R2B. The Pathology Officer needs to know how to troubleshoot the deployable air-conditioning system, the Medical Technician needs to be able to drive the 40M Pax Modules, and everyone needs to know how to operate the radio.
In terms of equipment, if it doesn’t contribute to the nine identified damage control surgeries or damage control resuscitation, then it is not needed. Similarly, there is a specific kind of person who is suited to the R2B, one that is comfortable with acceptable clinical risk, sharing of equipment, and a general mindset of making it work. The surgeon that demands robots to be able to operate is perhaps better suited to the Role 3.
Broadly, we see this capability as being effective across the spectrum of cooperation to conflict. As we continue to engage with allies and partners in the near region, it can provide a surgical effect in remote areas to mitigate risk, whilst also sustaining the force and acting as a force multiplier via training of partner forces and provision of health support to the local populace.
Given its logistical versatility, we also value its ability to provide short-notice response to Humanitarian Aid and Disaster Relief or Non-combatant Evacuation Operations. The R2B could easily deploy to a remote airstrip via strategic air to provide an immediate response. It offers a solution to the risk of relying on rotary wing air medical evacuation (RWAME) to access maritime-based surgical capabilities for ground forces and can be underslung via CH47s deploying to a landing zone.
The R2B could rapidly establish and provide a surgical effect on the ground that links back to the facilities offshore. It’s highly capable combination of health effects in a small logistical footprint make it effective for highly dispersed, remote, and logistically difficult to sustain littoral operations. Finally, an R2B could be deployed as far forward as a Combat Service Support Team (CSST) in support of large-scale combat operations – for example, in an underground carpark or using existing infrastructure to be as close to POI as feasible.
Whilst it could not be the only surgical effect in an area of operation, one per battlegroup deployed forward with a larger Role 2 Enhanced (R2E) further rearwards, combined with perhaps a Role 2 Forward (R2F) deployed further forwards in support of a Combat Team conducting a particularly high risk tactical action, is one method in which R2B could be deployed to reduce the risk to timely evacuation by being able to conduct surgery forward and hold patients for extended periods.
All that said, the R2B is not the golden bullet for all circumstances. The ability to conduct surgery and hold patients comes at the cost of mobility. While we may be able to establish and collapse in less than two hours, once a patient’s chest is cracked open, we are not moving, and ICU patients will need to be evacuated rearwards before a move can occur.
Similarly, it does not hold all the capabilities of a R2E and is not by default the right tool for every mission. We would describe it as the 80% solution and is a good starting point to work from – no option should be considered the 100% solution without analysis. Each mission profile and operating environment is unique, hence the need for health planners’ involvement in the planning process so modular amendments can be considered for the deployment of the optimal capability in the context of the overall Common Operating Health Picture.
We would also note that this is not revolutionary and has been done before. Parachute Surgical Team, Forward Light Surgical Team, and Role 2 Light Manoeuvre are all names for similar capabilities that have existed in previous versions of doctrine around the world. Our recent focus on Afghanistan and the Middle East and its lack of air threat enabled large-scale medical treatment facilities to prosper and essentially grow exponentially. We could easily achieve clinical best practice, and the reliance on RWAME and strategic AME mitigated most concerns relating to timely evacuation.
We are now just re-learning the lessons from our past. The key will be for medical professionals to embrace these lessons and quickly adapt. Our tentative successes so far have seen us deploy as far forward as a CSST in a large-scale combat operations environment in support of 9th Brigade Exercise RHINO RUN, and our planned deployment to an A2 Echelon in a littoral environment in support of the 1st Brigade on EX PREDATORS RUN.
Our journey so far has been a team effort and our successes have been a result of deliberate planning and considered analysis. In 2023, 2 SURG was in the unfortunate position of being a surgical company with no surgical equipment, and a flawed plan to not deliver this until 2026. However, inversely, this afforded us the rare opportunity to reduce tempo in other areas and focus on planning in support of modernisation.
Through a series of working groups; robust discussions; and targeted, informed professional military education with our allies and partners we were able to conduct a comprehensive and deliberate military appreciation process that resulted in a clear path forward. We are now starting to reap the benefits.
It has not been easy, in fact at times it has been incredibly frustrating, but it is thanks to the team and everyone involved that we are now starting to deliver what we feel is a highly versatile, capable, and logistically deployable surgical capability that is ready for operations. It is also perhaps a strong reflection of the power and value of deliberate planning and the military appreciation process.
