It started out as a boring day. Sitting in a makeshift hospital situated in an austere and hostile environment at an undisclosed location, Maj. Alexander Le and his fellow Special Operations Surgical Team, or SOST, members welcomed the monotony. After all, a busy day for the members of the surgical team would mean the worst possible day for someone else. Unfortunately, this calm day would soon be met with chaos.

Special Operations Surgical Teams (SOST) are composed of active-duty Air Force medical professionals, including a trauma surgeon, emergency physician, nurse anesthetist, surgical scrub tech, critical-care nurse and a respiratory tech. During combat operations, the teams provide far-forward medical care. Video // Peter Ising

Le, an emergency physician, remembers hearing cars race towards their security checkpoint and wondering if it was a patient or a foe, while mentally and physically preparing for either. Screams and moans came from the back of two truck beds making it clear help was needed.

The insticts of the team began to kick in.

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Major Alexander Le, an emergency physician with the U.S. Air Force Special Operations Surgical Team (SOST), prepares for a rapid infiltration mission aboard a MC-130H Combat Talon II from the 15th Special Operations Squadron, Hurlburt Field, Fl., as part of Exercise Emerald Warrior 19, Jan. 16, 2019. U.S. Air Force Photo // Tech. Sgt. Gregory Brook

As Le climbed over the back of the truck he saw it was filled with bodies and body parts and the cries became deafening.

“Everybody is in pain and it’s your job to get in the back of that truck and do everything you can immediately to save lives,” Le said. “You also have to sort through and figure out which guys need to go to the operating room; who is dead and who can I save now, and you begin to prioritize each patient to take care of them. All this while you’re kneeling down in blood and guts and getting your hands dirty, it’s not pretty and it’s beyond stressful.”

This type of situation on the front lines spurred the medical readiness innovation of SOST for the Air Force. Originating in 2001 and operational by 2003, the surgical teams are comprised of mobile emergency and surgical specialists with advanced medical and tactical training enabling them to save lives anywhere and any time. This not only means saving the men and women in uniform, but host nation fighters and locals; sometimes while bullets and mortars fly overhead.

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U.S. Air Force Special Operations Surgical Team members check their gear on a MC-130H Combat Talon II from the 15th Special Operations Squadron, Hurlburt Field, Fl., during rapid infiltration training as part of Exercise Emerald Warrior 19, Jan. 16, 2019. U.S. Air Force Photo // Tech. Sgt. Gregory Brook

In recent years, SOST has learned the critical strategic impact they have for local fighters. Often knowing they have American surgeons prepared to provide them medical care if need be, the fighters were more determined and would persevere, willingly putting their faith in their American teammates.

See more SOST photos on Flickr

The team members carry specialized equipment and gear mostly in backpacks designed to support a wide spectrum of operations and missions. These teams function far forward and independent of any established medical facilities. This enables SOST to function as a light and lean capability with a smaller footprint than conventional surgical assets, but also means they must be knowledgeable and skilled in medical practice with limited resources.

“Our surgical team is really designed to push that golden hour forward. So what we don’t want is to have a big gap in time between where our special operators are, if they were to get injured, to where someone is who can treat them surgically,” Le said. “The Air Force and the military overall realized that if we had somebody who could get into the abdomen or chest in a reasonable amount of time, data showed lives could been saved. So that’s really what the SOST team is all about. It’s pushing care forward, quick enough to make a difference.”

The “golden hour” term is widely attributed to Dr. R. Adams Cowley, an Army surgeon after World War II who is known as the father of trauma medicine. Itrefers to a period of 60 minutes or less following injury when immediate definitive care is crucial to a patient’s survival.

SOST members train to support special operations forces around the world. They are assigned to Air Force Special Operation Command’s 24th Special Operations Wing within the 720th Special Tactics Group. SOST deploys as a six-member team consisting of an emergency physician, general surgeon, nurse anesthetist, critical care nurse, surgical technician and respiratory therapist.

SOST provide four unique medical capabilities: advanced trauma resuscitation, tactical damage control surgery, post-operative critical care and critical care evacuation.

Becoming a Special Operations Surgical Team member is no easy task. Candidates are evaluated during a rigorous week-long selection process.

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Members of the Air Force's Special Operations Surgical Team (SOST) practice emergency room procedures at the University of Alabama at Birmingham hospital in Birmingham, Ala. SOST members work and train with the same airmen they will deploy with downrange. U.S. Air Force photo // Tech. Sgt. Perry Aston

SOST candidates must demonstrate teamwork, critical thinking, high stress tolerance, effective communication, sound situational awareness and leadership traits. If selected, new team members go through 10 months of specialized training before deploying on their first operational mission. The training includes a number of survival, evasion, resistance and escape courses, advanced operational medical training and several months of demanding SOF specific operational and tactical training. Finally, they participate in full-mission exercises with special tactics and other joint SOF units.

SOST was designed as the tip of the spear in cutting-edge medical readiness and some of the equipment developed and implemented on the front lines has also led to innovations in military and civilian medical effectiveness.

“These are very tight-knit teams and it takes some time to get the skills necessary to provide that level of care and support and that is critical for the job they do,” said Maj. Gen. Robert Miller, director of medical operations and research at the Office of the Surgeon General. “When SOST is not deployed, their duty location is actually at a civilian Level 1 trauma center. This enables the whole team to stay together in a continuous training mode, so their trauma skills are unsurpassed and when they are called upon to deploy; together they are ready.”

Miller states working with civilian partners is critical. In a perfect world, the Air Force would be able to provide all of its readiness training inside the direct care system, but the demand for this type of training exceeds the capacity of care provided at military locations.

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A members of the Air Force's Special Operations Surgical Team (SOST) adjusts a light while practicing emergency room procedures at the University of Alabama at Birmingham hospital.

U.S. Air Force photo // Tech. Sgt. Perry Aston

“We are dependent on working with our military partners, interagency partners and, most importantly, our civilian partners to get the surgical and trauma skills needed,” Miller said. “Today we have about 800 technical assistance agreements to work and train with civilian facilities in different areas of medicine.”

There are a very few successful programs in the advancement of Air Force medical readiness with partnerships in the civilian sector, said Miller.

There is C-Stars, or Center for the Sustainment of Trauma and Readiness Skills, at the Level 1 trauma centers in Baltimore, Cincinnati and St. Louis. Through the C-STARS program, Air Force medical providers embed in one of the nation’s highest volume trauma centers, training them on vital expeditionary medical skills. The C-STARS program, which is part of the 711th Human Performance Wing at Wright-Patterson Air Force Base, Ohio, demonstrates how civilian partnerships ensure the readiness of the medical fighting force. This is especially important for medical Airmen stationed at military treatment facilities with few trauma cases.

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Members of the Air Force's Special Operations Surgical Team (SOST) practice emergency room procedures at the University of Alabama at Birmingham hospital. SOST members work and train in civilian trauma centers to keep their skills sharp because there are few trauma cases at stateside military hospitals. U.S. Air Force photo // Tech. Sgt. Perry Aston

In a similar vein there is the Sustained Medical and Readiness Training or SMART in Las Vegas. SMART is a mechanism to help Air Force medical personnel maintain proficiency in their particular medical specialty. Clinical currency is the foundation for medical readiness skills, regardless of the particular specialty area. Advanced medical readiness training builds even further on that foundation.

For SOST, the teams are partnered with Level 1 trauma centers in Miami Las Vegas and the University of Alabama at Birmingham, or UAB.

“Military hospitals in the states typically don’t see a lot of trauma,” said Dr. Jeffrey Kerby, UAB’s Division of Acute Care Surgery director. “For a medical team to keep their skills sharp, they need a more challenging environment.”

Kerby, who was an Air Force surgeon before joining UAB, is the conduit between Air Force Special Operations Command and the hospital.

“UAB is a good training ground,” Kerby said. “We are the only adult Level 1 trauma center within a 150-mile radius. We see a great many penetrating trauma cases here from gunshot wounds, stabbings or car crashes. Unfortunately, we are a good place to hone trauma skills.”

The SOST Airmen are fully accredited staff at UAB, treating patients in the emergency department, performing surgery and caring for those in intensive care units.

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Members of the Air Force's Special Operations Surgical Team (SOST) practice emergency room procedures at the University of Alabama at Birmingham hospital in Birmingham, Ala. SOST members work and train with the same airmen they will deploy with downrange.

U.S. Air Force photo // Tech. Sgt. Perry Aston

“I think I speak for all of us and when I say that I’m extremely grateful to be here at UAB,” Le said. “The staff here is extremely helpful and they’re so supportive. I think a lot of it comes from Dr. Kerby; he gets what we do and he understands the mission and they really found a good way for us to integrate here to be helpful, but they also understand when we have to go out the door and train or deploy.”

At UAB, the SOST Airmen are essentially extra hands on deck when they are not training or deployed; there’s plenty of work to go around helping the members easily integrate into the hospital system, Le said.

UAB hosts three, six-man SOST teams, who rotate on four-month deployments at the host medical facility. SOST Airmen are also vital in instructing their civilian resident peers and other medical students at the university on the lessons learned from the battlefield.

Le says the SOST members at UAB also make it a priority to get out into the community to promote the Stop The Bleed campaign to educate schools and the public on techniques to control blood loss, including the proper use of tourniquets, compression bandages and hemostatic dressings.

The training helps dispel misconceptions about the use of tourniquets, which have been historically associated with amputation. Studies during the Iraq and Afghanistan wars showed the use of tourniquets greatly increased an injured service member’s chance of survival with no increase in amputation.

“It is interesting from a research and development standpoint…a lot of the tools SOST uses are based on needs they have addressed downrange. Like a means to stop bleeding when a tourniquet cannot be used. There are tools that have been developed thanks to the SOST teams that have identified a need,” Miller said. “It’s really amazing what our medics can do with limited resources to save lives.”

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A new medical device, the resuscitative endovascular balloon occlusion of the aorta, or ER-REBOA, is buying vital time for critically wounded patients by helping stop hemorrhages in the pelvis and abdomen.

Courtesy photo

One of the SOST innovations Miller speaks of is the use of the Resuscitative Endovascular Ballon Occlusion of the Aorta, or REBOA, catheter.

For the first time ever in a forward wartime environment, UAB SOST Airmen performed a procedure that inserted a balloon catheter through a critically injured patient’s femoral artery into the aorta. The balloon catheter was then inflated in order to stop the bleeding. This temporary measure provided valuable time to stabilize the patient and allowed him to survive en route to the operating room. This device was used three more times during the deployment, saving four patients who otherwise would not have survived.

Le said when a team only has one surgeon and a line of patients, applying the REBOA catheter can allow the team more time before patients bleed to death.

“Data shows most combat-related deaths result from a patient hemorrhaging or bleeding out before getting to an operating room,” Le said. “(A patient) can bleed to death in minutes; this is why it is important to be in close proximity to the fight. If you can stop the bleeding and stabilize the patients and get them to the next echelon on care, you give them a chance to survive.

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Members of the Air Force's Special Operations Surgical Team (SOST) perform a ruck march through Red Mountain Park in Birmingham, Ala. SOST members are trained to seamlessly provide life-saving surgical care and trauma resuscitation on or near the front lines of battle. U.S. Air Force photo // Tech. Sgt. Perry Aston

Le said there have been patients with serious injuries the team has doubted would survive. Sometimes members of the team will see or hear back from these patients weeks later thanking them for saving their lives.

“If we’re working on you, we know it’s probably the worst day of your life,” Le said. “They really don’t know that you were there or remember your face, but they know the capability was there and we’re doing everything that we can to give them a shot at survival and that’s enough for us.”