Cloak and Scalpel: Special Operations Surgical Teams

Special Operations Surgical Teams (SOSTs) are a lightweight, mobile, and rapidly deployable medical and tactical unit trained to provide trauma resuscitation and also life-saving surgical care on or near the battlefield. SOSTs bridge the gap between front-line and conventional medical care.

The ability to function in resource-constrained environments, which necessitates extraordinary individual preparedness and teamwork to improve survivability, is the main way that SOSTs differ from other medical units. These teams are capable of defending themselves and their patients, securing a space, like a room or small building, and are also capable of rapidly setting up a casualty collection point. They are also highly skilled in the core combat skills of shooting, moving, communicating, navigating, and surviving. [source]

1 Motto, Patches, and History

In 2001, the U.S. Air Force recognised the need for mobile surgical teams capable of providing immediate, life-saving care in forward-deployed locations. The necessity of forward surgical support and other special operation-specific care became apparent as a major takeaway from early stages of Operation Enduring Freedom. A directive to create an organic resuscitation surgical capability specific to special operations was issued by Special Operations Command, also known as SOCOM by October of that year. The services assessed the smallest surgical units in their inventories, including the Air Force’s Mobile Field Surgical Teams (MFST), the Navy’s Forward Resuscitative Surgical Squadrons (FRSS), and the Army’s Forward Surgical Teams (FST), in order to meet this requirement.

The shortage of very small surgical units in their services’ traditional inventories hampered other components from contributing to the effort, but Air Force Special Operations Command (AFSOC) was able to quickly set aside a few MFSTs and start creating the tactics, procedures, training, and techniques needed to meet the needs of the special forces community.

Those teams returned home from Enduring Freedom, determined to change the concept surrounding their operations and equipment packages of the standard MFST, despite the fact that they performed admirably during the invasion, according to all reports. Their experience brought to light the need for special surgical units to have a well-defined operational objective, function under certain constraints, and also have the adaptability to offer tailored solutions that meet the precise mission requirements required by special operations. This initiative resulted in the establishment of SOSTs, with the first teams becoming operational by February 2003. [source]

1.1 Motto

QUIS ILLOS BELLATORES CUSTODIET,” or “Those Who Care for the Warriors.” [source]

SOST members are steadfastly committed to their profession, their team, their mission, and also the lives of their patients. In the event that a special operator or attached personnel falls, SOSTs are ready to provide critical, life-saving care, demonstrating their dedication to excellence and resilience. Their motto reflects their deep commitment to their mission and also their values.

1.2 Patches

SOST Insignia.

The SOST insignia prominently features a red handprint over a globe, encircled by 16 stars. Though no official interpretation exists, the imagery symbolises global reach, unwavering commitment, and sacrifice. 

2 Organisation

2.1 Place within Broader Government Structures

SOSTs operate as part of the 24th Special Operations Wing (SOW), which is housed within the 720th Special Tactics Group. These teams play a vital role in supporting one of the Wing’s four primary mission capabilities: global access, precision strike, personnel recovery, and, of course, battlefield surgery. 

The 24th Special Operations Wing (SOW) is a key component of the Air Force Special Operations Command (AFSOC), which is additionally a part of the US Special Operations Command (SOCOM), the unified authority overseeing all Special Operations Forces across the various branches of the military. 

2.2 Internal Structure

The SOSTs are composed of six team members: an emergency physician, general surgeon, nurse anaesthetist, critical care nurse, surgical technician, and also, a respiratory therapist. These specialisations enable the teams to provide four distinct medical capabilities in the theatre: advanced trauma resuscitation, tactical damage control surgery, post-operative critical care, and also critical care evaluation. [source]

Members of SOST are globally engaged in training and supporting Special Operations Forces while remaining officially assigned to the 24th SOW at Hurlburt Field, Florida. They also maintain their clinical expertise and currency by performing duties as embedded participants in premier Level-1 Trauma Centres, including University Medical Center in Las Vegas, Nevada, and the University of Alabama at Birmingham Medical Center in Birmingham, Alabama. 

During this assignment, hospitals fully integrate military medical professionals, allowing them to take independent calls and week-long clinical rotations while still meeting their need for rapid deployment. Military personnel work independently but on the same schedules as civilian personnel, with the hospital ready to continue operations during their short-notice assignments. [source]

2.4 Recruitment

SOST’s recruitment process is supported by an effective digital presence. SOSTs actively communicate with potential candidates via social media platforms such as Facebook, Reddit, and YouTube. Additionally, the official website of the 24th SOW provides detailed information and application resources.

The 24th SOW’s recruiting teams also actively participate in outreach by visiting universities and meeting with both ROTC (Reserve Officer Training Corps Cadets) and regular students. They hold informational sessions for youth organisations and high school students to pique their interest. They also promote local-level community engagement by participating in public events, which broadens their reach and raises awareness about SOST opportunities.

SOST’s recruitment stand at Joint Base Langley-Eustis.

2.4.1 Requirements

In the past, SOSTs have recruited active-duty Air Force personnel, reserve personnel, interservice transfers, civilians, first-time non-selects, and guard personnel. However, recruitment varies by cycle, and not all roles are open each year/selection period. To qualify for the SOST, candidates must meet the following requirements:

2.4.1.1 General Eligibility

  • A minimum Secret clearance and eligibility for Top Secret clearance are required
  • A minimum score of 90% on the most recent Air Force Fitness Test.
  • Must be eligible for Permanent Change of Station (PCS) within 12-24 months of selection.
  • Must complete a 9C/Operation Support Flyer Physical and submit DD Form 2992.

2.4.1.2 Rank and Grade Requirements

  • Officer Candidates must hold a grade of O-3 to O-4 (consideration for +/-1 grade is possible on a case-by-case basis).
  • Enlisted candidates must hold a grade of E-5 with 7-level qualification or the ability to achieve it within six months of selection. E-4 candidates may be considered on a case-by-case basis.

2.4.1.3 Specialty Code and Qualification Requirements

  • Air Force Speciality Code (AFSC):
    • Candidates must hold a qualifying SOST AFSC:
    • Officers: 44E3A, 45A3, 45S3, 46Y3M, 46N3E, 46N3J.
    • Enlisted: 4H071, 4N171.
    • Sister Service Equivalents: Applicable for officer positions only.
  • AFSC Applicability:
    • Candidates with either a primary or secondary AFSC correlating to an approved SOST AFSC may apply. Those with a secondary AFSC must consult their leadership to confirm eligibility to leave their current career field and meet SOST requirements.

2.4.1.4 Licensure and Credentials

  • Candidates must meet or be able to meet licensing and credentialing requirements for Florida, Alabama, or Nevada.

2.4.1.5 Special Requirements for Specific Roles

  • Medical Corps applicants may only apply during the final year of their residency program.
  • Medical providers must be board-eligible at a minimum.
  • Nursing Requirements:
    • Active Duty Nurses: Must have two years of recent, consecutive experience in adult ICU, ER, or critical care flight roles. Their intent to join SOST must be reflected in Talent Marketplace/MyVector.
    • Civilian Nurses: Must hold current board certifications in CCRN, CEN, TCRN, or CFRN (considered on a case-by-case basis).

2.4.1.6 Sister Service or Civilian Candidates

  • Must meet Air Force entry requirements before applying.

2.4.2 Selection 

The SOST selection process is carried out twice a year by active-duty teams, with each assessment divided into two phases. These assessments are scheduled at random times throughout the year, based on personnel availability and also, operational requirements. In the first phase, a panel reviews and evaluates applications received by the specified deadline. Qualified applicants are then shortlisted and invited to the second phase, indicating that the assessment board believes the applicant has strong potential to join SOSTs.

The second phase includes a four-day in-person evaluation at Hurlburt Field, Florida. This stage is intended to assess candidates’ suitability for the unique requirements of SOST. Before the second phase, candidates are advised to prepare for the following:

  • Briefing and writing skills evaluations
  • Problem-solving events
  • Leadership ability evaluations
  • Tactical/field medical care scenarios
  • Extensive psychological testing and interviews
  • Weighted ruck marching
  • Distance running
  • Vigorous calisthenics sessions
  • Weightlifting
  • Patient transport via litter

Successful completion of this phase does not guarantee a position within the SOSTs. Following the evaluation, the 24th SOW Commander or their delegate makes the final decision on new SOST members. Candidates are informed of their selection or non-selection status as soon as the second phase is completed. [source]

During a question-and-answer live stream in November 2023, two serving SOST members shared insights into the selection process. Typically, 12-20 candidates apply for each Phase 1 intake. Of these, about 15 advance to Phase 2, with about four eventually being chosen to join SOSTs.

SOST selection exercise.
SOST selection exercise.

2.5 Training

After being selected, new SOST members go through an intensive 10-to-12-month specialised training program to prepare for their first operational mission. This rigorous program consists of, but is not limited to the survival, evasion, resistance, and escape (SERE) course; advanced operational medical training; and months of specialised operational and tactical training. Furthermore, trainees are thoroughly familiarised with SOST and Special Tactics operations, culminating in a 24-full-mission profile exercise with other specialist combat units to ensure seamless integration and mission readiness. [source]

Further training team members will undergo is as follows:

  • Special ops medical courses, 
  • Interoperability training with other units to enhance fluidity and mutual understanding of unit-specific tactics, techniques, and procedures
  • Critical care air transport team courses
  • Combat medic training
  • Military-civilian partnership engagement 
  • Small unit tactics training 
  • Survival evasion resistance escape (SERE)
  • Rotation between SOST roles within the team [source]

2.6 Involvement of other organisations

2.6.1 Special Operations Units

SOST is not solely dependent on AFSOC assignments and is capable of supporting a wide range of special forces units. This flexibility results from the fact that AFSOC is frequently not responsible for the majority of SOCOM missions that require frontline surgical care. Consequently, SOSTs often offer vital assistance to Army, Navy, and Marine Corps special operators.

2.6.2 The University of Alabama at Birmingham

The partnership between The University of Alabama at Birmingham (UAB) and the Air Force started in 2006 when UAB hosted two-week rotations of Air Force combat medics and pararescue jumpers (PJs) to keep them medically proficient in between deployments. Currently, UAB trains close to 150 PJs and medics every year.

The first SOST team was embedded at UAB in 2010, and there are now four SOSTs, all of whom are fully clinically integrated healthcare professionals. Active duty Air Force personnel can receive the practical clinical experiences they require to maintain clinical excellence at UAB, a high-volume, ACS-verified Level I trauma centre.

This partnership is critical to developing the capabilities of SOSTs since the demand for surgical training exceeds the capacity of care provided at military locations. This is largely due to the lower volumes of traumatic injuries on military bases, especially given the limited scope of current U.S. military deployments. UAB also benefits greatly from the continuous advancements in military medicine, which can be directly applied to patient care at Birmingham. This partnership keeps UAB at the forefront of innovation in trauma care.

A recent example of battlefield medicine saving lives in Birmingham is the implementation of whole-blood therapy on ambulances. Birmingham is now one of the first cities in the country to implement this practice, which provides life-saving whole blood to critically injured patients on the scene. [source]

3 Equipment

To maintain their status as an extremely lightweight, mobile, and rapidly deployable force, SOSTs rely on deliberately modest kit and equipment. As expected, sources that describe and depict SOSTs in training and operational settings reveal that the majority of their equipment consists of specialised surgical and critical care instruments.

3.1 Weapons

  • M4 Assault Rifle:
    • Several different AFSOC teams use the M4 rifle and its variants, and it generally remains as the general assault rifle for tactical teams. SOSTs are often depicted with variations of this rifle; however, the majority of images show them without firearms at all.
  • Glock Handgun:
    • The Glock pistol also appears to be the preferred sidearm for SOSTs. Specific variants of this handgun are widely favoured among AFSOC forces and other special operations units.
SOST members in Afghanistan, 2021.
SOST members in Afghanistan, 2021, equipped with their primary and secondary weapon systems.

3.2 Vehicles

The strategies used by SOSTs to enter and exit combat zones ultimately depend on the mission. These teams are extremely flexible and can also work directly from a wide range of vehicles that have been selected to satisfy the needs of the environment and the mission. These can include, but are not limited to:

  • Fixed-Wing Aircraft:
    • C-130 Hercules and its variants.
    • C-17 Globemaster
  • Rotary Aircraft:
    • V-22 Osprey
    • UH-60 Black Hawk
    • CH-47 Chinook
  • Ground mobility vehicles
    • Polaris MRZR LTATV
    • Oshkosh JLTV 
    • Flyer 72 – Heavy Duty
  • Boats

3.3 SOST Specific Kit

The team’s equipment is primarily stored in highly adaptable, mission-specific modular backpacks, resulting in a significantly smaller footprint than other special operations forces or conventional medical assets. Each individual backpack, or bag set, can be expected to fulfil a unique capability, whether it be anaesthetist equipment, surgical tools, or critical care supplies. In total, each member carries over 100 pounds of battle kit, including helmets, weapons, ammunition, and medical instruments.

The standard kit allowance consists of three separate equipment categories: Quick Response, Electronics, and Sustainment. These categories are further divided into bag sets, each fulfilling a distinct role to support mission success:

3.3.1 Operating Room Bag

  • Includes everything needed for ten or more surgical procedures
  • Arranged in modular panels for convenience and effectiveness
  • Transparent sections for easy recognition
  • External quick-start packs for instant surgical readiness
  • Products arranged to help non-team members during operations

3.3.2 Litter Bag

  • Consists of four stanchions and two foldable litters
  • Can be used as a backup casualty stretcher or as an OR table
  • Includes resuscitation or irrigation fluids

3.3.3 Emergency Response Bag

  • Small trauma bag for preliminary assessments and resuscitation
  • Multiple trauma cases are supported by additional supplies based on mission requirements

3.3.4 Anesthesia Bag

  • Designed to administer anaesthesia and manage airways in sterile environments
  • A tiny pack is included for easy emergency anaesthesia setups
  • Includes materials for several surgical procedures

3.3.5 Electronic Package

  • Includes electronic and communication tools for patient care, such as portable suction equipment, defibrillators, and ventilators
  • Fits into a single tri-wall container and weighs less than 400 pounds
  • Improves the effectiveness of patient monitoring but is not necessary for all austere environment surgical treatment

3.3.6 Sustainment Package

  • Increases capacity to ten more surgeries and supplies essential resupply
  • Includes a sturdy operating table and an extra Operating Room bag
  • Allows for both forward-deployed and centralised operations

The packages are intended to be adaptable and can be deployed as a whole or broken down into individual components to meet specific mission requirements. While the entire set is too large and heavy for backpacks, the modular design ensures that only the necessary items are taken, maximising weight and space for each operation. [source]

4 Tactical-Operational Information

4.1 Deployment Rotations

AFSOC currently coordinates its operations using the Air Force Generation Model (AFFORGEN) deployment cycle. This is a 4-phase, 24-month cycle, consisting of 6 months per phase:

  • Available to Commit (1):
    • Rotational Deployments
    • Ready Response Force
  • Reset (2):
    • Basic Unit Training 
    • Upgrade Training
    • Aircraft Readiness Recovery
  • Prepare (3):
    • Advanced Spectrum Training
    • Multi-Unit Tactics and Training 
  • Certify (4):
    • Certification Event – Large/Joint Force Exercises 
    • Maintain Readiness

4.2 Notable Operations 

SOSTs have been actively deployed on many operations despite only being established 20 years ago, and the Middle East conflicts in the intervening years have given them invaluable opportunities to hone their skills. Through quick resuscitation and transfer to surgical care during the crucial “Golden Hour,” their efforts helped combat wounds in Afghanistan and Iraq achieve previously unprecedented casualty survival rates.

Given the often classified nature of the SOSTs’ missions and their support for special forces operations, it is likely that they have taken part in more operations than have been publicly disclosed. 

SOSTs operating on a local fighter who was wounded fighting the Islamic State in 2016.
SOSTs operating on a local fighter who was wounded fighting the Islamic State in 2016.

4.2.1 Operation Enduring Freedom

Afghanistan was one of the first instances of SOSTs deploying on active operations. However, accounts suggest that their unique capabilities were only required for a small percent of the time. This provided SOSTs the opportunity to visit a number of different locations and augment other coalition facilities while waiting for missions specific to their capabilities.

During this time, SOST members made significant contributions, including working in Afghan hospitals, mentoring Afghan surgeons, providing medical care to the local Afghan community, and supporting FSTs. In addition to enhancing local medical capabilities, these initiatives promoted cooperation and goodwill among the communities they served. [source]

4.2.3 Operation Inherent Resolve

During the U.S. campaign against the Islamic State in Iraq, Syria, and Libya, SOSTs treated over 750 patients, oversaw 19 mass casualty incidents, carried out 16 life-saving operations, and treated victims of chemical weapons exposure. Five members of a SOST were presented Bronze Stars and a Meritorious Service Medal for their actions throughout Enduring Freedom. [source]

Members of a Special Operations Surgical Team were presented Bronze Stars and a Meritorious Service Medal.
Members of a Special Operations Surgical Team were presented Bronze Stars and a Meritorious Service Medal.

4.2.4 Withdrawal from Afghanistan

Following the Taliban takeover in 2021, SOSTs were sent to Afghanistan to assist in the evacuation of hundreds of thousands of Afghan, American, and foreign citizens. SOST members responded to the deadliest mass casualty incident of the Afghanistan War during the suicide bombing at Kabul’s Abbey Gate on August 26. They treated more than 60 critically injured patients and carried out 15 major surgical procedures.

Notably, five SOST members received Bronze Stars for their actions. SOSTs continued to play a crucial role until the very end, departing on the second-to-last C-17 out of Afghanistan. [source]

5 SOST members are presented with the Bronze Star Medal.

4.3 Core Purpose

The core mission of SOSTs is to provide advanced, life-saving medical care directly to forward-deployed special operations forces. This mission is achieved through a set of critical battlefield surgery capabilities designed to operate in austere and high-risk environments:

  • Deliver military and civilian trauma expertise:
    • Leverage extensive experience in both military and civilian trauma care to provide effective treatment
  • Project forward surgical operations:
    • Rapidly establish surgical facilities close to the point of injury, significantly reducing mortality rates
  • Perform low-light surgery:
    • Conduct complex surgical procedures under limited visibility conditions to ensure mission continuity in operational settings
  • Mobile Role-2 capabilities:
    • Provide advanced trauma management and emergency medical treatment, including resuscitation, limited surgical intervention, and stabilisation, while maintaining the mobility required to support frontline units [source]

4.3.1 Operational Medical Capabilities

In theatre, SOSTs deliver a comprehensive suite of medical interventions tailored to the demands of special operations. These capabilities are divided into four critical areas:

  • Advanced Trauma Resuscitation:
    • Tactical Damage Control Resuscitation
    • Dynamic Triage with Tactical Combat Casualty Care and Diagnostic Sonography
  • Tactical Damage Control Surgery:
    • Advanced Haemorrhage and Vascular Control
    • Advanced Theracoabdominal Damage Control Surgery
  • Cost-effective critical care:
    • Advanced Monitoring and Ventilator Management 
    • Casualty Evacuation Packaging
  • Critical care evaluation:
    • Intensive Care Unit Level Critical Care Transport
    • In-Flight Advanced Monitoring 

[source]

4.4 Tactics

The SOSTs are made to quickly set up and dismantle their surgical capabilities. The AFSOC surgical teams’ design is perfect for missions that call for the temporary forward positioning of surgical capability for short periods of time. A key skill of these teams is their capacity to support far-forward direct action missions by forward-positioning surgical capability for as little as a few hours.

The majority of media coverage shows SOSTs working in a variety of settings, such as aircraft, tents, self-constructed shelters, and buildings of opportunity. SOSTs were observed treating patients in hallways and on stretchers during the 2021 withdrawal from Afghanistan.

SOST and Pararescumen using a shipping container as a makeshift operating room during a field exercise.
SOST and Pararescumen using a shipping container as a makeshift operating room during a field exercise.

4.5 Personnel size

In terms of SOSTs personnel size, the exact figure is undisclosed. That said, SOSTs are not meant to be mass-produced. To train with these specialised teams and hone their skills in some of the most difficult surgical settings, they need highly motivated medical professionals who are prepared to leave the comfortable surroundings of a hospital. In order to create surgical units that can meet the rigorous requirements of high-speed, low-drag special operations, non-volunteers must be chosen, or teams must be placed in environments that do not foster team building. [source]

5 The Future

In previous deployments, the possibility of detection presented by modern warfare technologies might not have been as important, especially during counterinsurgency operations. Localised threats and direct engagement were frequently prioritised over sophisticated electronic warfare considerations in these missions. But as adversaries use more advanced detection techniques, like electromagnetic sensor systems, overcoming these obstacles has become essential to the survival and efficacy of surgical teams that deploy forward.

Electronic medical equipment used in SOST operations, such as patient monitors and ventilators, emit electromagnetic radiation, that adversaries can detect using sensors and analysis systems. In turn, the operational success of such operations is heavily dependent on SOSTs avoiding detection of any kind.

Preventing adversary forces from detecting electromagnetic emissions is especially difficult due to the wide range of medical devices used in care. Shielding multiple devices in a room is generally more practical than trying to counteract the various frequencies emitted. Shielding is a passive method of containing emissions, whereas using a jammer actively broadcasts electromagnetic signals, which could reveal the location of a sensitive US team or asset. 

Reporting suggests that neither of these techniques has yet been applied to forward-deploying U.S. surgical teams, including SOSTs, in a standardized manner. As a result, SOSTs must consider electromagnetic shielding options while implementing practical solutions to reduce detection risks. Understanding the threat landscape and specific vulnerabilities allows SOSTs to develop and implement effective shielding techniques that improve team survivability while also contributing to the overall success of special operations missions. [source]

6 Conclusion

The ability of SOSTs to provide life-saving surgical care in high-risk and resource-constrained environments highlights their unique significance. SOSTs are a critical innovation in battlefield medicine that bridges the gap between both front-line care and also conventional medical facilities. SOSTs have a vital role in enhancing survivability for special operations forces, showcasing the exceptional preparedness, adaptability, and also teamwork required to meet the challenges of modern warfare.

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