December 2019

Saving Lives in Tomorrow’s War, Today

“Go, go, go!” an instructor shouts, and combat medics race down a dirt road through smoke and the sound of gunfire. Four soldiers are sprawled in the dirt. One has a ghastly facial wound, convincingly simulated by latex, and his labored breathing suggests internal injuries. Blood is everywhere, fake stuff squirted around by instructors. It’s barely dawn on a stormy morning at Camp Bullis, the military range on San Antonio’s far North Side, and these Army medics are training for trauma care. Staff Sergeant Jordan Blas, thirty, drops to his knees and snaps on his headlamp, bending over his patient, sweeping the body in a quick inventory of wounds, clearing simulated blood and broken teeth from the mouth. He finds a chest wound, and the patient begins choking and gasping. “Gimme a cric kit,” Blas says to his junior medic, preparing to slice into the patient’s throat to insert a breathing tube, a procedure called cricothyrotomy. “All right, buddy, you’re gonna feel me touching your throat,” he murmurs. Other medics are working to stabilize patients with arms and legs blown off and deep head wounds. The medevac chopper, they are told, is minutes away.

So far, standard stuff, easily within the experience of medics who’ve saved thousands of lives under fire in Iraq and Afghanistan. The Army calls it point-of-injury care or, less formally, “scoop and run.” Clear the breathing passage, stop the bleeding, package the patient on a litter, wrap them  in a Mylar blanket, strap them in, and wave in the medevac helicopter to whisk the patient to a nearby combat surgical hospital. Fancy medicine is left to the surgical teams and intensive-care nurses there. 

Effective scoop-and-run care has achieved a medical marvel unprecedented in warfare: the overwhelming majority of Americans who have fallen in battle in Iraq or Afghanistan have been saved. Well-trained medics, standby medevac helicopters, and an abundance of forward surgical hospitals enabled the military to carry out a 2009 directive from the Pentagon requiring that every deployed American be within sixty  minutes of higher-level care, usually at a surgical hospital. That lifesaving window of time is known as the “golden hour.” Almost 60,000 Americans have fallen in combat since 2001; of those, some 53,000, or 91 percent, have come home alive. In Vietnam, it was 75 percent. 

That success rate, however, is fast disappearing, probably forever. Today, a dwindling number of Americans are deployed, so many field hospitals have closed. Medevac times have, in some cases, expanded from sixty  minutes to hours or more. Luckily, casualties nowadays are relatively few. But when they do occur, combat medics can find themselves struggling to treat grievous wounds that exceed the limits of their training and without easy access to the sterilized instruments, whole blood, and diagnostic tools common in a proper operating room. 

These delays in combat medical care will get worse. Military planners and strategists increasingly see the golden hour of recent wars as an anomaly. Our enemies in Afghanistan and Iraq lacked air forces and had limited means to track and kill aircraft. American medevac helicopters could fly almost at will onto battlefields. Surgical hospitals could be placed where needed, and the big medevac jets, basically flying intensive-care units that ferried the severely wounded away to bases in Germany and on to the United States, could operate from airfields unimpeded.

Combat medics treated this soldier's simulated wounds. Now they race the patient toward a helicopter landing zone to be airlifted away for advanced surgical care.

Photograph by Jeff Wilson

Rising military forces in China, Russia, Iran, and North Korea, to name just a few potential adversaries, will not be so accommodating. They are perfecting long-range precision weapons designed to challenge American control of the air. Medevac helicopters will be at extreme risk, if they fly at all. High-tech weapons have proliferated far beyond the big powers: in Yemen, Houthi rebels are using armed drones and cruise missiles. Even without such threats, military tacticians say, keeping troops within sixty minutes of a surgical hospital is dangerous; it tells enemies where your forces will be concentrated.

This emerging reality has sent shock waves through the U.S. military medical community, particularly at Fort Sam Houston, in San Antonio, which is responsible for initial training of new medics from the Army, Navy, and Air Force and advanced training for Army medics. At Fort Sam, the young Army medics—often nineteen or twenty years old—get sixteen weeks of training in first-aid skills, practicing what’s known as algorithmic medicine, a simple decision ladder of steps they memorize: in this situation, do this. What will confront them on tomorrow’s battlefields is far beyond their current training and experience. 

“Prolonged field care” is the term for what medics will find themselves doing in the next war. It’s an entirely different and vastly more complicated kind of medicine than scoop-and-run emergency patch-up. Basically, it requires moving much of the work of hospital emergency rooms and intensive care units into the hands of combat medics working in the dirt. This new burden on medics comes at a time when wounds are increasingly complex. Rather than a simple gunshot wound or shrapnel injury, patients evacuated from Iraq and Afghanistan each averaged more than four wounds—one or more limbs blown off by a roadside bomb, perhaps, but also a genital injury, a traumatic brain injury, and internal bleeding. In the kind of slugfests the Army foresees, soldiers with multiple wounds are expected to be even more common. Lasers, directed-energy weapons, and thermobaric bombs all cause deep burns, wounds that are exceedingly difficult to treat.

“In high-intensity combat against potential adversaries like Russians or Chinese or even, let’s say, North Koreans, the scale of casualties will be significant—really significant,” Army General Mark Milley, now chairman of the Joint Chiefs of Staff, told a congressional hearing in April. “The ability to evacuate those casualties in sixty minutes—that expectation—well, we’ll try,” Milley said. “But I’m not guaranteeing that.”

Back at Camp Bullis, combat medic Blas has his patient breathing okay, bandaged, blanketed, secured on a litter, and ready for the medevac chopper. But this exercise is not about scoop-and-run; it’s about prolonged field care. Blas is part of an experimental program at Fort Sam for advanced medics, testing how much medical skill a basic medic can absorb and use to keep a wounded soldier alive far beyond the golden hour. In 26 weeks, Blas has gotten an earful, including 5 weeks of advanced anatomy and physiology, blood chemistry, cell mechanics, and advanced pharmacology. Now he’s being put to the test: instructors are grading how well he can translate classroom lectures into a high-stress situation in the field.

So here comes an instructor with bad news for Blas: the medevac has been canceled, and enemy riflemen are closing in. “You gotta move now!” Blas and three helpers grab the litter and trundle away through the woods. They’ll have to move one more time before getting to a simulated aid station, a grimy, unlit building that at least has a waist-high stand on which to set the litter. There they work feverishly, standing in pools of rainwater and fake blood.

Basic combat medics have to learn 70 separate skills. For prolonged field care, medics like Blas must learn as many as 480. Basic medics work with just five drugs; for prolonged field care, advanced medics have to study the uses of dozens of drugs and their interactions. If a medic is holding a patient for a few minutes before the medevac chopper arrives, a shot of ketamine may suffice to keep the patient out of agony. Over hours or days, a medic has to constantly monitor and adjust medications to try to alleviate pain, while also preserving limited supplies for newly wounded soldiers.

This particular patient is beginning to groan loudly, struggling to move on the litter. “I’m giving fifty milligrams of ketamine,” Blas says calmly. To Private First Class Emily Williams, his assisting medic, he says, “Starting TXA [tranexamic acid, which aids in blood clotting]—I want ten drops every six seconds, repeat that.” Explosions sound outside as Williams repeats, “Ten drops every six seconds, roger that.” Blas to Williams: “I need an IO, tibia plateau, your leg of choice.” That’s an intraosseous needle, one drilled directly into the bone to get medication quickly into the patient. After the simulated IO goes in, Blas scans the patient’s chest with a portable ultrasound machine. The left lung is not fully inflating, the machine tells him, which would explain the patient’s struggle to breathe. “I’m gonna tube him,” Blas says, holding out his hand for a scalpel. A second patient is delivered into Blas’s care. Blas quickly determines him to be a lesser priority and continues working with the first. 

If this were a civilian emergency room, the instructor, a former special forces medic named Marcus Smith, whispers to me, “there’d be thirty people in here, surgeons and nurses and techs, all working as a team. These two medics are doing it all.” Later, he will ask Blas why he didn’t clean out the soldier’s wound. “I didn’t have time,” Blas will answer. “It was chaos; I ran out of time. I would have liked to provide my patient better care.” But even so, if the simulation were real life, his patient would have lived.

Under the eye of an instructor, combat medics working in a forward aid station work to save a patient with simulated severe wounds.

Photograph by Jeff Wilson

During treatment of a wounded patient, Private 1st Class Emily Williams constantly monitors heart rate and blood pressure.

Photograph by Jeff Wilson

Left:

Under the eye of an instructor, combat medics working in a forward aid station work to save a patient with simulated severe wounds.

Photograph by Jeff Wilson

Right:

During treatment of a wounded patient, Private 1st Class Emily Williams constantly monitors heart rate and blood pressure.

Photograph by Jeff Wilson

Command Sergeant Major William “Buck” O’Neal wears a perpetually furrowed brow as he stalks the hallways of the U.S. Army Medical Center of Excellence at Fort Sam. Tall and gleamingly bald, with a faint Georgia drawl and a direct gaze, O’Neal has seen war as a paratrooper and combat medic. Now, as the senior enlisted soldier in charge of all medic training, his job with his staff is to figure out how to equip Army medics to handle prolonged field care. What do medics need to know? What new skills do they need? How much can they learn and how quickly? What new technologies and tools and medicines can help? After their initial sixteen weeks of training, Army medics return to their units but cycle back to Fort Sam periodically for additional training. How much more will the medics need to learn, and who will teach them? And where? There are 34,000 of them serving in the Army, half of them on active duty and the rest in the National Guard or Reserves. Fort Sam doesn’t have room to retrain them all. If a big war comes, will the U.S. need all of them in combat? How much time does Buck O’Neal have to get this done?

Fort Sam’s first try was to create a new job classification, expeditionary combat medic, which required advanced training focused primarily on prolonged field care. The Army surgeon general in Washington endorsed the idea, and Fort Sam created a snazzy brochure, a distinctive badge, and a motto: Post Horam Auream (“Beyond the Golden Hour”). The effort got going in early 2017 with a series of seven-month pilot courses. Of those who showed up, some students had trouble with the academic work—“a couple of college courses in a few weeks,” as one told me. “Like trying to drink from a fire hose.” The training included four weeks on veterinary care and dentistry, which seemed beside the point for combat medics.

O’Neal and his team made some changes. Out of the curriculum went veterinary care. Out went dental care. By the time Sergeant Blas was being tested at Camp Bullis, he was working under a different new training designation: advanced combat medic. More basic anatomy was added to the training, along with a big new section on treating burns, a job previously left to surgical hospitals. The precise number of advanced combat medics to be run through the training hasn’t yet been determined, but instruction will probably begin with medics assigned to combat units most likely to be called for big wars. On the battlefield they’ll be assisted by basic medics who’ve gotten an additional four or five weeks of training in prolonged field care. In five years, O’Neal says, every combat medic in the Army will have at least some training in prolonged field care. “It’s not gonna be cheap, and it’s not something that is gonna be done today,” he says, “but our job is to get it started the right way.” 

Not so fast, say some skeptical seasoned medics. “It’s not possible!” scoffs Iraq war veteran Greg Dotson, about O’Neal’s plan. A resident of Fort Worth, Dotson trained at Fort Sam and went on to save 145 lives during two combat tours, before he lost a leg in a roadside bomb explosion. His views on battlefield medicine are hard-earned, and as he sees it, all the training in the world won’t do much until the Army figures out how to get the supplies and lightweight equipment required for advanced care out into the field.

“As a line medic out in the stink, you have very limited supplies,” Dotson explains. “If you have a [medevac] bird in the air and you’re getting somebody to higher-level care within the hour, that bird is gonna restock you. So burning through four bags of simple saline, just keeping a guy’s blood pressure up, you know that within the hour you’re getting those bags back. If you take another casualty you’re good to go.”

Combat medics prepare ketamine and tranexamic acid drips to ease the patient's pain and help control bleeding.

Photograph by Jeff Wilson

Combat medics, he continues, got two syringes of morphine when he was deployed; now medics are more likely to use 500-milligram vials of ketamine for pain management. “You can hit a guy twice in an hour if you know you’ve got birds on the way, just to make him comfortable. But if you’re sustaining that life for a day or two, you’re gonna hit him only when you have to.” That, or you run out of supplies and can’t manage your injured pal’s pain at all.

Battlefield supply and resupply for prolonged field care is an issue that’s largely unresolved. But it’s high priority. If medics are expected to care for a patient whose internal injuries are causing cardiac arrhythmia or kidney failure, how are they supposed to carry the heart monitors or devices for renal dialysis? Severely burned patients will need not only gallons of fluids over several days but also regular application of a silver sulfadiazine salve to help prevent infection. Each such patient, every day, will need two 400-gram tubs of the salve, each basically the size of a coffee can. What a single burn patient needs over two or three days is beyond the ability of a medic to carry and may exhaust the stores in the resupply truck—assuming there is a truck. As one veteran combat medic puts it, “How’re they gonna carry all this shit?”

“There’s no silver bullet that’s going to solve all these issues,” says Dr. Jerome Buller. He’s a colonel in the Army Medical Corps and commander of the Army’s Institute of Surgical Research at Fort Sam, whose team is tasked with finding and developing practical and technical—and lightweight—solutions for medics. Those thermobaric and directed-energy weapons have the institute’s attention, particularly for the risk they pose of “burn shock,” a common response to severe burns, in which fluid loss can lead to organ failure and eventually death. Administering just the right amount of fluid is difficult: too much can cause fatal swelling. So they’ve developed “decision support” software for mobile devices that can lead medics through the tricky steps of keeping burn patients alive.

Getting blood to wounded patients is also receiving high-powered attention. “Patients who’ve lost critical amounts of blood, what they need is blood,” says Army hematologist Dr. Andre Cap, bluntly.  “If you have to [care for] people for seventy-two hours and you don’t have any blood to give them, you’re gonna have a bunch of dead people.” So the Army is working on producing a freeze-dried version of plasma, the fluid that makes up about half of blood. Currently the plasma they use is imported from France. Bleeding patients also need blood platelets, the cells that help in clotting. Researchers have figured out how to extend the shelf life of platelets from five days to two weeks. And drugs are in development that can change the body’s metabolism, slowing its need for more blood. 

Some of the ideas coming out of Buller’s research institute are actually resurrections from wars past. One approach, common during the Korean war, uses unwounded soldiers as a source of fresh blood. The concept is called a “walking blood bank.” It involves blood-typing all soldiers to find those with O-positive blood and low levels of antibodies. The test is simple and allows a medic to quickly find donors for transfusions without having to carry heavy supplies. Says Cap: “You bring the blood with you in the bodies of your friends.”

Another idea revived from last-century wars is antibiotic powder. Army researchers are perfecting a one-gram vial of new antibiotics, weighing less than a paper clip or a jelly bean, that can be poured in an open wound and, perhaps in the future, combined with anti-inflammatory pain medication. Medics will have these in a year or two. The list of solutions in prototype or already in the field goes on: a device that can find veins when they’re flattened from loss of blood; a device that can be threaded up through the groin into the chest cavity to plug a torn artery by inflating a tiny balloon; a device that clips on the finger and can detect imminent hemorrhagic shock; a system to transmit signals from such sensors to a central screen display, so that an overworked medic can monitor many patients with an occasional glance, just like in a hospital.

Then there’s the mechanical leg brace that would enable a patient with leg wounds to get up and walk, relieving the medic of having to find a litter and four soldiers to carry him to safety. That one’s getting off to an especially fast start. “A year ago we were working on stem cell regenerative therapies,” Dr. Josh Wenke, an Army physiologist, marvels. “Now we’re working on an exoskeleton.”

Army Staff Sergeant Jordan Blas, training as an advanced combat medic, receives his evaluation after a grueling field test.

Photograph by Jeff Wilson

Greg Dotson’s story suggests another way to help solve both the timing and the supply problems in a big war. In Iraq, with foresight, he’d trained his troops on what to do if he went down, because he was their combat medic and if he was wounded, there would be no one else to save him—or them. So when five hundred pounds of high explosives detonated beneath Dotson’s Bradley Fighting Vehicle, his soldiers pulled him out of the deck hatch and got to work. It was July 2007, outside Baqubah, about forty miles north of Baghdad, and insurgents launched a furious attack immediately after the blast. While troopers were returning fire, several in Dotson’s unit dug for his medic bag in the wreckage, knelt and got tourniquets high on his shredded legs, slid a breathing tube down his nostril and another into his throat to keep him from choking on his blood, and got a field dressing secured tightly around shrapnel wounds in his abdomen. One tried to start an IV but failed; Dotson had lost a lot of blood, and his veins were almost flat. They taped splints on his legs and strapped his six-foot-six-inch frame on a litter as the Blackhawk medevac clattered in. Minutes later he was on the operating table at the U.S. air base in Balad, where surgeons began emergency surgery. 

Some of Dotson’s comrades had taken the forty-hour Combat Lifesaver course, which is currently required of at least one in five servicemen and -women. Combat lifesavers, in addition to their tactical combat responsibilities, carry basic devices for treating abdominal and chest wounds, inserting a nasal breathing tube, starting an IV, and bandaging wounds. But Dotson had trained them beyond CLS. He made them practice on one another, controlling bleeding, strapping on tourniquets, finding that elusive vein. So when it happened for real, they were able to work even as the firefight raged.

Dotson owes his life not only to the golden hour but also to the combat lifesavers in his unit. His experience suggests that soldiers who aren’t fully trained as medics can help ease the load of those who are. If the Army provided some upgraded CLS training, he believes, soldiers could be treating immediate casualties under a proper medic’s direction and freeing up the medic for the prolonged trauma care. O’Neal says he and his staff are already on that, as they examine the continuum of care from point of injury to eventual evacuation of seriously wounded patients back to the U.S. 

As the Army works to ensure crucial care for wounded soldiers on the battlefields of tomorrow, the unconditional devotion of medics will be as important as their medical knowledge and skill. They must be ready to race into deadly peril, without hesitation, to save a wounded buddy. “The guys I served with in my platoon were closer to me than my family,” Dotson says. Success in battle depends heavily on that kind of love and trust.  

“One reason soldiers run headlong into battle,” O’Neal says, “is because there’s a medic right behind them.”

David Wood, a Pulitzer Prize–winning journalist, has covered war and the military for more than three decades.

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