Casualty Care in Tomorrow's Wars

Our casualties have this long transport, sometimes 8,000 miles, two rotary wing transports, fixed wing transport, or something that in a civilian trauma center would be an elevator ride. 100 casualties at the baton level in the Lisco fight in a major battle, what is that one surgical team going to be able to do for me? Not a lot. You know, this is a maneuver problem. The prolonged casual care plan in simple will be owned by maneuver commanders become a logistical problem in Lisco. This conversation is really about what happens when the goal now goes away. Hey, welcome back to the Modern War Institute podcast brought to you with the generous support of the West Point class of 1974. I'm John Amble, and this episode features a discussion about a really important subject, prolonged casualty care. During its post-9/11 counterinsurgency operations in Iraq and Afghanistan, the US military had its lowest case fatality rate in history. Huge numbers of soldiers who suffered wounds that would have been fatal in any previous conflict survived because of the care they received. But that occurred because of a number of conditions that won't be present in the case of a major war, and it rested on assumptions that won't necessarily hold on a battlefield characterized by what the army calls Lisco, large-scale combat operations. To discuss this subject, I'm joined on this episode by two army officers with unique and valuable perspectives. Colonel Jennifer Gurney is the chief of the Department of Defense's Joint Trauma System, and Lieutenant Colonel Max Ferguson is the commander of Second Battalion 14th Infantry Regiment with recent real-world experience thinking about the issue from the perspective of a maneuver commander. We had a fascinating discussion, but before we get to it, a couple quick things. First, a very special thank you to the West Point class of 1974 for their generous support to MWI, and second, as always, what you hear in this episode are the views of the participants and don't represent those of West Point, the army, or any other agency of the US government. All right, I hope you enjoy the conversation. Jen and Max, thank you so much for joining me on this episode of the MWI podcast. Thanks for having us, John. Thanks. It's great to be here. So we're going to talk about an issue that I know is near and dear to both of your hearts. It's one that, you know, just as we've been talking, you've kind of impressed the importance of it on me, and that is prolonged casualty care. Here's what we've heard a little bit about you in the introduction to this episode, but, you know, Jen, maybe if we can start with you, I wonder if you can kind of maybe give the audience a sense of your background and what brought you to the point where, you know, where you're talking a lot and writing a lot about this issue, prolonged casualty care. Yeah, you bet. Thanks so much for the opportunity. So my name's Jennifer Gurney. I'm a colonel in the US Army. I'm the chief of the joint trauma system, which is the DOD's trauma system, which that's a whole other conversation. But since we brought it up, the US military did not enter the conflicts in Iraq and Afghanistan with any type of trauma system. This was built over time and space by a lot of personalities that really pushed this and we became officially established in the NDA in 2017. So I'm an Army surgeon. I've deployed a few times. I had a chance to work with Max's team, second brigade of the 10th Mountain Division, and really have realized over time that if we're going to make real change in medicine, we have to be partnered with line and maneuver commanders. So that's how I started working with Max. Max, I'm glad that Jen mentioned that she had worked with you and that you're a battalion commander and second brigade 10th Mountain Division. You're an infantry officer by trade. What brought you into, you know, I guess, thinking about this as a problem set is an important issue. Yeah, so, you know, it goes back to our most recent deployment to OIR where I was in Baghdad and we had a walking blood bank. I came to the unit they'd already established it. I wasn't familiar with the walking blood bank, but it was something that was critical to our treatment of casualties in our planning efforts. So I started to dig into understanding what does my role one have and what is this capability and what does it mean? How do I activate it? And as I learned more about the walking blood bank and talked about it, I realized I've been in the army for 20 years now. I have not been exposed to this concept directly. I've heard of the term, but I've never been responsible for managing it. We're activating one and pulling it. The more I learned about walking blood banks and the whole blood in the battlefield, the more I've been reflecting on the consequences of the list go, this conversation is really about what happens when the gold hour goes away. What do we do going forward? And, you know, I've got six deployments. I've been a striker, light infantry, a range of regiment. I've deployed and earned multiple things. I've seen lots of casualties in the battlefield. I've always been able to get those casualties from the point of injury back to a surgical table within the hour, saved a lot of lives, kept a lot of amputees and, you know, permanent damage, but still alive because of the capabilities we had in the past. And as you think forward, I don't know that we're going to have those capabilities. And the more I worked with Jen on understanding whole blood, the more I understood the importance of adapting our capabilities for the future fight. And that's what this conversation is about because it's going to be a completely different dilemma that tacked minors like me are going to deal with and how do I train and prepare not just my medics, but also my companies, my platoons to support what will become an operational issue, not just a medical issue. You know, one of the other podcasts that we produce at MWI is called The Spirits, our podcast on the combat experience. For the spear, I've had the chance to talk to dozens and dozens of people who have relayed stories of how they were wounded, how they became casualties in combat. And they kind of described the process. Some of them don't remember the process. They say they woke up in Germany, you know, but the process of sort of tactical combat casualty care, I guess, and through these various stages of more intensive, more capable, I guess, care that they've received, you know, I guess to sort of frame this conversation, when we use the phrase prolonged casualty care, when does that begin? And I guess how long does that sort of continue? I mean, I can start with that and Max can be my operational translator since I realize a lot of times medical people talk and we need operational translators. So first, I think it would be good to put in the context of what our battlefield continuum of care is, role one through role four. And role one care is essentially pre-hospital care done by medics, pre-hospital providers, you know, medics. So when I say medics, I mean all services, right? So any pre-hospital provider, role two care the way that we in the medical community define role two cares forward, surgical care. So damage control surgery. Role two cares are relatively new construct on the battlefield, really understood after Vietnam, realizing that casualties with severe injuries who will not be able to survive a long transport need forward surgical intervention. So forward surgical care, fast surgery, hemorrhage control, blood transfusion, then there's role three care, which is the highest level of care on the battlefield. That's typical combat support hospital is what people think about. Role four cares, the first level of care outside the battlefield, a longitudinal medical center, which you know, fixed wing transport from sent comm to longitudinal essentially like a cone space hospital just outside the theater of operations. And then role four, cone is care, well to read, BAMC, you know, big hospitals. And I think it's important to talk about that because our casualties have this long transport, 8,000 miles, two rotary wing transports, fixed wing transport, or something that in a civilian trauma center would be an elevator ride. So linking our entire trauma system from identifying the patients, moving the patients, and providing the right care. So the four rights of the joint trauma system are right patient, right time, right place, right care. And that's like, that sounds simple, but that's not simple when you're talking about large casualty volumes. When looking back to the H. Kaya mask, cal event in August of 2021, we still had challenges identifying patients, right. And that's after 20 years of having time to get better. So what happened, so what's prolonged casually cared? I mentioned I worked with a joint trauma system. The joint trauma system consists of three defense committees on trauma. One of those is a committee on technical combat casual care. And they're the ones that, you know, these are volunteers. So I want to give a call out to everybody who works on COTC, who put out the TC3 guidelines and they also have a prolonged casual care working group. You know, our community definitely recognizes the need to be able to give guidance for this. And so the official definition from the tactical combat casual care committee or COTC committee on tactical combat casual care is PCC is the need to provide role one casual care for extended periods of time when the tactical situation may limit or prevent prompt or optimal medical care. So the foundation to be able to do this well is everyone knowing how to do TC3. The reason that Max and I think I talked about talking about this is when we were working on the whole blood project. I said to Max, you know, this is something that you own. I don't own this. I can't fix this environment. This is a non medical space. The prolonged casual care plan in simple will be owned by maneuver commanders, become a logistical problem in LISCO. And it's really when the golden hour goes away. And you're not able to have a small medical footprint on the battlefield and transport casualties rapidly from point of injury to roll two forward surgical care and then along that continuum that I just described. Max, do I need an operational interpretation of that? Yeah, that was a great answer. I would just say it's keeping casualties alive, right? This is my job at the brigade below level to keep my casualty alive until he gets that role three or above. And so prolonged casual care in the olden time wasn't prolonged because it was 16 minutes or less there at the role three. And oftentimes in the past 20 years, a conflict that I spend a lot of time supporting, we bypass our role ones in role two's because at the point of injury at the tactical level that platoon or sustain a casualty called in a meta-backed bird and they flew straight to the role three. We can't expect, we might get that, but we can't expect that we're going to have the environment, you know, it's going to be contest environment, air superiority, assets, you know, isolated units. We're not going to be able to get them there. Therefore, prolonged casualty care in a nutshell is how do I keep my casualties alive within the brigade medical capabilities long enough to get them to that proper hospital? And I'll just say right off the gate when Jen talked about the difference describing tactical care at the company level, role one being the battalion A station with a PA, a role two to her as a joint medical provider. She says she implies that there's a surgical capability that role two. I'm in the Army and a BCT, the role two to me in my mindset is the Charlie Med, the medical company that my brigade has inside the BSB and they have, you know, more beds, they have more providers, but they don't have surgical care. And so in the other services, a role two implies surgical capability for us in the past conflicts, we've had forward surgical teams attached, you know, all different levels. When I was a Ranger company commander, I had a J-MAL who had their own CH, MH-47 and they were able to do surgery right there, you know, at the point of injury in flight, but we at the brigade level don't have surgical capabilities organically attached to us. So as an Army guy, I say role two, I think it's just my Charlie Med, more providers, more beds, more equipment, but if they got a dentist, right, they got all kinds of things, radio loud, they can do X-rays, they can't do surgery. And so even just defining these terms of what is a role two, is super important for us because we have battalion brigade surgeons, but they're not actually surgeons, that's just a legacy name. And so we at the Army level need to clarify what capabilities we have at echelon and then how long can I expect as a maneuver commander for my medics based on their proficiency to keep those casualties alive so I can plan an operation to back all those casualties and get them to the next level of care. And that's the dilemma that I face is understanding how long I have to coordinate that operation to get those casualties to next level of care and that's missing or it's poorly defined. We can go into that further. Yeah, and Max, you know, a dilemma that we all face, he said that to the dilemma you face, you know, a dilemma that we all face is having a standardized lexicon to really understand battlefield casualty care. So, you know, the Army is a little bit, and I've spoken with the doctrine guys about this, we're a little bit behind, I mean, every, the other services and NATO. You know, so we're going to talk about a joint interoperable battlefield. We all have to have an understanding about what role two care is. And so role two care in our mind and in, you know, every, the other services and a NATO mine is for surgical care. So, you know, an area support medical company, a physical therapist and a dentist, those are great capabilities, but those aren't going to help keep a casualty alive on the battlefield. You know, it's, it's role two surgery. So, the other definitions, I think are important to clarify. You know, one of the kind of defining memories that I have of my year long deployment in Baghdad in 2008 was we were out on patrol. We got hit by a number of IEDs. We had casualties. And so we pulled into the nearest joint security station. I was called JSSO Baydeep, sort of on the southern edge of Saadar city in East Baghdad. It was an old cigarette factory and had these two tall buildings across East Baghdad. Most of the buildings were maybe two stories tall. And then we had these two that were six or eight stories tall. And just as we were rolling in the gate, we could hear and then see the Medevac helicopter coming in. And it did this sort of incredible aerial maneuver to almost fly on its side to get between these two buildings and land where it needed to land. And I thought, man, that is impressive. But if you think about a totally different environment, a large scale combat operations environment, that's great that you can fly that way, but we won't have air supremacy. And there's a very good chance that you're not going to be able to make it anywhere near that landing zone. So Max, I guess as an infantry officer, from that sort of boots on the ground perspective, I wonder how you think we might have to recalibrate our expectations of what care is going to be available for casualties on the battlefield? Yeah. So the battle drill, combat lifesaver learned it in 2006. So I'm definitely rusty in terms of what I was taught. But the business rules and practices in the past, 15, 20 years of fighting was slap turn a cannon at Packafull Gauze, Package the Casually, Keep 'em Warm, Prevent Shock, and get 'em on the bird. That's pretty good. You remember it. Yes. The problem is, if the bird's not coming, then how do we evaluate those casualties and keep them alive for, I think, the realistic standard. The army says, right now in this vague standard, that my medics should be able to keep us casually alive for 72 hours. That based on the training and their proficiency and the type of wound that we can expect is wildly aspirational and probably not the case for a majority of the severe trauma patients. I think the realistic thing is you can keep alive for two to six hours at the battlefield. And that might include turnipids for wounds of the extremity, if it's a wound to the chest cavity, what medical term calls non-compression torso hemorrhage. So I got that right. But that is basically, you can't compress it. It's a torso bleeding chest stomach. All the places that a trinocate doesn't fit, which is the perfect place for a shrapnel to find this way around a body armor, you know, fight largely with fires. How do I keep that person alive and the shift that we need to be thinking about? If I can't get them on a bird in 60 minutes, it's getting them whole blood. Whole blood in the battlefield is the ability for us to keep someone who has internal bleeding and I can't. I don't have a surgeon. I'm not able to go in there. Maybe I can pack with a gauze, but there's bleeding can't be controlled in the same way as effectively as a trinocate could. If I've got a, you know, a leaky bathtub, I got to be able to keep water in it in order to keep that volume there and that's through whole blood. And that's where, I mean, it's just so beautifully simple. You know, I don't need, I can have whole blood storage. They got these fancy backbacks. Rangers are great at using plasma and platelets and all these freeze-dried blood, but that volume isn't there for the amount of casualties we may encounter in a Lisco fight. And so one or two units in a fancy backpack is really cool. If you're one-pure to darkness raid and you're expecting, you know, one or two casualties, but at the scale that we could expect in the time, I got to keep that, you know, casualty alive, a walking blood bank where I is a, oh, you know, pause person. I'm able to give blood. I keep a store. It's always fresh. There's no, I don't have to reheat it. When I put it into somebody because it's warm out the gate, it's the perfect medium and you have to give them that whole blood within 36 minutes. And I say that as a general with thumb, right? All these numbers are based on all kinds of factors. But based on the evidence that we have today on the amount of casualties they've looked at, the rule of thumb that we, if goldnower was the old rule of thumb, the new rule of thumb needs to be 36 minutes getting somebody whole blood and starting that blood transfusion on the battlefield can, is the first step at keeping casualties alive for what I think is based on Jen and her colleagues across, you know, the trauma military community, two to six hours of what I can expect to keep somebody alive before they need to get to the higher level of care. And maybe that's just damage control or cessitation at the role one where they can do and a more life support and they can continue on their journey back going to casualties to eventually a surgical table. And that's not going to save. So a couple points. So Max really well said, you know more about medical than some medical people. So great job. Seriously. But you know, when you said that about being in the bank, like you are the bank. So the walking blood bank, the person who's the donor is the bank and that's kind of, because this is a term that we're also, you know, that NATO is adopted and that's kind of been a hard sell because we think of blood banking is something different, but that's a whole other discussion. But, you know, so in that two to six hours, we really thought about that, you know, talked with a bunch of other trauma experts because we don't do that experiment, right? How can we keep somebody alive who's bleeding to death when they're not getting hemorrhage control? Because really the precedents of blood transfusion and hemorrhage control. And if you can't control hemorrhage, so, you know, NCTH non compressible torso hemorrhage, so hemorrhage in the abdomen or pelvis, what can you do as a golden hour extender? So that's what we're really looking for in PCC is what can we do to extend the golden hour and how can we empower pre-hospital providers? So it's not just going to be blood transfusion. It's a whole bunch of other things. But if we're talking about people who are bleeding to death, those casualties that we were able to save and have the lowest case fatality rate in history, it's blood transfusion. And so in powering that down to the level of role one providers and ensuring that everyone is trained and manned and equipped to be able to do transfusion at that level will save lives on the battlefield, like unquestionably. We've had incidents in the army. I'm thinking of the battle of cop-keating in Afghanistan in 2009 where blood transfusions save lives. Cop-keating, that was only possible because the battalion PA happened to be at the cop and knew how to do it. He used his own blood. But that's really kind of relying on good fortune. It was I guess rare for a unit, especially a company-sized unit to have that knowledge in Cape Illinois. I think it still is. So what would be required now to make sure that in a LISCO environment, say there's an incident with multiple casualties where we can't evacuate them immediately, what would be required so that we could make use of these walking blood banks? So two things. One, pre-screening. We need to pre-screen every service member to understand their blood type and what their titers level are. And Matt, Matt's really talked about this in detail on his paper. And then the second thing is training. This needs to be trained like anything else. Blood transfusion, if done wrong, has a risk. So we need to be sure that everybody is getting trained on that. And that's been a bit of a challenge to get that paid for. We have it as a requirement, but we're a little bit behind the Army's little bit behind in who's going to pay for donor screening. You know, is it going to be the defense health agency? Is it going to be units? Is it going to be the services? But donor screening and training would be. the short answer and then max if you want to elaborate on that. Yeah, so I think that it's great that across the formation, what 40% of people are Obed type blood, which is the universal donor and then Jen you'll tell me that another 40% are A blood type, which is another useful common number. But the problem is you can have all the blood and the proficiency is really easy. We think it's over complicated, but if you can stick someone with an IV, you've basically got the basic capabilities to do a walk in blood bank from a potential skill set, but you're right, it takes training and the screening. Because there's two things. One is the blood type. Okay, so your Opozro neg, one, it's not just Oneg, Opoz can do it too, and that's the common form a lot of people are Opoz, so that's a useful thing to have. But then this idea of tighter screening is something that I can't do rapidly. So I can test you in five minutes using Eldon kit, which is just a little finger prick, and they say, yep, okay, we know your blood type, but you had to be really careful about the titers, which is this other thing that takes a while for labs to test. What is that? Jen, go ahead, please do a better job than the blood type. No, there's four different blood groups, A, B, A, B, and O, and so you have natural titers. Everyone has titers. So if you're, so it's too complicated to explain, but like if I'm type A, I have anti-B antibodies. If you're type B, you have anti-A and vice. That's just the way that we're made. Type O has anti-A and anti-B antibodies. However, it's the universal donor because of the way that the red cells look. But the way that it's the universal donor for other types of blood when it's whole blood is you have to be low tighter. Otherwise there's a risk of himolysis. So those titers being tested before you deploy and knowing your blood type before you deploy, that's crucial. And it's easy. And we do a bunch of other tests before we deploy. So adding on, you know, donor screening tests, so you have your walking blood bank roster figured out when I was a, when I was down range with 210 on the PDSS, these role one medics, they were on top of this. They recognize the importance of this life-saving capability and they had rosters. They had the Elden cards tested. They were so on top of this, knowing that if it ever came to be that they had to do a walking blood bank, they wanted to be ready. The Rangers have done this during fire fights. I mean, this is something that with the right training, conventional units up to special mission units can do this and it can save lives. It's not, it's not something that you can just make the assumption can be done without training. And it certainly cannot be done safely without blood typing and tighter testing beforehand. Yeah. And I'll say that. So when I was in Baghdad, most of this last deployment, we had all done our tighter testing as a brigade. So there's 200 of us from our brigade on this base of 1500 people and we are the only ones that had been tested. So even if there were other Americans and we were comfortable, we hadn't been tested. And overseas, you can only do the blood type. You can't do the tighter testing because you know, you have to send those sample packets. It requires a lab. It's not something you can do. Field expedient detectives exist. And so it happened to be, there were 30 of us in this base. There was also a response from security. There were the only 30 that happened to be eligible for whole blood. So if there was a mask out, whether it was a rocket strike, a drone strike or just whatever, a fire, accidental environmental risk, something happened. The only people that were eligible to give walking blood bank because we were the only ones that tested because we chose to out of our operations, maintenance funds, prior to pulling, were the same people they're supposed to be guarding the walls and providing the first response. Which is ironic because you get all these people in a rear echelon type base where you get all these staffers that are perfectly suited if nothing else come into the A station and you probably are capable, but we weren't able to test you because it's not standard for American units to get this tighter testing prior to going overseas. So it's super simple, we're already drawn blood, we're already sticking you, we're already testing for HIV and all these other things. Just add to that mix the whole blood testing and then you have this Excel file and it doesn't change. If anything, if you're high tighter as a younger age, it probably gets better over time. So once your low tighter odds are right now, we expect you to remain that way. So just get your blood type because it's really important to not mess that up because you can have the blood poisoning in the rejection if you accidentally do it. And Jen's absolutely right. The Rangers have been doing this for a long time. They call it ROLO and they've been doing it where you're in a firefight. There's a CCP at the Bluetooth level. They call, hey, we need a blood bank. So when these blood ranger comes in, they stick them, they draw the blood. He's back on the fight within 10 minutes because they have that battle drilled down. And that's the proficiency that needs to be trained by guys like me at the operational level where we activate the call. Those people know who they are. They know exactly the steps, the medics stick them. They collect the blood and they go back to the front lines and get back into the fight. So it's not like I'm losing that fighter for that donor. I just need to be able to identify who they are and get them back there, which is at the platoon level. They'll be a handful of guys. But when it's a larger area, we got to make sure that we understand who is eligible in the wider the population, the more I can choose which ones I want to activate and how much blood I need to pull for that casually. And then those rosters get identified before way early. So ranger, rollo, ranger, rollo, titaro. So their rolloes are identified. Everyone in the unit knows who they are. They carry a rollo card, identifying them. They're always sure that when they go out on mission that they have one or two rolloes with them. I think that this is sort of the most obvious challenges. We shift gears toward kind of a list goal environment in terms of our mindset. Is that we're going to have higher numbers of casualties and we're going to need to be able to provide some sort of care right there where the casualty is suffered. But if we zoom out, I guess if we just kind of go one step further in the casualty care process to the role two facilities, I guess at the brigade level, every brigade has a surgeon. And I just learned as we were chatting before we started recording that a brigade surgeon is not necessarily a surgeon. Is that something that I guess we're going to have to change or rethink in terms of making decisions about how far forward we put surgical capabilities in order to give casualties that next level of care? You know, for sure. So if we're going to be serious about saving lives on the battlefield, not only do we have to lean into prolonged casualty care. And there's a quote if I could just read this quote from the prolonged casualty care position statement from the PCC working group, the willingness to adopt PCC across the full range of military operations demonstrates an unwavering commitment to continually improve battlefield survivability for our force and unwillingness to accept any gaps in the continuum of care. So that's, you know, but the other thing we have to lean into and so the golden hour is going to be very hard to achieve like we talked about before. But something that we're learning about in the Ukraine experience and that is that in some situations, the golden hour definitely exists. And that's if you move a roll to forward surgical team very close to where the fighting is. I think one of the things is we don't have enough surgical teams to really be able to do this. I think that's one thing that we're, that's like the big elephant in the room. Do we have enough forward surgical teams to be able to handle Lisco? In the army, we've got 49. And we're not, you know, the more of those are in the reserve and guard component than in the active component. So we do have to rethink it. We have to understand the continuum of care and that two things need to happen if we really want to save lives on the battlefield for those casualties that are bleeding. Hemorrhage control and whole blood transfusion. Another golden hour extender, which we won't get into much is the need for having free stride plasma or dried plasma for that's another golden hour extender. But I do think we have to rethink the battlefield continuum and move capability closer to the point of injury. And we can't do that. And so is prolonged casualty care and the goal of prolonged casualty care is to get that casualty, get that unit, get that team out of the prolonged casualty care environment and move them along the established battlefield continuum. You know, for a guy like me and they tell me I got a surgical team attached to my company, battalion, whatever, that makes me feel good. You know, it gives me more confidence that I can go and lock horns with the enemy and I can be more aggressive because I know that there's that, you know, real estate capability of getting those guys to proper level of care. But at the macro scale, macro being battalion and brigade level, say I have a surgical team at make it a real role to at the brigade level. Charlie Meddett is augmented with one or two surgical teams or at the battalion level. I have a role one, but they pushed me some kind of forward surgical team. That is not as simple as, okay, check the block, move on, milestone complete. I can now, you know, assume more risk because the size of that team, the number of beds, the capability is there. They might be the best surgeons ever. How much class eight they have? How many, you know, how big is their team? And so their capacity might still only be good enough for one or two surgical patients, right? So at the company level, battalion level, you know, five, six, seven hundred people and we're in some kind of like H.E. fight where there's now, you know, dozens, you know, 100 casualties at the battalion level and the list go fight in a major battle. What is that one surgical team going to be able to do for me? Not a lot. Not a lot in the expectation of they might be the best surgeons ever. How much class eight do they have and how many people can they actually affect? And so there is also this like expectation management of, okay, great. I got a surgical team. I have two beds, you know, how many, not just can I perform the surgery, but then can I keep them alive? You know, in ICU and the amount of attention and it's not just the surgeon, it's the team and all the support staff that they have because I might have a surgeon and he or she might be awesome, but do my medics know how to support them and have they been experienced in keeping those patients alive again for 24 plus hours before I can get them to that next level of care? Do I have the right to equipment to do that and there's only a couple things like an ultrasound, you know, and these there's some very basic things that we could you know push our Roll ones and our roll twos to ensure that they have the ability to even perform that even if they have the experience in the knowledge So they have the equipment and do they have the supplies and the further forward you go You can expect that they're gonna have less supplies because they're gonna need to be light and mobile because they're gonna have to be able to move And so you don't want this massive, you know guy showed up with pelican cases, you know fill in the back of an LTV For our company because it's just not realistic in terms of the ability to Keep them moving on the battlefield to keep them alive and small surgical teams in coin have done, you know great things But it was for one or two patients at a time, you know looking at the casualty load These teams will get tasks saturated very quickly. We've looked at this a lot at the joint trauma system There's a position statement about the risks of single certain teams. There's and small surgical teams There's no question that they can do stuff But for LISCO and huge numbers of casualties units will be assuming a lot of risk commanders Will be assuming a lot of risk if they think that they can manage large numbers of severely injured casualties one severely injured Casualty could tax out a small surgical team. There's a great quote from over a hundred years ago And I in every talk I give on this I use it It's but from Ogle V from the 18 late 1800s good surgery must be done as far forward as possible If it's too good in the sense of too elaborately equipped it will not be far forward enough And if it's too far forward it will not be good good enough I mean that's the real dilemma that that is you know going back to Napoleon's war was recognized You want to bring the capabilities far forward But if you need have the capability that you need it's not going to be Nimble agile and equipped enough to be able to be in that you know contested space I guess what it sounds like I'm hearing and correct me if I'm wrong But does that mean that there is no right answer and that in effect the right answer is making situation dependent environment specific Decisions in each tactical case a hundred percent which is why we have to integrate a trauma system and have an agile Adaptive trauma system that can be responsive to whatever the threat is on the battlefield like really being threatened formed and Understanding where the risk is and being able to move teams and being able to understand the system where the capability is You know really like I said those four rights of a trauma system the right patient to the right place at the right time That can deliver the right care. It sounds simple, but it's not but when you have a trauma system that's integrated with the maneuver force That's how you really support the battlefield and another thing that I think we have to think about for This go or any type of large scale common opportunity is from a medical perspective We're not going to really Help win the war we can help with morale we can help with data all this stuff But man if we have a horrible medical system that fails we will bleed out combat power and we can contribute to a lot of loss during any conflict And John I'll just say from my perspective. There's two sides of this is really important one is just the humanitarian I you know I want to make sure that we are best posture to keep people alive just for the life-saving mindset But in a list go fight. There's a second more pragmatic issue that it's also Addressed in how we approach prone casual care and that's reconstitution Preserving combat power making sure that we still can sustain the fight after the first battle because If we're not properly trained equipped and in the mindset to focus on how to keep these patients alive will either Apply turn to kids that aren't necessary and then with role for will lose limbs and create problems down the road for Their long-term health because having a turn to kid on for an hour is different than having a turn to kid on for 10 hours and what happens to Not just the limb but also deliver functions and everything else and the kidney function to the internal organs starts a sufferance Therefore dialysis no kinds of long-term issues, but those soldiers potentially could come back into the fight Right if I didn't have to put on the turn to kid I knew how to stabilize that casually Maybe it would take a couple weeks or a couple months, but I could get that soldier back into the fight Which in a list go from you know fight we're seeing right now, you know years into the Ukraine battle The combat power preservation is a huge component for our ability to win these long-term enduring conflicts And so PCC is as much about Saving lives mostly saving lies, but there is also a secondary Conversation about preservation of combat power and reconstitution and and how much you know people will have to go back return to duty In Lisco in order to win this fight in the long run You know one of the challenges that we have in the army is that anytime we talk about a problem or an issue those conversations They certainly tend to start and sometimes they remain within particular communities Everybody in the army is part of a branch. You're part of a unit. You're part of a command and those become You know, I don't want to I don't want to say echo chambers But they become the communities where discussions take place and it can be difficult to kind of break free of those boundaries and yet the thing we're talking about the subject of each of those discussions It can potentially impact everybody. I think that challenge is magnified It becomes even more daunting when we're talking about medicine right this highly specialized field remembers that community Our experts they went to school for a long time and a lot of their conversations are difficult even to comprehend because it's an entirely different lexicon for instance How do you kind of you know, I guess how do you overcome those boundaries and take the discussions that you know Jen that you're having in the meetings and the conferences and the other places where you go and you're talking about this How do you take them out into the operational force? We have to be linked line in medical maneuver and medical to be talking about this You know because you're John you're right we stay in our own silos and there is Real risk to force if if guys like max Don't really understand medical capabilities. It's more than just a sustainment function once the trauma system goes down on the battlefield All other war fighting functions will be threatened I mean, I have strong opinions. I think that I've been trying to message line and maneuver commanders ever since I realized as a medical provider like You guys own this like all this medical care if we're not linked with you We are not going to get better. This is we essentially work for you. I'm like in the civilian trauma system where I work for civilian medical people in the military we work for operational commanders and Us understanding each other and and medical guys being able to speak your language I mean not to max because he clearly knows medical language, but like you know The other is is important. That's how we save lives and really act as a as a force enabler It's interesting, right? There's I mean if this is the if if the right decision on where to place a forward surgical team is You know if if that decision needs to be made based on conditions on the ground Then you're sort of requiring that brigade commander or battalion commander that tactical leader to understand enough about this to make the best decision and You know, I guess maybe we kind of took it for granted in Iraq and Afghanistan and didn't have to make decisions like that because there was an Infrastructure in place anytime you went outside the wire you knew I mean you probably saw the medic that was accompanying you if you had that But you knew that if you went down you were going to be taken care of that there was a process for this stuff And yet if that process has to be more fluid and and based on conditions on the battlefield Then those decisions have to be made by in all likelihood I'm maneuver brigade or battalion commander that hasn't had a lot of experience making those kinds of decisions Max, you know, I guess I'd love to hear your perspective as somebody who's been forced to think about this at that level I yeah, but I'll say I only've been thinking about this for a year right in terms of I will Gladly show my ignorance and speak ask the dumb questions on behalf of the you know whatever small percentage Maybe a lot of people already know all the stuff and they're like max I got it everything we're talking about is super intuitive Everything we're talking about is something that anyone who just takes a second to think about is like yep This all makes sense. I get it. I see the problem to The only thing I want to do is take the conversation out of the medical community that have been resting with this and understanding And seeing this for a long time and and put it where the conversation needs to be which is in the operational community because that's exactly The community that's actually going to one own it and two help solve it. So Everything we're also talking about is a really low cost high return on investment shift in a little bit of training a little bit of mindset a little bit of planning factors I'm not saying that we got to buy this billion dollar B2 You know jet in order to fix this problem It's just adapting to what we intuitively know is coming and Thinking about how we're going to shift our planning factors, which is me at the commander, you know tactical commander level All I need to know right I understand fires I understand sustainment I think about burn rates of fuel You know how much ammo I'm consuming for you know indirect far this is just another planning consideration that has been vaguely codified so therefore I've just assumed that my medics know it simple concepts like turn to kick conversion I was I asked general is like hey what exactly explain that to me because I mean I could just break it down Again intuitively and thinking okay, it's taking their turn to get off, but who doesn't right like is that is that a CLS? You know is that a line guys job or is that my medics job? Is that something that only a surgeon to do or a PA like I can get the idea of it But we should go just a couple more inches deep for a guy like me The maneuver team to understand, you know, what are the capabilities and who is responsible for this? So I think just learning some of these basic terms like okay, we just talked about titers It's a weird concept we haven't talked about that before, but it's totally easy to grasp, you know And then understanding some of these basic planning factors goes a long way and it doesn't require a lot of money There's a little bit of equipment. I'd love to have more surgeons, but in the absence of more surgeons let's at least have a Pragmatic understanding of what my capabilities are within what I have and work with I have I'm in the 10th bound division right so worst we We are aspiring to be true light infantry get rid of or vehicles, our strikes helping that. And now we got to talk about fighting in rugged, austere, and isolated terrain. An isolated terrain could be something, actually on the side of a mountain or deep engage with enemy. Or it can just be isolated because I'm in one farming village and this is where my company's fighting from. And I can't get five kilometers to the rear because the enemy's got me zeroed in and I have to fight within these buildings because in this little hamlet that I'm in. What sears in my mind for the example of to think about is a wall or two battle called the Battle of Morten where second battalion of the 120 infantry, a motorized unit, right? And so you think I'm light of a tree, so it's stuck in my brain 'cause I don't have all these vehicles. I strike your unit, might feel more comfortable. Ground cast the back, I'll figure it out and so they'll kind of wish it away because they've got trains always in their disposal so it'll just buff out. But the truth is, second battalion of 120 in the Battle of Morten was a motorized unit who was told to hold this hill and for six days they were isolated. They could see the rear, but they just physically couldn't get off it and the casualty they took, this one battalion on this hilltop, guys were groaning in the middle of the night and dying of sepsis. And that's something that you talk about eroding the morale of your team of thinking about 100 people in your CCP isolated just a couple kilometers away is all they need to get supplies. And they were so desperate, they were taking out allume rounds and packing it with class eight and trying to fire class eight onto their own friendly positions to resupply them with medical supplies. Morphing, right? Just to keep these guys and some gauze 'cause they ran out of gauze. A hundred casually sitting in the CCP isolated for six days and people were groaning to death in the middle of the night. If I'm in a foxhole and my buddy can't get help and we are not proficient at keeping these guys alive, that will erode the morale and that will have second, third or consequences in terms of casualties. And so isolated terrain and a contested environment can be for all types of units and in this day and age with one way of tact drones, everyone, the frontline isn't the only element. We were seeing strikes, you know, hundreds of kilometers away when we were in OIR for the drone strike. So it is something that needs to be considered. Physical isolation also just the ability for isolated from supplies. And so as a commander, if I'm going to backhaul casualties, I'm going to tie it to forward pushing of supplies. And so nothing's gonna come in without something going out. It's a deliberate operation. And I need my medical team to say, yep, boss, you've got 24 hours before the majority of these casualties expire. Okay, my planning factor is 24 hours. You know, in, you know, 22 hours, I'm gonna get, I'm gonna coordinate this mission and I'm gonna concentrate mass resources to allow those supplies to come in and the same breath evacuate those casualties back. And that is an operational function. That is what I'm considering. And it is more than just, you know, my medics problem now is now in the operational side to figure out to time that. And I just need to know how much time I got, right? How much time do I have this aircraft conversation? How many rounds do I have left? How much time do I have is the first step of figuring out the decisions I have to make in order to get those casualties out of the rear and prevent sepsis from kicking in, which is gonna be the next biggest thing that we haven't been talking about and haven't had to deal with in past conflicts. You know, in the army, we have lots and lots of enablers. Capabilities that aren't typically organic to a maneuver unit, for example, but can be used to augment that unit. But there's this maximum, right? Train as you fight. I think everybody intuitively understands that we'll make better operational real world use of those enablers if we've had a chance to work with them, to train with them. Is this something, I guess that would similarly benefit from adhering to that maximum? Are there opportunities to give brigade and battalion command teams and staffs more exposure to say surgical teams, maybe during a CTC rotation, so that it isn't a, I guess, a consideration that you don't really have to confront until you're essentially boots on the ground. - I mean, there's lots to talk about in terms of the preparation leader for this. At the tactical side, what the CTC's evaluate us on and give us credit for is what we're gonna prepare for and train for. So I know that the CTC's are adapting how they're evaluating casualties and are the CTC's giving you credit for demonstrating, not just like hand waving, here's a blood transfusion kit in my hand, therefore I gave to that transfusion, but if you can talk through, and if the OCs are actually evaluating their ability to perform a walking blood bank and reinforce that culture, then they'll be able to do it. When it comes to the four surgical teams, the battalion or brigade level wherever they're at in the battlefield, not only are the maneuver leaders understanding of the capabilities, true capabilities and limitations constraints and requirements in order to employ that, the amount of beds and the type of casualties and training them, is that team training together, right? And this is where I would never send a platoon to combat without doing platoon life fires. When there's a Abrams crew, they do gunnery and the armored community gunnery is a huge thing. They lock in that crew and that crew, like that, you know, platoon sergeant may have done this 15, 20 times in his or her career, but now as a crew, they are certified. Are the surgeons super proficient, knowledgeable, extremely capable, but do the whole team, the six to 20 people on that surgical team, have they trained together in a not just, okay, high five orientation, let's talk about each other's names and her hobbies, but actually performed surgeries in some kind of realistic sense before they deploy and that way they are certified, 'cause I'll tell you in general, probably jump on this. Those surgical teams are pickup games and that we, you know, just throw them together and send them overseas and they'll figure it overseas. That is not the time I want them, 'cause I wouldn't send a platoon with a bunch of seasoned squad leaders and platoon sergeant, all these people that have done this before somewhere else and say, okay, go do a maneuver, you know, against the enemy at night and on familiar terrain. That's not how it works in any other kind of combat scenario. So we should be certifying those crews together as a team before they go overseas. And that's just internal to that surgical team. And ideally, they've trained with and there is a familiarity of the employment considerations with the unit that they will be attached to. So there's lots of different things to be thinking about before they actually go forward. - John, going back to your question before about kind of the battlefield construct and the trauma system on there, you were talking about brigade surgeons and how to inform this, you know, expertise and experience. We don't, when we, when you guys have a brigade surgeon and if they're a, you know, primary care doctor, psychiatrist, dentist, nurse, if they don't have experience and expertise and trauma systems. And I, you know, it's hard to say this and not come across as like an arrogant surgeon. We really need the right people in this. You guys do that. You recognize talent management. And not to say that a brigade surgeon isn't incredibly if they're a, you know, primary care doctor or a psychiatrist. Not to say that they're not very good at certain command elements. But understanding trauma capability and battlefield trauma systems, they don't get trained in it and they don't know it. And we've been lucky in coin operations that we've had air superiority, rapid EVAC, you know, good comms. That is not assumed for the future battlefield. So having leaders who understand trauma capability, role 2 capability, role 1, and what a trauma system looks like, that's how we really support the maneuver element. And you can't just throw people into these jobs and say, you know, you graduated from a residency, you have doctor after your name, you are a brigade surgeon. But that's what we do. And you guys not knowing, and I've worked for, you know, very senior leaders who had no idea that their task force med commander was not a surgeon and not even a doctor for that matter. So I mean, I think that you guys, that, you know, these conversations are important so we can all learn to communicate better and that we also learn to speak your language. If you guys don't think that, you know, you guys need to ask the questions about expertise and battlefield planning for trauma systems. - I'll say one more thing about the, you know, battalion or brigade surgeon, so on this last deployment. I've had Profis docs attach me throughout multiple, you know, deployments over the years. I had a great one attached to me, this last one, Doc Hohlweg. He was an internal medicine doc. And I would ask him, okay, like, tell me your background. He's like, oh, I'm an internal medicine. I've done bubble, blah, blah. And I said, well, what are the typical types of Profis docs that, you know, we get augmented with? And they're either an internal medicine doc or a family practice doc or usually the ones. You know, but it could be an OB/GY and it could be all kinds of random things. The medical doctor of some capacity they get pushed to us. And so in my mind, look, I'll be honest, I don't know what an internal medicine doctor does, right? Even to this day, I don't really know what he does. But I'm like, okay, he's worked in an ER and he's an internal medicine doc. That must mean if I get shot in the stomach, he'll be able to at least go in and kind of pull out the bullet and tighten me up and stabilize me and go for it. 'Cause internal medicine, whatever that is, right? - No. (laughs) - But that's what I think. - No, but yeah, I know. And that's why we have a failure to communicate. We have a failure to communicate capabilities. And we either we're not communicating them or you're not understanding them. But I think it's on us. I think we have a failure to communicate and not having that expertise at every level, you know, at Battalion Brigade Division is going to, you know, bring some risk. So that's one of the reasons we're having this conversation. I mean, Max, when you guys realize some of this stuff, we started talking more and we both learn from each other and I think these conversations need to happen more between, you know, line leaders and medical leaders. - Well, I hope that this podcast will be, will be a part of that conversation. If we zoom out a bit then, you know, we've talked about a number of ways in which the system is currently constructed and conceptualized is insufficient for the challenges ahead. But what are the biggest things, I guess, that hamper the army's ability to adapt the system? Or really the joint forces ability to do so? Is it personnel and manpower? Is it training? Is it doctrine? Is it the communication challenges that we mentioned? These sort of siloed conversations? What are the biggest hurdles to overcome? I'll talk at the tactical level and then I'll let Gengo be on my scope. So I'll just say the brigade level. One is, you know, the past 20 years, over time, our medics and our soldiers were more proficient, so the casually support was better because they've been exposed to trauma patients to really bad combat injuries throughout their career from the junior age, so they had just more experience. That experience is winning, naturally. That's a good thing. I'm glad in a very holistic sense that our medics have had less exposure because that means less people are getting hurt. But how do we replicate that experience so that way, you know, we can do cadavers and we can do, you know, live tissue labs with animals and all those kind of things in the mystic centers where they have the simulation. Those are great. But there's also this idea of there's nothing like being in an ER, seeing somebody actually, a human being, a live human being, fighting for their life. And we can, you know, so the idea is like right along, so having run around with EMTs, but also, you know, going to trauma centers across the country, there is, you know, rural health and how many people are, you know, would love to have additional support, but there's legal practice and all these other things. The thing to be thinking about is like if I sent them to some like hospital in Boston or Chicago or Atlanta where there's going to be gunshot wounds and stabbing some other things, it's almost an artificial condition because in that level one trauma center in a major city, they have all of the capabilities. They've got MRIs, cascades, all of the systems, but somewhere more rural, like a level three trauma center in some small city in an area where there's one doc and his job or her job is to stabilize a patient to life light them somewhere else. That's the role one role to experience. That's the bubblegum and shoestrings kind of, you know, practices that our medics are best served to learn from. So getting our medics real world experience and there's plenty of places across the country or around these military bases, especially like Fort Drum all over northern New York, you would be great to have my medics spend not just one or two nights in a ride along where they may or may not see something, but a true experience in a level three type civilian trauma center where they're having to do more with less and learn from these docs. The other side on the tactical side for me is not just exposing my medics to that level of intensity and that level of injury, but also across the force understanding this whole bug program and making sure that my individual platoons and companies are proficient at providing whole blood in the battlefield. At the SRP, you know, we do it, you know, but for pre-deployment activities, making sure that we're actually screening people for whole blood. So that way we not just have the skill set, but we have identified who those people are who are able to do it. And then just common terms, right? What is a surgeon? I think we should drop this battalion brigade surgeon unless you're actually able to perform surgery and just something as simple as redefining these terms and making sure that, you know, there's nothing wrong with being a PA. I think they're awesome. They do tons of God work for us, but we should be focusing at the tactical level at damage control with cessitation and making sure that my PA at the battalion level and my medics are capable of performing those things to keep those organs and that volume of blood in the body so that way they can continue to stay alive to the next level. And then if you can do damage control surgery, understanding the limitations of that, and so at the tactical level, it's understanding the capability's limitations, who can do what, and just managing my expectations and giving me realistic time standards for me to plan the operation going forward. That's at the tactical level. And Jan, if we zoom out sort of more broadly? Yeah. I mean, I just, Max, I really appreciate you and what you've learned and what you've taught me. So, so at every level, tactical operational and strategic experience saves lives, experience saves lives, and we've got to get every level of provider experience. Max was focusing on the medics, but you can talk about that for all levels of providers. And if we're honest, the military health system is in crisis right now because we're not getting that experience in our MTFs. We're really leveraging mil-sive partnerships, but all that experience at the operational and strategic level. We have to understand the importance of a learning healthcare system on the battlefield. And that learning healthcare system on the battlefield requires appropriate leadership and adopting the trauma system concepts. When I talked about it already, right patient, right time, right police, right care, easy to say, hard to implement. We're working in the each of one of the combatant commands to set up frameworks for the combatant command trauma system. That's having these frameworks to really support a data-driven healthcare system, which is done with, we didn't really talk about this much, but setting up frameworks for performance improvement and medical performance optimization in every combatant command with trauma medical directors who have oversight and work with the command, we say surgeons, but command maybe the, you know, medical operation commanders, you know, to work with them and each one of the combatant commands to ensure that these frameworks are being implemented. And then at the strategic level, really embracing the concepts of the joint trauma system, having leadership communicate, the appropriate risk, looking at the battlefield lay down in the medical concept of operations, how it links with the evacuation priorities, and then using data that's generated from the care of every casualty from the pre-hospital environment with the tactical combat casualty care card or the 1380, all the way through role for care. Every time a patient or casualty gets taken care of, that's documented. That data goes into the Department of Defense trauma registry, and I know we didn't really talk about this, but, you know, that data being generated goes into our registry. We use it for medical performance optimization, which is using that data to inform doctrine, organization, training, material, personnel, and leadership. And so that's really at the strategic level. And only when we're talking about these things and maneuver commanders like Max and some of the other people have been privileged to work with, understand the importance of a trauma system and how it's implemented, you know, at the tactical operational strategic level and the importance of training, education, leadership, and communication about this. Then we're going to really be able to implement a battlefield trauma system that's going to support maneuver commanders, keep people in the fight, enhance return to duty, have rapid education, and really, you know, rapidly optimize. You know, we talk, I just want to say one more thing. We talk about our lowest case fatality rate in history in coin, and that's great, and we have it. That's true. And that is an incredible accomplishment that we should be proud of. However, it took us about three years to really make that change. It took us three years of an unacceptable number of death from survivable injury and US service members to really start changing that. And we're not going to have that time in Lisco. You see this, we work with the Ukrainians a lot. We get to hear from their experiences. And if we don't implement these things now, then we're going to just, it is going to impact, you know, combat power, return to duty, and impact war fighting function. So that's kind of my probably too long answer. No, it's great. To be honest, you know, this is one of those episodes where I'm really struggling to kind of keep it short. I guess we usually try to record for no more than an hour or so. And I'm struggling to do that because I feel like every time one of you says something, there's this new sort of thread that I want to pull on further. We do have to stop somewhere. And before we do, you know, just because it is such an important subject, I want to make sure that it's as complete a discussion as we can have in this format in about an hour. So is there anything else that we haven't touched on that you think is just important to note? John, the only thing that I think that is worth highlighting is this work, we're, I'm an Army officer so Jen, so we're think we're talking Army that I just want to keep my scope of what's appropriate. So I'll talk about the tactical level and I'll talk about the Army because that's where I serve and that's where I come from. But this is not just an Army ground force problem. And we had some really great contributions from some Navy medical folks that Jen works with. And it is just as relevant for service warfare officers and the likelihood of sustaining significant casualties on a destroyer or some other naval ship and the limitations for surgical care and the limitations and the need for a walking blood bank on a ship is just as relevant as a company or a battalion, you know, fighting an Eastern Europe route in the Pacific. So it would be a shame to box this into an Army problem with two Army officers, three, you know, counting yourself, you know, Army background folks and saying this is an Army issue. And you know, air bases are going to have the same issues where they're going to be targeted and there's likelihood for mass casualties at an air base, you know, somewhere in theater and the Navy for sure is behind the duck just like the rest of us are in understanding the requirements for prolonged casualty care for both at sea, on land for the ground force and for anyone who's in a theater because the enemy can now range us with cheap fast or cheap slow but long range munitions. And so the idea of a mass cal need to treat casualties before we can set the conditions for an evacuation of flight all services. Yeah, no, you know, that's a great reminder. This is not just an Army issue, but I do think we are going to wrap up there. Max and Jen, I want to thank you both so much for taking the time and for coordinating your schedules across time zones so that we could have a really, really fascinating and I think really important conversation. Thank you. Thanks, John. and social media you can find us on Twitter, slash X, Facebook, or LinkedIn. It's a great way to stay up to date on all of the new articles, podcast episodes, research, and more that we're publishing every day. Thanks again.