During the wars in Iraq and Afghanistan, military medical teams were well positioned on the battlefield to support the "golden hour" response – the ability to get wounded warfighters off the battlefield and delivered to the care of a full-scale military hospital within about an hour.

And that was a realistic goal given that the U.S. military had total air superiority and maintained top-tier trauma centers in-country. Wounded troops were rarely very far from the life-saving care they needed.

But the next conflict might be very different.

As the Pentagon prepares today's force for a "near-peer" fight against a large military adversary, the Military Health System is challenged to provide life-saving support for large-scale and dispersed operations. That's especially true for the medics supporting troops on the front lines.

Imagine a wounded Marine stranded on a remote Pacific island. The highest level of care available might be an independent duty corpsman. Evacuation to a higher level of care might take several days. For military medics, this scenario requires a new kind of training, new equipment, and a new approach to casualty care.

"We're worried about future casualties because those distances [to hospitals] are so great," said Air Force Col. Stacy Shackelford, chief of the Joint Trauma System (JTS), Joint Base San Antonio, Texas.

In the future, a lack of U.S. air superiority and vast distances could prohibit quick evacuations.

Those conditions likely mean that the "golden hour" handoff to a surgical team will not be possible, Shackelford warned.

The golden hour is the critical time window for trauma patients to receive a series of life-saving interventions – starting at the point of injury and transitioning to handoff to a surgical team. Moving patients quickly through that process is essential to saving lives and improving outcomes.

If wounded warriors are unable to get that care within the golden hour window of time, service medics, Special Operations medics, and independent duty corpsmen will "need a lot of skills, such as in administering pain medications, long-term pain control, airway management, and nursing skills like changing dressings, even things like rolling the patient," Shackelford said.

A near-peer conflict in the Pacific could leave injured warfighters near front lines for days. "Africa would be the same type of issue when we would have overland transport versus water evacuation," Shackelford said.

"All of those situations make us think that we may need to hold patients at lower levels of care, where you're going to have medics taking care of patients for days, including patients that need surgery. Not being able to get to a surgeon means having to stabilize those patients for longer periods of time at lower levels of care," she explained.

The mission of JTS, part of Defense Health Agency, is to improve outcomes for combat casualties from the strategic level down to the scene of conflict through evidence-driven performance improvement. Under the DHA, the JTS also has expanded the data capture and collection capabilities of its DOD Trauma Registry with the addition of special injury registries.

Preparing for the Next Fight

Medics' training is changing dramatically in advance of possible future near-peer conflicts.

To meet this challenge, medics' skills are being upgraded from the very start of their training, and the entire DHA is developing or reworking tactics and stratagems to reflect the new reality.

"We expect that with large-scale combat operations, every echelon of medical care will need to be better prepared to treat large numbers of casualties with limited resources," said Army Col. Johnny Paul, who is the department chair for the Army Combat Medic Specialist Training Program at the San Antonio Medical Education and Training Campus located at Fort Sam Houston.

For example, Paul said, you may get whole blood transfusions through donations to the Armed Services Blood Program or from "walking blood banks," i.e., combat buddies who can donate fresh blood via direct transfusion.

Medics are now receiving newer, advanced training, instilling in them potential life-saving skills and methods. Paul said that includes:

• Use of whole blood
• Operating a walking blood bank
• Telemedicine
• Bladder catheterization
• Ventilator management
• Airway management
• Prolonged casualty monitoring to include nutrition and nursing care

Army Medic Training

To address these needs, the Combat Medic Specialist Training Program (CMSTP) has developed an Introduction to Delayed Evacuation Care component to its capstone 72-hour combat field training exercise.

The goal is to expose the Army's point-of-care medical personnel – the "68 Whiskey" Combat Medic Specialists – to the principles of prolonged field care. The 68W are assigned to the Army Medical Center of Excellence at Joint Base-San Antonio.

The first class of 275 medics who took the prolonged care course graduated in August 2021, and its medics are trained to transfuse blood on the frontlines. That is a skill that medics have traditionally learned only later in their careers.

Paul said the addition of prolonged casualty care training puts a different focus on the advanced knowledge and skill sets students will need to learn in class. That's a big change from previous combat medic courses, which focused on the treatment of casualties at the point of injury, with the assumption that a patient would soon be evacuated.

A new training program for all medics, known as Tactical Combat Casualty Care (TCCC), became operational on Dec. 15, 2021. The curriculum includes training for Care Under Fire, Tactical Field Care, and Tactical Evacuation Care.

TCCC guidelines are the blueprint for combat care at the frontlines for all branches of service. They are updated continually with best clinical practices.

The courses for prolonged casualty care include airway management, acute traumatic wound care, analgesia and sedation management, burn wounds, and crush injuries.

Some of the TCCC curriculum is given to first responders in all services in case there is no medic or corpsmen immediately available.

"This additional training will result in a higher level EMT [Emergency Medical Technician] certification for graduates," Paul said. That "will directly translate to more advanced medical credentials for combat medics."

Currently, medics are on a national certification registry at the Basic EMT level. The new curriculum will upgrade that certification to Advanced EMT. "These certifications are nationally recognized," Paul noted.

Battlefield Medicine

The Navy and Marine Corps are also preparing corpsmen for prolonged casualty care and for crisis situations that might require healthy Marines to donate blood on the battlefield to help treat injuries.

On the battlefield, Combat Life Saver-trained Marines are an essential asset in stopping preventable deaths before a corpsman is available.

However, the skills learned in CLS aren't only relevant to the battlefield. The principles of CLS can be applied across a range of medical emergencies, Marine Corps officials said. Clearing an airway, mitigating blood loss, and splinting a potentially fatal bone fracture are some of the skills taught during CLS.

Lt. Gen. Robert Miller, Air Force Surgeon General, testified recently at a Senate appropriations hearing where he emphasized the importance of preparing today for tomorrow's battlespace.

"Future conflicts may see medics needing to hold and treat patients in deployed settings for longer periods than in the past," said Miller. "We are actively evaluating how our teams can remain agile and leverage technology to provide Trusted Care…anytime, anywhere."