Improved Combat Casualty Medicine

Aug. 1, 1981
It isn’t the kind of information doctors routinely pick up as students in medical school: that a fractured jaw can wait ten days before definitive care is required. That eye injuries and surgical wounds (with enough antibiotics) can be delayed in treatment up to twenty-four hours. It is the kind of information being stressed to Air Force physicians as they participate in a round of exercises titled Medical Red Flag (MRF). It’s knowledge that will enable them to do the most good for the largest number of people, with limited time and equipment, in a mass casualty situation—the kind of situation anticipated by the United States during a major conflict in, for example, Central Europe or Korea.

Historically in war, Air Force people have worked out of areas of relative safety away from the conflict. This may not necessarily be so the next time, reasons USAF. Men and women working on the air bases, and not just those who fly, may be subject to injury from conventional, chemical, or biological weapons, and even nuclear attack. In a location like Europe, if dependents aren’t evacuated before the start of hostilities the problem of mass casualties will compound itself. The priority is to sustain the fighting force.

In 1979, supporting that priority, Lt. Gen. Paul W. Myers, USAF Surgeon General, began a program that has come to be known as Medical Red Flag. It furnishes one week of training in combat casualty medicine to Air Force health-care providers. Twenty-five hours of classroom lectures carry such titles as Wound and Shock Management, Biological and Chemical Wound Management, Aeromedical Evacuation, Infectious Diseases, and Maxillofacial Injuries. The ten hours of practical exercises that accompany the lectures include working while wearing protective chemical suits and masks, bandaging and splinting, and triage. While all health-care providers participate in MRF, the training focuses on the roles of the surgeons and other physicians.

Dr. (Lt. Col.) George Crawford, who specializes in both internal medicine and infectious diseases at Wilford Hall USAF Medical Center, Lackland AFB, Tex., is one of more than a thousand Red Flag trained health-care providers. He also helped run the exercise when it was conducted at this Texas medical center. “Initially, feelings were negative” among those participating, he said.

First of all, he explained, most people don’t like to think about war. Another factor was the inconvenience, since MRF participation was an additional duty for the doctors who at the same time remained responsible for most of their normal patient loads. “At the end, realizing they were getting good information, most were extolling and were all, at the very least, reasonably enthusiastic about what they learned,” Dr. Crawford commented.

The idea is to give structure to casualty management. Dr. Crawford made it clear in describing the applied portions of an MRF that even physicians have a lot to learn, from setting priorities for the care of the injured during the two triage modules to the hands-on experience gained in the splinting and bandaging module. One of the best-kept secrets in medicine, he said, is that doctors aren’t expert in the immediate stabilization of injuries requiring splints and bandages.

By 1982, USAF health-care providers in Germany, Korea, and at every USAF medical center in the United States will have seen a Medical Red Flag exercise. The Surgeon General wants future ones to be broader in scope, more sophisticated, and to expand the roles of other health-care providers. Nurses and physician assistants, for instance, will be introduced to accessory triaging and initiating life-support systems. Colonel Crawford, who anticipates a staggering number of casualties and possibly an inadequate number of doctors in a future conflict, calls this expanded training a critical need. He believes USAF’s other health-care providers must be trained to care as much as possible for the injured so the limited number of physicians can concentrate on those most seriously hurt. Medical Red Flag will also be used to introduce training in the use of such things as lighter-weight field operating room equipment, better lighting, and more compact lab instrumentation.

Echelons of Care

Medical Red Flag is the start of many readiness initiatives being incorporated into USAF’s medical programs. Significantly, all Air Force people may find themselves playing a part.

When alerted that an attack is imminent, most of the medical staff on an overseas base will move away to a safer location to avoid any chance of destruction or possible contamination of the medical environment. Doctors assigned to operational units will remain with those units; but, for the most part, those left to defend the base will have to rely on themselves for immediate medical care, known as self-aid and buddy care.

A new DoD directive requires all Air Force members to train in “life and limb-saving procedures.” Lt. Cot. Tom Forister, a medical readiness planner, is working now with Air Force personnel officials to implement a mandatory training program which for Air Force people will constitute their first echelon of treatment in time of war. Colonel Forister has also served as the Surgeon General’s Medical Red Flag project officer since that program’s inception.

Of the three remaining echelons, the next is an aid station. As the wounded are removed from the area of conflict, they will be taken to the closest aid station. These will be minimum treatment facilities staffed by the medical people who left the base earlier. If all has gone correctly, they will have relocated just a few kilometers from the base to provide enough care to return to duty those who can recover in several hours and send those who can’t to the third echelon of care, the Field Surgical Facility.

Here, for the first time, patients will find themselves in a hospital of 250 to 500 beds staffed with most medical specialties. Surgery will be performed, and those who can recuperate to return to duty in several weeks will remain. The more seriously wounded move again, this time to the last in-theater level of care, the general hospital, located as far to the rear as possible.

Europe for Example

At the outset of a major conflict in Central Europe, there will very likely be dramatically more USAF casualties than experienced in any previous conflict. Airmen will be treating themselves and others at the scene. Those suffering such minor injuries as mild burns, chemical distress, or lacerations may be treated on the spot or, after visiting an aid station, returned to duty. Many will suffer more seriously, including severe multiple injuries requiring advanced life-support and trauma-support systems. The seriously wounded who can be helped must be identified, rushed to aid stations to be stabilized, and moved quickly from there to field surgical facilities.

Medical planners estimate that several aid stations will feed one field surgical facility. USAF is currently negotiating with the German government to use a former hospital near Zweibrücken as one such third-echelon facility. Both there and at general hospitals, located in the United Kingdom if supporting Central Europe, the question becomes one of who goes into the operating a room first.

Medical Red Flag teaches that patients can die from shock, hemorrhage, or asphyxia before other injuries. These people get first priority. The key is determining the seriousness of the injuries and knowing in each case how long surgery can safely be delayed to accommodate the volume of casualties.

Exactly which facilities may be second, third, or fourth echelon depends on where the conflict focuses. In Korea, for instance, Clark AB in the Philippines will provide fourth-echelon care. For the Middle East, hospitals in Germany may be tapped for those services. In all cases, the goal is to return as many people to duty as quickly as possible. Those who can’t will be aeromedically evacuated to the United States.

More Training Expected

Different factors influence how much and what types of training USAF must provide to ensure well trained medical people for combat. New members, compensating for the normal turnover of people, require training. All medical people are routinely required to undergo refresher training anyway. And then, different specialties call for different training requirements. All of this has led USAF to develop three levels of training for its medical officers.

One program gives in-house training to physicians, dentists, nurses, Medical Service Corps officers, and Biomedical Sciences Corps officers. Since surgeons represent a critically undermanned career field that will be vital in war, this program, called Corps Training, teaches the other officers specific skills, in addition to what they normally do, to support the surgeon war-zone operating room. The subject matter is extracted from the Medical Red Flag topics and is presented mostly on videotape. To gain practical experience, dentists, for instance, are working half a day per month as surgical assistants in their hospital operating rooms. By virtue of their education and what they learn in Corps Training, dentists will become qualified to give anesthesia and to augment surgical capability.

The other two levels of training are courses that have been designed for the physicians, dentists, nurses, and veterinarians. The first one is described as the Tri-Service Combat Casualty Care program mostly for interns, residents, and new accessions. Combat Casualty Care is a direct outgrowth of Red Flag. It’s broader in scope and is open to all three services, taking a student through Fort Sam Houston, Camp Bullis, and Brooks AFB, all in Texas. In contrast to MRF, students concentrate on further development of their combat medical skills. For example, an M-16 round damages tissue extensively and can cause gangrene if the wound is not properly cleaned. So students learn to debride wounds created by high-velocity weapons.

Other aspects of the program include tent living to get the flavor of wartime conditions. And practical exercises include caring for three patients aboard a helicopter in flight and learning how to escape from or evade an enemy. Combat Casualty Care is oriented to the doctors working in the battalion aid stations and second echelons. Being phased in now, by 1982 it will be offered ten times yearly. USAF dentists are increasing participation in this program.

The training that General Myers says puts the “polish” on the medical-readiness effort began in February and is conducted four times a year at Brooks AFB. The five-day program, called Battlefield Medicine, is for USAF physicians who are not surgeons. The half lecture, half practical experience course is geared to supporting the second echelon. It differs from Combat Casualty Care primarily in the types of injuries or wounds studied. Students learn about the ones USAF believes most likely will afflict its people on an air base that has come under attack, injuries such as those caused by bombing and collateral damage, and from chemical and biological agents.

Stateside Medical Support

A critical link between the overseas and Stateside medical facilities will be Military Airlift Command’s aeromedical evacuation system. So it can surge to the maximum extent possible, only the minimum number of people will comprise each medical crew, making more crews available for more flights. For at least the first thirty days, no comfort pallets will be carried. This will also help increase the use rates of the aircraft. And USAF has increased by seven the number of strategic aeromedical staging facilities and by eight the tactical ones, all to be centralized under MAC control during a conflict.

As patients are returned to the US, they will be taken to the medical facility that can best administer to their needs. Each USAF medical facility is picking up a specific wartime mission. In conjunction with DoD, USAF is also coordinating agreements with large civilian hospitals to use portions of their facilities.

In August 1980, USAF, through its Scott AFB, Ill., hospital, signed agreements with thirty-four area hospitals. Each pledged a minimum of fifty beds for DoD to use if needed. It was the first such agreement in DoD’s quest to line up a minimum of 50,000 beds for use in a large-scale emergency. All eight Air Force medical centers should be administering agreements reached in their parts of the United States by 1982.

USAF hospitals are being identified for expansion and for the types of specialty care each is able to provide to returning casualties. Regional hospitals, as casualty receiving centers, will handle patients requiring acute care. The Sheppard AFB hospital, for instance, is a psychiatric center now, so it will most likely expand in that role. The Air Force is also looking at bases that will have lots of dormitory space available; that is, bases that will have deployed their operational units overseas. These will be turned into minimum care and convalescent care facilities.

General Myers intends that his entire medical readiness program will be ready to go by 1986. White the actions described above cover its major ingredients, other less noticeable efforts are also contributing to its success. Negotiations continue to establish host country agreements for enough off-base medical facilities dedicated to US personnel and for the prepositioning of medical supplies.

Considering that Europeans see any future conflict as taking place in their front yard, “It’s very difficult,” General Myers explained, “to tell us, ‘You can have that hospital over there,’ when they’re going to fill it up with their own. And who knows how many civilian casualties they’ll suffer?

“I think the European countries are working this problem the best they can under some very realistic limitations. They have a deep appreciation for our requirements that have to be balanced with their own very real needs,” General Myers emphasized.

Research and construction proposals have also been made to support medical readiness. In such high-threat areas as Germany, the United Kingdom, and Korea, efforts are being made to acquire hardened on-base medical facilities. The School of Aerospace Medicine at Brooks is designing a way to maintain a clean environment in USAF’s air-transportable hospitals for use in areas subjected to chemical or biological attack. The key, always, will be to sustain the fighting force in combat.

Maj. Thomas L. Sack, USAF, was Contributing Editor during his one-year tour with AIR FORCE Magazine, June 1980-June 1981 under the Education With Industry (EWI) program. He is now on public affairs duties at Hq., Allied Forces Central Europe (AFCENT), Brunssum, the Netherlands.