Consider This from NPR - Battlefield medicine has come a long way. But that progress could be lost

Episode Date: June 3, 2024

When the U.S. launched its invasion of Afghanistan and Iraq in the early 2000s, it had been a decade since a full-scale deployment of American troops. That's why when the wars started a lot of the medical corps' experience came from big city emergency rooms. But a few years into the wars, the military was facing hundreds of casualties each month between Afghanistan and Iraq.Military surgeons were seeing wounds requiring double amputations, the kind of thing you might never encounter before serving in a war zone. The military was able to turn that real world experience into breakthroughs in battlefield care. Some of them were simple tweaks like pop up surgical teams that set up close to the battlefield. Over the course of the war, small innovations like this tripled the survival rate for the most critically injured troops, according to one study Now that the post 9/11 wars have ended, some veteran military doctors say those gains are at risk. The Pentagon has tried to cut its healthcare costs by outsourcing medical care to the private sector. And that could hurt battlefield medicine in a future war.Learn more about sponsor message choices: podcastchoices.com/adchoicesNPR Privacy Policy

It's hard to practice battlefield medicine without, you know, a battlefield. And when the U.S. launched its invasion of Afghanistan and Iraq in the early 2000s, it had been a decade since a full-scale deployment of American troops. That's why, when the wars started, a lot of the medical corps' experience came from big city emergency rooms. This is the closest thing to being in combat that you can get without actually being in combat. That's an Army surgeon named Tom Newth at Miami's Jackson Memorial Hospital speaking to NPR in 2003. But a few years into the wars, the military was facing hundreds of casualties each month between Afghanistan and Iraq. Military surgeons were seeing wounds requiring double amputations,

the kind of thing you might never encounter before serving in a war zone. I could probably count on one hand how many double amputations I'd had to take care of or do. And now, how many? I don't even know. It's a lot. It's pretty regular. That was Lieutenant Colonel Rachel Height talking to NPR's Quill Lawrence at the Joint Theater Hospital on Bagram Airfield in 2010. By that time, the military had turned all this real-world experience with traumatic injuries into breakthroughs in 2010. By that time, the military had turned all this real-world experience with traumatic injuries into breakthroughs in care. Some of them were simple tweaks, like pop-up

surgical teams that set up close to the battlefield designed to get care to wounded troops faster. Here's Colonel Chris Benjamin, the commander at the hospital back then. The soldier out in the field that encounters an explosion or a gunshot wound, the most important part of his entire chain of survival, from the explosion until we can get him to Walter Reed, is what his battle buddy does, the guy in the next vehicle or the guy who was 50 meters away. Over the course of the wars, small innovations like this

tripled the survival rate for the most critically injured troops, according to one study. Now that the post-911 wars have ended, some veteran military doctors say those gains are at risk. Consider this. The Pentagon has tried to cut its health care costs by outsourcing medical care to the private sector, and that could hurt battlefield medicine in a future war. From NPR, I'm Ari Shapiro. It's Consider This from NPR. Even before the wars in Afghanistan and Iraq had ended, the Pentagon had activated

a plan to cut health care costs for its millions of troops and retirees and their families. NPR Veterans Affairs correspondent Quill Lawrence has been looking into the consequences of that plan, and he picks up the story from here. War is the mother of invention, and the 20 years of U.S. deployments in Iraq and Afghanistan produced a lot of medical advances, including people, battle-tested doctors and nurses. My name is Todd Rasmussen. I'm a vascular surgeon, professor of surgery at the Mayo Clinic in Rochester, Minnesota. The Air Force put Rasmussen through med school. For that, he owed them several years of service, and then he figured he'd go into private practice. He started a few weeks before September 11th. We were only about eight miles from the Pentagon.

You could sort of see smoke from the Pentagon. And I think from my perspective, I thought, boy, my military career as a surgeon, it's going to be vastly different than what I expected. Rasmussen switched to trauma surgery as casualty numbers lifted to the highest rate since Vietnam. At first, the way patients arrived so quickly from the war zone amazed him. They'd been severely injured, you know, five or six thousand miles away just three or four days earlier. The wonder wore off, though, because patients weren't getting care soon enough. They arrived with contaminated wounds too late to treat. It's hard to admit we could have done better, but I think

maybe the only thing worse is not admitting it. And the military did do better, getting surgery done inside what's known as the golden hour after injury. At first, they improvised, tent hospitals where patients arrived with tourniquets made from cargo straps. As the war ground on, newly designed tourniquets became standard gear. Units of whole blood seemed to work miracles. By 2005, about when he had planned to be going into private practice back home, Rasmussen deployed to Iraq and saw the innovations in real time. I remember one U.S. service member who came to us from the front lines in Fallujah, and he had been operated on by a small group of

surgeons near the front line. I think the assumption was that we would need to amputate. The doctors near the front line had used a temporary shunt in a new way. Basically, they stuck a plastic tube into the thigh to keep the blood flowing around the wound and save the foot. We said, wait a minute, we can actually fix this because of what the surgeons have done in their creativity and skills. Sort of put the amputation saw away. Rasmussen deployed six times between 2005 and 2012. On the last one, in Afghanistan,

he operated in a fully equipped hospital with new concrete floors and access to MRI and CT scans. Then the wars wound down, and Rasmussen noticed a drastic change. There were efforts to outsource beneficiary care from the military treatment facilities to civilian institutions, which emptied out and hollowed out storied military medical centers like Walter Reed. That outsourcing was planned. In the past decade, the Pentagon tried to tame its massive health care costs by pushing medical care, especially for family members, into the private sector.

The result was a sort of spiral. Military hospitals lost the numbers of patients they needed to keep doctors in practice. Because of that, and also the pandemic, many clinicians left the military. And the cuts kept going, says Rasmussen. And lastly, even, you know, what I would, in my own words, call like crazy ideas, you know, that were floated to close the Uniformed Services University, right? I mean, why do we need a military medical academy? The Uniformed Services University is the military's medical school.

OK, I'm Dr. Art Kellerman. For seven years, I was the dean of the Uniformed Services University, the health sciences. Art Kellerman was a leading voice against downsizing the system, especially the university, which he says preserves and supports all the military medical advances from the past 20 years and many of the doctors who made them. They achieved the highest rate of survival from battlefield wounds in the history of warfare. They were able to save people that would have died in any prior conflict. That, as much as a helmet or flak jacket, gave U.S. troops confidence, Kellerman says, to rush into a firefight knowing they would probably survive. U.S. allies joined the fight knowing that an American medevac would fly to

the rescue within 30 minutes if they got blown up. And that they'd not just survive, but live well, Kellerman says. They dramatically improved their ability to rehabilitate wounded warriors after being injured. And many of them were able to return to duty, and others were able to return home to be with their families and to function for the rest of their careers. Some of them today are members of Congress. Kellerman says America needs that same ready medical force for any future conflict.

And the Pentagon now seems to agree. A Defense Department internal memo obtained by NPR found that outsourcing didn't actually save money, but did hurt readiness. The memo directs the Pentagon to reverse course, to bring more medical care back to its hospitals on base and increase medical staff. But the next war may be very different. In Iraq and Afghanistan, the golden hour was possible because the U.S. had air superiority. The enemy had no planes or helicopters. Sooner or later, somewhere, we're not going to have air superiority. And I don't care if

we think we are. We should plan for not having it. Dr. Sean Murphy served 44 years, retiring as Air Force Deputy Surgeon General. He's thinking about Ukraine, two conventional armies squared off with massive casualties being evacuated by ground. Or even more extreme, a possible conflict with China around Taiwan. What we've realized when we start looking at a theater like the Pacific and the distances and a peer-to-peer fight, there is no way we're going to get to the golden hour. The solution, says Murphy, is to make every soldier and sailor a medic. To do that, he says, the Pentagon needs, urgently, to build back its ready medical force.

Dr. Todd Rasmussen agrees. The most important fighting system or weapon system we have is the human system. It's not a plane or a ship or a tank. Rasmussen says he saw that again and again when he served. That's the most lethal and most important fighting system we have on the battlefield. And that human system is only optimized and cared for if there is a robust and expert military health system. And I think degrading that risks our national security. Rasmussen retired after 28 years, and he is, finally,

a civilian vascular surgeon at the Mayo Clinic. He still mentors military doctors, though, and the ones who do join give him great hope. That was NPR's Quill Lawrence. This episode was produced by Walter Ray Watson

and Connor Donovan with audio engineering by Stu Rushfield. It was edited by Andrew Sussman and Courtney Dourning. Our executive producer is Sammy Yenigan. Thank you. You can sign up at npr.org slash consider this newsletter. It's Consider This from NPR. I'm Ari Shapiro.