This podcast was recorded for the Special Operations Medical Association in 2017 by Jim Czarnik, Army Colonel, Emergency Medicine Physician. It is a phenomenal explanation of the future of warfare and how medical personnel and processes must adapt readily to win in a complex world. Operational military medical providers, especially those in leadership, this talk is for you. Below I’ve included my notes from the podcast. Enjoy!
Wars like the AFG/Iraq wars are not the wars of the future. These wars were very kinetic and the medical infrastructure in these countries was robust. Throughout each of these conflicts, death rates decreased despite the ESI of injuries increasing. Eventually the deployed trauma system had better survival numbers than the US civilian trauma system. We are very good at medicine, but very poor at adapting to the surrounding environment. In Iraq/AFG we adapted the environment to us. In 2009, SECDEF Gates mandated that all Medevacs of life-threatening-injuries be completed within the golden hour. This led to a build up of medical infrastructure and medical planning that shortened Medevac times and increased survival.
The line community has become accustomed to this capability and expects this same capability in future wars. But the future of combat is austere, rapidly changing, and we may no longer have the ability to provide this same rapid response for a variety of reasons.
It was easy to work in failed states, especially when we were the ones that made them fail – we could do whatever we wanted in AFG/Iraq. But in the future, we will be working in permissive, semi-permissive, and some non-permissive environments. We may have no authority to operate in certain countries without that government’s or the ambassador’s approval. We will not have the same robust infrastructure available, but battlefield commanders will still expect the same medical capability as past wars. It is our job as medical providers/planners to inform them, and their job to understand this dynamic and mitigate operational risks.
We are mandated to “win in a complex world,” but what does that mean?
What does “win” mean? Winning requires us to use every instrument of national power to bring conflict to an end. This means that we understand and leverage the whole of government including – DImE (Diplomacy, Information, military, Economic). The “m” is lower case in DImE because the military should be used the least and as a last resort, but this is often not the case. Often the military is used first to show a rapid response while the rest of government gears up for the conflict. If we are to leverage every means to end conflicts, we must learn how to think “Joint.” We must learn to work with the State Department, CIA, FBI, and think about these as other instruments of national power that can be incorporated.
What does “complex“ mean? The future of warfare is “unknown, unknowable, and constantly changing.” We cannot predict the future. We can describe the future, but we cannot predict it. And even if we did know the future, if it were able to be known, it would then rapidly evolve and change from that known.
What does “world” mean. The “world” is the whole multi-domain battle-space. This includes not just military – it includes the Army, Navy, Air Force, Marines, Coast Guard, Public Health Service, SOCOM, and other government agencies. We must also expand our “world” to JIM – Joint Inter-organizational Multinational environment. These are governmental and Non-Governmental Organizations – the Red Cross, UNICEF, UN, WHO, and other NGOs. Some of these organizations embrace military, but many will not. We may be working in sovereign nations with coalitions, NATO and non-NATO countries. What do you do if you find yourself working side-by-side with the Chinese or the Russians? We must check our egos at door and say “I need help.” Are you able to check your ego at the door? If not, you will miss threats, or will not take advantage of what is available.
If we can’t predict the future, how can we win? What do we focus on?
Our ability to adapt must be equal to or greater than the rate of change of the world. We cannot focus on specific tasks or task completion, we must think about and build processes that are flexible. Special Operations Forces have mastered the basics of their craft better than anyone else, so they are able to adapt and readily change the application of the basics. They don’t lose the forest for the trees. They keep the principles and priorities the same, but adapt their techniques and how they are applied.
We must behave similarly. What about the use of foreign medical facilities? We have classically been taught that foreign medical services may not offer same level of care as US. While this may be true, what if a service-member becomes ill or severely injured during a humanitarian mission in a semi-permissive environment, where there is no US footprint, no Golden Hour, and you are lucky if there is a golden 48 hours? We must know these foreign facilities and their capabilities. Can you enter that environment and use their equipment and capabilities? This requires significant research, planning, networking, interfacing, and site visits to each of these locations. Remember, the commander must mitigate risks, but it is our duty as medical leadership to inform them of our capabilities, and then build a workable medical plan around their mission and mandate.
We must practice good medicine in bad places, but we cannot not tolerate bad medicine in good places. We must suppress our egos and ask for help in a resource limited environment. We must be willing to think outside the box. What about blood product usage in developing countries? Would you choose death over the possibility of HIV? Again, classically we have been taught to avoid in-country blood products. But what if your team member is severely injured and dying in a resource limited setting, and it will be 48 hours until medevac is available? Do you consider using those blood products? Again, there is no golden hour in AFRICOM, or in future wars, our job is to keep our people alive until they reach further care. To do this, we must forget convention, and think outside of the box.
What about inserting medical personnel into a country via civilian aircraft/airlines? Instead of via military aircraft? Especially when entering a sovereign host nation? This may be a more rapid solution than waiting for approval for the classical military medevac. It may be possible to get medical teams into sovereign nations on civilian airlines with their medical gear in pelican cases stripped and loaded to within airline weight restrictions in less than 24 hours.
We must also research the medical infrastructure of host nations, and assist in the development and improvement of their medical capabilities with US. medical personnel and equipment. These facilities do not need C-17s with conex boxes loaded with medical gear, they need clinical judgment and skill development. By preparing the battle-space years ahead of conflict, we will be ready and able to adapt quickly to evolving threats. This is how we plan during peacetime for a winning in a future complex wartime environment.
This adaptive, flexible mindset sounds oddly familiar though. Preparing for emergencies instead of reacting to them is reminiscent of the five SOF truths:
- Humans more important than hardware
- Quality is more important than quantity
- SOF cannot be mass produced
- SOF cannot be created after emergencies occur
- Most SOF require non-SOF assistance
To win in a complex world, we must continue to prepare intelligently. We must adapt readily. We must change our way of thinking. We must alter our expectations. We must master the basics and focus on robust adaptable processes instead of perseverating on task completion. We must win, and we will win with this mindset.