The latest trend in the U.S. military is “near-peer conflict.” After nearly two decades of mainly counter-terrorism and counter-insurgency operations, the Pentagon is changing gears. It is taking a step back in time to a more Cold War setting in preparing for conflict against potential adversaries like Russia and China. 

We can argue that open warfare with the Russians and/or Chinese, while entirely possible, is still very unlikely. As we’re seeing unfold in many places, large states are employing proxy forces as the U.S. has traditionally done since WWII. So the belief here is that while large state conflicts may erupt for short periods of time, the next conflict will be more of what we’re seeing now: wars by proxy. 

Yet, there still exist sub-state actors, like al-Qaeda, ISIS, al-Shabaab, etc. The threat from the combination of those types of forces makes for a very volatile mix. It will make it difficult for the U.S. to balance where our resources are employed in order to deal with these multiple threats simultaneously.

However, with the military gearing up for “near-peer” conflicts, we were curious as to how much the realm of combat medicine will change — and yes, everything about combat medicine will be very different in the near-peer combat realm.

We were introduced to and spoke with retired Colonel Dan Irizarry who served 26 years on active duty. Dr. Irizarry’s career spanned the full spectrum of military medicine from direct combat medical support in multiple areas of operation at the tactical level with the 82nd Airborne Division and 3rd Special Forces Group, to operational command of garrison healthcare facilities and strategic SOCOM leadership as the first command surgeon for NATO Special Operations Headquarters (NSHQ) in Mons, Belgium. Dr. Irizarry is also the Senior Medical Advisor for TraumaFX that provides some of the most realistic medical simulators for troops in training.

As the NSHQ Command Surgeon, Dr. Irizarry built and led a team that envisioned and implemented the NATO SOF Medicine Development Initiative (NSMDI). The initiative is designed to improve SOF medical support through the establishment of the SOF Allied Centre for Medical Education (ACME). 

We spoke about the strides the U.S. military has made in combat medicine, especially during the wars in Iraq and Afghanistan. We also spoke about how many of those advancements may very well take a step backward in near-peer combat and why training, not just for the medical personnel but for the average soldiers is paramount moving forward. 

The realm of military medicine vastly improved during the wars in Iraq and later Afghanistan. In both WWI and WWII, the wounded-to-killed ratio for troops was 4:1. Today, that number has more than doubled; it currently stands at 10:1. That significant decrease has to do with a couple of factors: better training of medical personnel, the reintroduction of the tourniquet to combat troops, and the incredible strides in getting wounded troops to life-saving medical care within 60 minutes, often referred to as “the golden hour.”

Ranger medics treat a patient during an exercise (U.S. Army).

“We have the capability to get troops to a Level-1 medical care facility from anywhere in Afghanistan within one hour… you don’t have that capability in Idaho,” Irizarry said. 

“It took us 10 years to build that system (with total air superiority). In a near-peer fight, we’re not going to have that kind of capability.” He added that the number of surgeons that are in the military has been gutted and thus there will be a critical shortage of surgeons in a near-peer conflict. Additionally, there will not be time to develop a similar system in such a conflict.

He added that with a dearth of surgeons volunteering for the military, there is a lack of experienced combat surgeons. This brings us to the crux of the issue: “If you’re wounded in combat, the best hope a soldier has of surviving is the guy next to him. Everyone has to be trained.”  

“Medics will have to manage care for a lot of people with few medics available,” he said.

One of the things that hamstrung commanders in Afghanistan, to an extent, was the fact that they were not allowed to conduct operations where they would be outside of that 60-minute window for medical evacuation. That is not going to happen in a near-peer fight. Resultantly, the medical evacuation procedures will have to change.

The military had enough HH-60 Blackhawk helicopters to medevac one or two wounded troops to surgical facilities in-country. It could also use specially outfitted C-17s, essentially flying ICUs, to transport wounded troops to Germany. Near-peer combat will overstress the capabilities of the Blackhawks and that means that CH-47 Chinooks or V-22 Osprey would be pressed into service. But they would be prone to more groundfire, surface-to-air missiles, drone-directed fire, as well as attacks by enemy aircraft. 

Irizarry pointed to the possible employment of drones or unmanned aircraft to transport patients to a field hospital. He said that there is the technology in hand that will allow the military to use casualty care drones. These tiny drones are about the size of a coffin but look like small Chinooks, he said. The patient will have to be stabilized prior to being put in a drone and there will have to be a way to monitor the wounded soldier while in-flight. Communications bandwidth will become critical.

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Training the soldiers to care for the wounded while continuing the fight is critical. Dr. Irizarry used the example of how the Ranger Regiment under General McChrystal changed the entire paradigm of combat casualty care to the “Commander’s Casualty Response System” as they called it. The Rangers made it a leadership issue while acknowledging that the commander has to allocate the resources for care and training. By making it a commander’s responsibility, the results of what the Rangers did are startling. 

“In the general-purpose force in Afghanistan [read conventional troops] there was about a 24 percent of wounded troops that died, that could have been saved,” Irizarry said. He calls these “preventable deaths.” Had the right things been done at the right time, these troops would have survived. 

However, “in the Rangers, it was zero percent.” The Rangers trained every soldier well in the basics, during live-tissue training, and in simulation. They rarely, if ever, get shortchanged before deployment. And they document everything during training. That helps a commander by pointing out where his unit’s shortfalls are. 

“Because of this and the fact that they know, if they get wounded in battle, the Rangers fight harder, better, and more effectively than nearly everyone else.” 

“In a near-peer conflict we still have a long way to go and our surgical systems are in no way prepared for combat on that magnitude,” he added. 

“So, what’s the answer?” we asked him. “The best way is training at the individual level,” he replied. “Providing realistic training through simulation gives you a better chance of having the troops survive during the next conflict.” 

The simulations with live tissue training are invaluable and the technology is out there for the troops. But medical training seems to always be the first thing on the military’s chopping block and frequently for what Irizarry calls “stupid s**t.” That needs to change. 

So, in the next conflict, if that is indeed in the “near-peer” realm, there will have to be a lot of changes and improvements done to our combat medicine procedures. For example, there seems to be the prevailing train of thought that the “golden hour” will lengthen, perhaps by quite a bit.

The military showed it could adapt and change to improve combat medicine in Iraq and Afghanistan. It will have to do so again.