Document created: 6 December 01
Published Aerospace Power Journal - Winter  2001

DISTRIBUTION A:
Approved for public release; distribution is unlimited.

Operational Medical Support for the
Tip of the Spear

The Heart of Air Force Special Operations Forces
 (AFSOF) Medicine

THE TERRORIST ATTACKS on 11 September 2001 in New York and Washington, D.C., as well as the crash of the hijacked aircraft in Pennsylvania, reminded Americans of the traumatic necessity of providing medical assistance to the injured, especially in time of war. Prior to the attacks on the World Trade Center and the Pentagon, the fact that the United States had suffered relatively few friendly casualties in recent conflicts (e.g., the Gulf War and Kosovo) may have created the impression that we could fight relatively unscathed. Though understandable, such expectations are extremely naive, especially when one considers the dangerous world of special operations. United States Special Operations Command (USSOCOM), as established by Title 10, section 167 of the United States Code, has principal missions, including “combating terrorism” and taking “direct action,” that involve inherently dangerous activities. Consequently, as USSOCOM’s air component, Air Force Special Operations Command (AFSOC) must ensure effective medical support for its people—a huge challenge for a force designed to be “light, lean, and lethal.”

In the decades prior to 1990, one could not distinguish the Air Force’s medical support to special operations forces (SOF) from that provided to conventional forces. The air-transportable clinic provided conventional aviation medical support as well as disease and injury prevention to deployed bases. Designed to support a system of echelons that met theater and strategic-planning models during the Cold War, the clinic proved successful with conventional forces. A squadron medical element, consisting of three personnel (including one physician), could take a single pallet of medical equipment and supplies to a fixed base and provide routine medical care with some limited trauma support for 30 days to a fighter squadron–sized unit of approximately 500 personnel.

But this process could not accommodate SOF. First, medical personnel often found themselves supporting other units; occasionally, the Air Force physician was the only medical officer deployed in support of a joint operation.¹ Flight surgeons faced a scope of responsibility broader than their medical skills could support. Second, they found themselves on unfamiliar ground since most squadron flight physicians were in their first operational assignment, had never worked with SEAL and special forces units, and had no experience with medical issues related to such matters as diving gas mixtures and high-altitude, low-opening jump operations. Third, airlift for medical equipment was almost nonexistent. Organic aircraft had no space for a palletized clinic, and nesting boxes and backpacks became the mode du jour, each medic deciding what to take on any given occasion. Replacements for items left behind were purchased locally with little consideration of suitability and standardization. Thus, over time, each unit accumulated different—sometimes incompatible—medical equipment.

The word special in special operations does not imply a rejection of conventional Air Force processes in search of independence. Rather, it refers to unique missions driving different tools and training that require unique medical support as well. This raises certain questions: How much “medical” capability is needed and supportable? Why should it be different? What does it need to do? What tools are necessary? What are the desired characteristics of the interface with the rest of the medical system? This article describes efforts to develop operational support for SOF that have taken place during the last decade. In addition, it outlines current initiatives to improve the conduct of that support, including the interface of SOF medicine with conventional theater support and the aeromedical-evacuation system. Finally, it suggests future improvements for SOF medical support. The paramount message for successful medical support is simply that SOF medicine must be operational medicine.²

The Focus on Operations

SOF medicine must be operational medicine because a preponderance of SOF activities are not associated with fixed-base operations. AFSOC owns only one base, and it has only an outpatient medical facility. All other special operators are in AFSOC tenant units that regularly deploy to fixed-base or beyond-fixed-base locations, where they often are not the lead units and where the logistical tail and links to higher levels of medical care do not exist. In some cases, the presence or absence of higher-level care is irrelevant since, for security reasons, one cannot establish linkage to aeromedical evacuation or deployed military hospitals. In sum, the medical-support plan may assume an isolated capability from the start. If casualty transfer is possible, it would probably move rearward to interface with the aeromedical-evacuation system or hospital, using opportunistic airlift and organic medical personnel for en route care.

The constraints of far-forward medical care drive a set of challenging, unique medical requirements for personnel, equipment, and training. As codified by joint doctrine, special operations rely on “adaptability, improvisation, innovation, and self-reliance,” emphasizing “small size, unique capabilities, and self-sufficiency (for short periods of time).”³ The challenge has always been to take these characteristics and determine the right mix of medics, medical equipment, and medical training to provide the best possible support to the special operator.

The conundrum is that the demand for flexible capability and self-sufficiency flies in the face of the necessity of remaining small and light. Obviously, all medical-support planning must deal with this dilemma, but not to the extreme that SOF does. For example, in time-critical rescue and disaster-response scenarios, SOF forces must determine what (and how much) needs to go on the first aircraft, the number of Security Forces assets to secure the area against further damage and injury, and the types of medical assets to treat existing casualties. Unfortunately, such decisions are sometimes made during highly vocal, last-minute flight-line discussions.⁴

How Much Organic Medical
Capability Does AFSOF Need?

The answer to that question starts with recognizing that special operations are hazardous. According to some sources, SOF accounted for 31 percent (71/228) of total US combat deaths (killed in action) from Desert One through Allied Force.⁵ This percentage, disproportionately high for such a small fraction of the total force, argues for a robust medical-support capability that caters to the dangerous missions these units undertake.

Again, the challenge lies in being robust and light/lean at the same time. In the past, operational medics received training in basic lifesaving skills, used basic splints and bandages, and accepted the fact that they could do little for casualties until they arrived at a fixed medical-treatment area. “Acceptable” loss then becomes a planning factor but an abhorrent one, especially when medical science can accomplish so much more if provided immediately (i.e., far forward). An alternative process involves seeking trade-offs, alternatives, and substitutions that maintain a flexible medical capability but reduce the footprint and support tail. A third option calls for maintaining a substantial off-the-shelf capability but modularizing the contents so that their usage depends upon the specifics of the individual mission.

In practice, both the second and third strategies have proved successful. They abjure large power supplies and equipment items for lightweight pieces such as hand-powered water purifiers and suction pumps. Using solar power panels for certain items remains an option, but high cost, inadequate durability, and low charge rates limit their utility. In addition, lightweight materials and minisized devices have been substituted wherever possible, a process not unique to special operations since the Air Force Medical Service as a whole seeks opportunities to reduce size, number, and weight.

Seminal efforts of this service have transformed the traditional echelons (levels) of care into an expeditionary medical-support system more capable of meeting the needs of our expeditionary Air Force. For example, traditional medical-support packages like the air-transportable hospital and the contingency hospital have given way to integrated building blocks that one can use to establish any level of capability, from mere initial response to that provided by a major fixed facility—and to transfer that capability to other medical assets, such as a civilian medical community, host nation, or nongovernmental agency. This approach is very similar to the one taken by special operations.

Keying on the third process of modularization, special operations is focusing on modularizing unit type code (UTC) equipment and personnel packages. For example, AFSOC’s rapid-response deployment kit and the consolidated SOF medical element are representative of this strategy. Conceived in 1992–93 and brought on-line the following two years, the new UTCs paralleled similar efforts of the conventional side of the medical service to streamline the medical-support “piece” of operations: in Europe, the United States Air Forces in Europe command surgeon had developed small surgical packages (mobile field-surgical team) and, subsequently at Air Education and Training Command, critical-care teams for casualty movement (critical-care aeromedical-transport team). That beginning, as well as the cross-fertilization of ideas that occurred between the mobile field-surgical team and the critical-care aeromedical-transport team on the one hand and the rapid-response deployment kit and air-transportable treatment unit on the other, laid the groundwork for development of expeditionary medical support. “Lighter and leaner” began to catch on.

The rapid-response deployment kit represents one step up from man-portable medical equipment.⁶ The kit weighs 790 pounds and consists of four nesting boxes organized along functional lines: cardiac, trauma, environmental, and medical. Three kits fit on a single pallet, and one can mix and match the components to suit mission requirements. The kit can be augmented with a laboratory module, and, in those instances in which airlift limitations are not as critical or the mission is of long duration, other options are available.⁷ If all modules are deployed, the assemblage and personnel can provide medical care for a population of 600–800 for up to 30 days. In practice, the smaller configurations are the most useful.

The strength and power of this arrangement lies in modularity—providing lightweight, highly mobile capability for austere environments in a building-block approach and increasing or decreasing this capability as the mission evolves. Medical personnel can either hand-carry or store their medical equipment in containers small enough to add to available space on board an aircraft or ground vehicle. This parallels the core philosophy of expeditionary medical support and supports the Air Force Medical Service’s doctrine at an even lighter/leaner level.

In addition, adopting this process helps answer how far and how much medical care one can take into the field. Defining limitations on what one can treat allows planners to anticipate situations that will exceed the capability of deployed medical forces. In this context, decisions that recognize supportable medical skill levels and plan to keep losses acceptable can make claim to moral authority. To the extent that the mission commander must balance mission accomplishment with casualty survival in the context of limited medical assets, a strategy that gives that commander information on how much delay he or she can tolerate prior to treatment by different categories of casualties will be of great use.

Toward that end, USSOCOM’s Biomedical Initiatives Steering Committee, with component sponsorship, has undertaken a study to establish protocols for commanders in the field that do just that. For instance, one could define the risk of limb loss over time for injuries that disrupt blood supply to the limb. In other words, once this type of casualty occurs, how much more time does a commander have to complete the mission before the risk of permanent disability and death becomes too great? Until we develop this tool, however, mission commanders must develop medical go/no-go plans in consultation with their deployed surgeons, theater medical planners, or Joint Special Operations Task Force surgeons.⁸

What Does It Take to
Use That Capability?

The truism that “knowledge has minimal weight and cube” is important in the pursuit of light and lean. The training necessary to provide the best medical care possible continues to grow. Medical technology is not static, and the special operator deserves the same care offered to any service member or citizen. In special operations, whose missions may occur in remote and hostile locations, the level of training must remain as high as one can possibly sustain since medical technicians or physicians, who operate alone and without backup, have correspondingly greater responsibility.

As mentioned above, the SOF medical officer often becomes the consultant for medical aspects of dive, jump, and aerospace operations for which standard flight-surgeon training is inadequate. Second, SOF medical officers and enlisted medics find themselves closer to combat operations than is typical for Air Force medical personnel. Thus, they need training in survival/escape and response to terrorism, as well as tropical-medicine courses. In addition, one cannot meet the often-encountered challenge of working with host-nation forces or civilian organizations just with enthusiasm and no training. The newly created position of international health specialist can fill this gap.

The enlisted medic in AFSOC frequently operates independently in providing patient care and casualty management, at least in the initial stages. Some casualty-evacuation missions may occur in proximity to ground combat and necessitate the same preparatory training as that received by officers.⁹ Doctrinally, the medical training necessary to operate independently in this environment is designated emergency medical technician-paramedic (EMT-P), with Air Force independent-duty medical technician (IDMT) certification. In addition, formal aeromedical-evacuation training is necessary to conduct the casualty-evacuation mission. In total, this formidable and unique level of capability makes the AFSOC medical technician one of the most highly trained medics in the Air Force. Even the pararescueman, also an EMT-P, is not trained or expected to provide nonrescue medical care.

Historically, the AFSOC unit commander’s greatest dissatisfaction with medical support is the fact that the unparalleled training (table 1) necessary to bring the SOF medic to mission-ready status takes up to half a tour of duty. Therefore, a training pipeline for AFSOC medics—something the other services have always had—is long overdue. An enterprise philosophy of interchangeable medical personnel among the major commands is the wrong answer for AFSOC.

Table 1
Higher Headquarters Requirements for AFSOC Medical Training

Flight Surgeon		Enlisted Medic
1 week	ISOC	1 week	ISOC
1 week	DIT	1 week	DIT
1 week	ACLS	1 week	ATLS
1 week	ATLS	1 week	Water Survival School
1 week	Water Survival School	1 week	Treatment of Chemical and/or Biological Casualties
1 week	Treatment of Chemical and/or Biological Casualties	2 weeks	Trauma Rotation
2 weeks	Trauma Rotation	12 weeks	IDMT School
2 weeks	Aircraft Mshap Investigation	12 weeks	EMT Paramedic*
2 weeks	C4	6 weeks	Air Evacuation Technical School
2 weeks	Global Medicine

 ____________
Sources: Air Force TTP 3-42.6, USAF Medical Support for Special Operations Forces (SOF), 5 September 2001, 28; USSOCOM 40-2, Medical Services: Organizational and Operational Alignment of Joint Special Operations Medical Training Center, 6 March 1997, 2, par. i; and AFSOC Instruction 48-101, Special Operations Aerospace Medical Operations, 1 August 2000, 10–12, pars. 10–11.

Dedicated But
Nonorganic Capability

Occasionally, AFSOF has medical requirements beyond those of the aviation-support packages discussed so far—an area that still needs work. The air-transportable hospital may have great capability, but it alone is larger than most AFSOC mission packages. Therefore, the answer lies in expeditionary medical support. The fact that its configurations remain pallet-bound suggests the need to graft the modularization idea onto an AFSOC-assigned expeditionary medical-support package that would tailor an already optimized UTC to SOF limitations.

Critical Interface with
Conventional Medical Support

The interface between SOF and conventional medical care is fluid, occurring farther forward on some occasions but still avoiding potential exposure to ground combat. SOF medics, on the other hand, must operate in proximity to ground combat, with the potential for direct exposure if dedicated rescue-and-recovery forces are not available.¹⁰ Where should we draw the lines?

As the Air Force Medical Service attempts to bring technology and expertise ever closer to the casualty-causing event, it should think out policy guidelines and make them available to the commander. This won’t be easy because it goes against Geneva conventions concerning combat status and involves debates about gender equity and opportunity. In the sister ser-vices, the SOF medic is a combat medic, expected to shoulder a weapon as a primary combatant—an asset for “reconstitution” in the event of severe loss of ground-combatant strength. Air Force medical personnel, however, are protected under the Geneva conventions and entitled to use weapons under that category only to defend themselves and their patients against brigandage.

For this reason, conventional aeromedical-evacuation personnel usually have not received sufficient training in combat skills to reasonably ensure survivability on, or in proximity of, the battlefield. Further, they require a fixed location to prepare casualties for further movement, whereas SOF may frequently relocate, making the lifeline for casualty evacuation tenuous. Hence, although ad hoc decision making may have served reasonably well in the past, it is no longer acceptable. We must have doctrinal and procedural adjustments to guide programming and planning for the delivery of operational medical support.

The Future of AFSOF Medicine

AFSOC has accomplished a great deal since it stood up as a major command in 1990. The Air Force Medical Service has transformed a large, static, slow-responding capability into a light and lean force, but today’s success has a finite life span. The future of AFSOF medicine calls for visionary thinking and dynamic adaptation along three paths: (1) modernization of equipment, (2) enhancement of diagnostic sensory inputs, and (3) further efforts to modularize and tailor medical equipment to mission requirements.

Modernizing equipment is an ongoing process, not only for the Air Force Medical Service but also for the entire Department of Defense. Medics must advocate improvement in lifesaving, with an emphasis on the operational-support piece of health care and the modernization needed throughout the force. In that endeavor, special operations must become a partner. The Biomedical Initiatives Steering Committee, mentioned above, has a charter that considers only the physiological enhancement, not medical care, of war fighters. Yet, modernization of SOF medical capability, as a treatment and prevention activity in operations, must proceed along service lines.

The second opportunity for the future, diagnostic sensory input, comes from personal observation of treating casualties—on board an aircraft maneuvering at low level and at night, blacked out on night-vision goggles, and marked by extreme noise and vibration. Much equipment is available to assess and stabilize casualties, if only the environment were more cooperative. But it won’t be. Medical skills would dramatically improve if one could perform basic techniques of observation, inspection, palpation, and percussion (not to mention probing, injecting, and the like) reliably under extreme adversity. For instance, a glove-mounted scanner transmitting an image to a heads-up display and using vibration-canceling technology would fit part of the bill. No theoretical impediment to such devices exists. To accurately assess and stabilize a life-threatening, intra-abdominal injury without requiring transport to a secure area would be a boon. But training will have to keep pace with technology if such a capability becomes reality.

Finally, as regards becoming lighter and leaner by modularizing the medical-support package for any given mission, the current test of success is limited to backpacks and nesting boxes. Given state-of-the-art computer systems and automated inventory management, one has no difficulty imagining clinical guidelines for mission scenarios that would link to the types of casualties expected and the medical equipment needed. It should be possible to configure in minutes a medical-equipment package that focuses on the scenario and wastes nothing. Or telemetry may permit the monitoring of an inbound casualty in enough detail to configure a real-time treatment kit ready to use immediately upon arrival. Some of this already occurs through voice communication but with a limited degree of anticipation. In SOF, the need is acute. SOF medical support must seek opportunities to carry all that is needed and, at the same time, only what is needed to do the job.

In the struggle against terrorism and other threats to national security, the demand for light, lean, and capable medical care will continue since the nation is likely to call upon SOF as the force of choice. This challenge focuses on technology and training to provide the necessary medical support when and where it is needed.  

Notes

1. To progress from intern or first-postgraduate-year trainee to Joint Special Operations Task Force surgeon can overwhelm the abilities of even the most talented physician. Imagine graduating from pilot training and immediately becoming a deployed mission commander.

2. One need not address each principal and collateral special operations mission and define the medical support needed for each type of mission since it matters little to a casualty’s future whether a penetrating chest wound, for example, occurred in direct action or special reconnaissance.

3. Joint Publication 3-05, Doctrine for Joint Special Operations, 17 April 1998, vii.

4. This happened in response to the Dar Es Salaam and Nairobi Embassy bombings in 1998.

5. Although the total number of combat deaths is small by world-war standards, many people have argued that low casualty rates will become more likely in combat scenarios for the foreseeable future. The data presented were collected from service sources by the Special Operations Warrior Foundation, a nonprofit organization that provides scholarships and counseling to surviving children of SOF personnel killed in the line of duty.

6. Each flight surgeon and medical technician carries a 70-pound vest and backpack SOF medical kit that provides for short-notice, first-responder support.

7. The air-transportable treatment unit—an AFSOC UTC—includes a trailer, tentage, power, and climate control but weighs 6,000 pounds.

8. The theater special operations commanders are autho-rized an international health specialist on their staffs to conduct medical-planning activities. This new Air Force specialty offers extra utility for SOF.

9. The term casualty evacuation describes a mode of movement that occurs prior to aeromedical evacuation, a convenient—rather than doctrinal—term.

10. Air Force pararescuemen, though not primarily medics, have paramedic skills. They deploy frequently and sometimes find themselves stretched thin. In their absence, commanders have had to decide whether to send medical personnel on rescue-and-recovery missions in proximity to ground combat.

Col James J. Dougherty (BA, Rice University; MD, Baylor College of Medicine; MPH, Johns Hopkins University) is command surgeon, Headquarters Air Force Special Operations Command, Hurlburt Field, Florida. He leads the directorate that drafts and oversees execution of policy related to direct medical support of Air Force special operations and provision of health care for beneficiaries within the command. He has spent most of his career in aerospace medicine, from squadron flight surgeon to tactical hospital commander. A chief flight surgeon with more than 1,000 flying hours, Colonel Dougherty is also a senior parachutist and jump master with 70 static-line deployments and a US Navy closed- and open-circuit diver.

Disclaimer

The conclusions and opinions expressed in this document are those of the author cultivated in the freedom of expression, academic environment of Air University. They do not reflect the official position of the U.S. Government, Department of Defense, the United States Air Force or the Air University.

[ Back Issues | Home Page | Feedback? Email the Editor ]