Prolonged Field Care published an article originally from the 2019 Special Warfare magazine on Survivability: Medical Support to Resistance which discusses “a whole-of society approach to preparing military and civilian medical resources that will build readiness and resiliency… improve casualty mortality rates and enable both resistance members and allied forces to sustain the fight.”
Hope is a primary driver of resistance movements, and the best way to keep hope alive in a resistance movement is to keep people alive. There are many aspects to enhancing survivability of a resistance movement, and medical support is one critical part. Doctrinal military health service support constructs, such as combat support hospitals or forward surgical teams, will be wholly inadequate to support resistance movements in a peer conflict in Europe for the primary reasons that they are overmanned and under trained. This article will discuss a whole-of society approach to preparing military and civilian medical resources that will build readiness and resiliency of our allies or partners, improve casualty mortality rates and enable both resistance members and allied forces to sustain the fight to regain territorial sovereignty against an illegal occupation. Medical infrastructure is vastly different in peacetime Europe than in more austere areas frequented by U.S. Special Operations Forces. Medical evacuations begin with calling 112, the European 911 equivalent, ambulances arrive to provide pre-hospital care, sometimes with physicians onboard, the patient is transported to a trauma center, and medical care is generally comparable to U.S. standards. If peer conflict occurs again in Europe, medical infrastructure will be severely degraded and significant obstacles to medical support will immediately arise, especially regarding extremely prolonged evacuation times and scarce resource availability. The U.S. military has not faced as severe a challenge to provide medical support since World War II. The SOF medical community has been bracing for the regression of medical support in emerging conflicts since at least November 2017 when U.S Army COL (Ret.) Dr. Warner “Rocky” Farr published The Death of the Golden Hour and the Return of the Future Guerrilla Hospital; yet the existential threat facing Eastern Europe poses the worst case scenario for medical support to resistance. The restricted mobility for friendly forces in territory occupied by a peer adversary will severely limit external medical support to U.S. SOF and our allied partners, including the resistance. The isolation of U.S. and allied forces in a denied environment will by necessity convert the delivery of medical care from a linear progression of medical evacuations from point of injury to higher echelons of care outside the combat zone, to a cyclical progression of evacuation, treatment, convalescence and return to duty, all completely within occupied territory.
A resistance scenario in Europe presents a unique risk to U.S. SOF supporting resistance movements, as organic capabilities will not be able to provide required medical support in this tactical environment. Recent exercises have demonstrated that U.S. SOF surgical teams will be severely restrained and may not be survivable in a denied environment, and conventional medical forces will likewise be absent. U.S. SOF medics are highly capable within their scope of practice, but over-inflation of their ability results in commanders miscalculating risk; a medic’s ability to reduce serious risk is often predicated on access to definitive care. The Maquis in occupied France and Partisans of Yugoslavia faced similar challenges in World War II but were still able to provide medical support despite great odds. The relevance of these historical precedents might be limited, however, by exponential advances in technology over the last 75 years. Providing medical support to U.S. SOF and resistance forces will be immensely challenging, but there is one great advantage over historical precedence: there is time and space now to enable ourselves and our allies and partners to be prepared to provide medical support to resistance prior to conflict, instead of reacting after a violation of a country’s national sovereignty.
In early 2018, SOCEUR conducted a multinational SOF exercise focused on irregular warfare and resistance in the Baltic region of Eastern Europe. Key medical lessons learned from the exercise were that medical evacuation in restricted areas during peer conflict is incredibly challenging, and U.S. SOF surgical teams as currently configured and trained will have low, if any, chance of survival in occupied territory. It was evident that planning medical support solely using only a U.S. military doctrinal construct was impractical and ineffective; civilian medical resources were identified as, and will necessarily be, the center of gravity for medical support to resistance. Resistance doctrine was turned to as a possible solution to the way ahead, but existing doctrine was found to be largely inadequate for the range of potential operational environments in future conflicts against a peer adversary in Eastern Europe. The focus of U.S. resistance doctrine on unconventional warfare and resistance movements assumes that conflicts have already begun or are ongoing. Furthermore, reverse engineering resistance constructs prior to conflict is difficult because it is impossible to forecast who and what will survive the initial invasion. The whole-of-society approach advocated by the Resistance Operating Concept was embraced as a potential solution for addressing critical gaps in providing medical support to resistance.
WHOLE-OF-SOCIETY APPROACH TO MEDICAL SUPPORT FOR RESISTANCE
The SOCEUR Surgeon’s Office has developed a whole-of-society approach to enable medical support to resistance (Figure 01) as a tiered approach to improve trauma care from point of injury through surgical intervention, convalescence and return to duty. Additionally, it aims to increase medical interoperability with Allies and partners in preparation for a resistance scenario in Eastern Europe.
U.S. SOF MEDICINE
The core of this approach begins with increased readiness for U.S. SOF. If peer conflict in Eastern Europe occurs, U.S. SOF medics will be required to treat casualties on extended timelines with limited supplies. Proficiency in Prolonged Field Care improves the SOF medic’s ability to do this, but is dependent on the medic’s ability to transfer casualties to higher echelons of care for definitive treatment or required convalescence. SOF surgical teams may be part of the solution, but will require manning changes and additional training in order to improve survivability in peer-adversary occupied territory.
Previously, the SOCEUR Surgeon’s office developed and conducted a course in UW medicine for surgical teams. This training was conducted as a proof of concept in Fall 2017, and was subsequently turned over to U.S. Army Special Operations Command with a request to further develop UW training for SOF surgical teams. Currently, the SOCEUR Surgeon’s office is continuing to develop Trojan Footprint as an opportunity for U.S. SOF medical units to practice UW medical tactics and techniques in a major exercise. The command is developing training opportunities for U.S. SOF medics and surgical teams to work in partner-nation trauma centers in Eastern Europe. This aims to achieve multiple objectives including enhanced interoperability of U.S. medical personnel and potential partners, information sharing regarding medical materiel and techniques and potentially to raise standards of trauma care as best practices are shared between allies and partners. The strong relationships that would be created by this course of action would be mutually beneficial. These types of training opportunities may be expanded beyond U.S. SOF to other U.S. military medical personnel, further increasing interoperability and alliance building. SOCEUR is also assisting USSOCOM to define the Special Operations Forces Baseline Interoperability Standards for medics and surgical teams. These efforts attempt to link SOF medical requirements to National Defense Strategy priorities in order to develop the force for the future, and not simply to fight the last battle. Finally, current U.S. SOF doctrine on medical support to resistance appears to have gaps in Eastern Europe’s potential operational environment, especially with regard to preparing Allies and partners to conduct resistance prior to conflict. Working with USASOC’s medical teams will help develop future iterations of doctrine in order to prepare U.S. SOF for best success in an extremely challenging environment… (continues)