Prolonged Field Care: Medical Support to Resistance

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.

BACKGROUND

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)

Click here to download a PDF version of the article.

Forward Observer: What’s Next for the Urban Insurgencies

Intelligence analyst Sam Culper at Forward Observer writes about the continuing urban insurgency in What’s Next for the Urban Insurgencies.

For the past couple months, I’ve been hitting some old counterinsurgency standby’s. The last time I read most of the these manuals and books was prior to deployments to Iraq and Afghanistan.

Somehow insurgency followed us back.

Given that the reelection of President Trump is likely to blow wide open these urban insurgencies, it’s long past time for us to begin or continue learning about the cat and mouse of the insurgent and counterinsurgent. In this case, anarchist insurrectionists are trying to foment a broader insurgency against local, state, and federal government.

In his book Counterinsurgency Warfare, author David Galula outlines six strengths and weaknesses that determine the potential for a successful counterinsurgency campaign. I’ll list them below with some brief notes on the current situation.

1. Galula writes that an absence of problems in a country makes insurgency virtually impossible. Since there is no absence of problems — we have both real and artificial problems in this country — an insurgency was virtually inevitable as soon as local, state, and federal governments were weakened, as they are now.

2. Next, a national consensus against insurgents is a strength that this country currently lacks. There’s no national consensus on anything, and there’s substantial support for the insurgents, which strengthens the urban insurgencies.

3. Resoluteness of counterinsurgent leadership is the next strength or weakness. The Trump administration currently has the resolve to wage counterinsurgency, but there’s been opposition from state and local governments. The insurgents’ political and social efforts will focus on degrading the administration’s capacity to execute a counterinsurgency campaign, increasingly so after President Trump’s potential reelection. (The activism against ICE in previous years is a good example.) The Trump administration will face significant problems in instituting a whole-of-government approach, likely leading the administration to take more deliberate or extreme actions, which will increase accusations of fascism.

4. A major factor in any outcome is the counterinsurgents’ knowledge of counterinsurgency warfare. The Trump administration will rely on those with experience in Iraq, Afghanistan, and other places where a shaky counterinsurgency strategy was unevenly applied. Regardless of strategy, defeating urban insurgencies could become a multi-year process in places like Portland and Seattle, as America experiences its own version of the “Irish Troubles” — albeit not an exact comparison.

5. The machine for control of the population includes four factors which a second Trump administration could lack: the political structure (x), the administrative bureaucracy (x), the police (), the armed forces (x/✓). If reelected, President Trump will either face a split Congress or a Democratic majority in both the House and Senate, and lack control of the political structure. The Trump administration doesn’t have control of the administrative bureaucracy now and is likely to lack control in a second term. The Trump administration will likely retain control over most federal law enforcement, and is likely to have influence over some local and state law enforcement — that’s certainly less the case in areas where there’s local political support for the insurgencies. Army Secretary Mark Esper and GEN Mark Milley, Chairman of the Joint Chiefs of Staff, last month demurred at the deployment of regular Army troops to confront rioters. Esper and Milley can be replaced with military officials who are more amenable to using the military to put down insurrections, but Democrat-majority Congress would cast doubt on how effective the use of armed forces would be.

6. The sixth and final factor is geographic conditions. These insurrections will primarily occur in urban areas, regardless if they trigger a national insurgency. The most important thing we learned about fighting against urban insurgents in Iraq and Afghanistan is that the counterinsurgency effort can be incredibly disruptive to the city.

Both sides are vying for support of the populace, so the insurgent must develop and propagandize a cause that will garner popular support — this is where the overall effort is won or lost.

These are some initial thoughts on what we could be looking at for at least the next four years, based on Galula’s factors presented in Counterinsurgency Warfare. These are not predictions, of course, but I do hope these initial thoughts are helpful in understanding the future…

American Partisan: The Auxiliary

If you’ve followed the writings of Mountain Guerrilla’s John Mosby (or other reading in insurgency or counterinsurgency), then you will already be familiar with the concept of the auxiliary. In this article at American Partisan, Johny Mac also writes about the auxiliary. Auxiliary typically refers to the portion of a population which provides clandestine support to an insurgent or guerrilla force or to underground resistance. With certain politicians talking about sending national guard troops to forcibly search and take people’s property (and, of course, destroy those who “do not comply”), these topics are getting active discussion in these “United” States.

John Mosby has written about both the underground and the guerrilla in his two volume Reluctant Partisan series. He also talks about the auxiliary in those books, but it does not have its own volume as of yet.

With the continuing events happening within the Washington DC Inner Loop and in states around the country, my worst fears of civil strife are sadly coming to fruition.  Yesterday, I sat there sipping my morning cup of coffee watching Senate Leader McConnell’s response to the two articles of Impeachment passed Wednesday night in the US House and realize frosty times are ahead. After all, sometimes drastic measures are needed to save the patient being wheeled into the trauma center.

The Rubicon has been crossed for me. I am done writing letters to my legislatures, the men and women I voted into office to uphold the US Constitution and represent my voice. All my focus now will be directed towards the training I will need for the up and coming conflict (s).

Many of the readers here are in a similar situation as I am. Looking ahead, I will be 64-years old in 2020 and what can someone my age or older do when civil conflict comes knocking at my door you may ask? You like I, need to focus on becoming part of The Auxiliary.

The first time I read about The Auxiliary was over at SurvilvalBlogwritten by Hugh James Latimer. The article really got me thinking as to what part I would play in my community during a civil conflict. It will not necessarily be running a gun, although I can do that. Heck, I can give many millennial’s a run for his or her money in that respect. No, running a gun will not become my role in the up and coming conflict. My role will be one of The Auxiliary. Let’s look at what that means for me – Maybe you too.

First, it means an honest assessment of my strengths but more important, my weaknesses. Once I determine my strengths, I need to get out there and train the folks who understand  their weaknesses and are seeking their own training.

Second, I need to get out there and address my weaknesses by seeking out additional training from others willing to give it. Whatever the cost will be in money or time, it will be worth it. Are you willing to do this or is your normalcy bias going to guide your future?

I will continue my training with NC Scout and his platoon of trainers along with other trainers that offer classes not just in running a gun but in; Preparedness, medical, radio, Intelligence, physical training, et cetera. Then I will offer my acquired skills to help the folks who will come late to the party…

Read the entire article at American Partisan by clicking here.

Related:

Mountain Guerrilla: Development of the Auxiliary

Mountain Guerrilla: Auxiliary and Support Functions, Part One

Mountain Guerrilla: Organization and Development of the Auxiliary

Mountain Guerrilla: Building Auxiliary Cells

Mountain Guerrilla: Formation and Organization of Resistance Movements

US Army: Tactics in Counterinsurgency (pdf 6MB)

US Army Special Operations Command: Undergrounds in Insurgent, Revolutionary, and Resistance Warfare (pdf 1MB)

FO: What Most People Get Wrong About Our ‘Civil War’

Sam Culper at Forward Observer has another piece in this series covering our ongoing domestic conflict, What most people get wrong about our ‘Civil War.’ It’s got some length to it, but it’s a good read with valuable information for you to understand.

…While a civil war, by definition, has not yet started, I do argue that a domestic conflict has already started (my specific thoughts are here, here, and here).

There are plenty of naysayers, and I understand their logic. They advise listeners or readers, “Go to your local Walmart or grocery store. Your local doctor’s office. Your local bank. Walk out your front door and talk to your neighbor.” They ask if Americans are at war with each other in these places, and use these anecdotes to explain that America isn’t locked into a civil war and won’t be.

They’re right in that regard. America isn’t at war.

But the problem with their argument is that it’s not all of America fighting the culture war, nor is it all of America fighting in the ongoing domestic conflict. It’s an ‘irate, tireless minority’. (The brunt of the ‘fighting’ in this conflict isn’t being waged by the average American, as two of my favorite thinkers people in the world — Victor Davis Hanson and Niall Ferguson — have alluded to. You can read my review of Ferguson’s latest book here.)

Another reason why most Americans — the overwhelming majority — aren’t engaged in our domestic conflict is because we’re still really early. Those engaged in establishing the battle lines of today’s culture war were ‘innovators’ in the 1990s. Those engaged in the culture war through the 2008 and 2016 elections were ‘early adopters’. But once the ‘early majority’ joins as soon as 2019-2021, the evidence of an active domestic conflict could be overwhelming. That’s a very distinct possibility.

My estimate is that we have maybe a few percent of the population pushing left or right extremes at the center of the culture war, but there’s an even smaller percentage (a fraction) that actually engages in political violence. There’s probably another 10 percent on either side actively engaged in political, information, and economic warfare. The remaining 75 percent is on the bubble, indifferent, or just plain stuck in the middle — a lot like other intra-state conflicts we’ve experienced.

So can we really have a domestic conflict with just a few thousand combatants?

Well, yeah. But we’re probably still very early.

To understand why we’re still in the beginning phases of our domestic conflict, we can look at three concepts…

Click here to read the entire article at Forward Observer.

Related:

The Organic Prepper: Are You Prepared for Lockdown? How to Stay Safe When All Hell Breaks Loose in America

…Add in the fiercely-fought midterm elections and the threat of civil unrest is high…

Strategic Culture Foundation: American Politics Is Now Just Civil War by Other Means

…Trump didn’t cause today’s polarization, he only exacerbates it because he punches back…

Monster Hunter Nation: The 2nd Amendment is Obsolete, Says Congressman Who Wants To Nuke Omaha

…We are so divided it’s like we are speaking two different languages. Hell, on this topic we are on two different planets. And it is usually framed with a sanctimonious left versus right, enlightened being versus racist hillbilly, unfailing arrow of history versus the knuckle dragging past sort of vibe…