Special Operations Forces, typically working in isolation in far forward positions that require stealth, must be largely self-reliant when it comes to combat medicine.  Their unique requirements have led to the creation of Special Operations Command (SOCOM) joint standards for both medics and individual warfighters that far exceed those of traditional forces, such as the Army 91W Health Care Specialist (medic).

“The 91 Whiskey course provides emergency medical technician training at the basic level,” SOCOM Command Surgeon Capt. Frank Butler, a Navy SEAL, explains. “Our training provides that at the paramedic level, so our guys get cardiac life support, pediatric cardiac emergencies, civilian trauma, and, in addition, get the same TCCC (Tactical Casualty Combat Care) principles the 91s get. So there is significant overlap, but our course is a bit longer – six months – and gives them a bit more depth.

“There are many things about our combat medics regulated at the component level. For example, the 18-Deltas (Army Special Operations Medical Sergeants) have skills that go above and beyond the standard we expect everybody to have. And the SEALs go above and beyond as well, but in a somewhat different direction, working more with diving medicine than Green Beret medicine. So we build the standard and the components build on that to fit their own particular needs.”

Col. Warner “Rocky” Farr, who serves as both Army deputy chief of staff-surgeon and command surgeon-Army Special Forces Command (USASOC), says a lot has changed since he was a medic in Vietnam, not only in the training SOF medics and team members receive, but especially in the equipment they carry into battle

In addition to training, SOCOM has sought to standardize equipment and medicines – all of which must fit into the medic’s pack, with few or no opportunities for resupply in the field.

“In all wars up until the current, the killed in action rate – those who die before getting to a medic – has been about 20 percent,” Farr says. “We have fielded enough new equipment, such as dressings – not just to medics, but to individual soldiers, as well – that those numbers have dropped substantially. A lot of that is due to technology, from tourniquets to dressings.”

USASOC fields two kinds of SOF medic, the 18Ds, who are cross-trained members of the Special Forces (Green Beret) A-Teams, and the Special Operations Combat Medics (SOCMs), who are assigned to the 160th Special Operations Aviation Regiment (Airborne) and Special Operations Support Command (Airborne). About 80 percent of USASOC medics are 18Ds.

“That SOCM has had a 24-week medical course, where the 18Ds get 46 weeks. We front-load trauma medicine into the first part, so the SOCMs have the same trauma training as the 18Ds,” Farr says.  “The 18-Deltas also are trained for unconventional warfare, where they go into a country to train a local indigenous force, which might include dependents or the local population. So the second part of the course they get has veterinarian, pediatric, and so on. The SOCMs go primarily to the Ranger regiment, where trauma training is the priority.

“We also have about 50 physicians. Each unit, down to the battalion level, has a physician and physician’s assistant. There are Special Forces Group surgeons and Ranger regimental surgeons – usually a lieutenant colonel – a battalion surgeon, who is a major, and a captain. Because Special Forces train indigenous forces, they have a lot more medics than they need for themselves. That also is true at the Ranger level.”

A significant change in how SOF doctors move through their careers took place in 1999. Prior to then, doctors coming out of medical

school would complete their internships, then join SOF units as general medical officers. After serving two years with a combat unit, they would enter a hospital residency program in their area of specialization and only rarely return to combat medicine.

The Defense Department Office of Health Affairs decided to reverse that path, requiring physicians to go directly into a residency program from their internships, then to the combat units as board-certified physicians. That transition occurred from 1999-2002, so today every SOF doctor has completed an additional three-to-five years of training and certification than was true prior to 1999. About half of those specialized in emergency medicine and the majority of the rest in family medicine, although a few other specialties also are represented.

During Operation Iraqi Freedom, regular Army and Navy doctors were placed in new forward teams, moving that level of medical care farther forward than had ever been the case for traditional combat units. SOF doctors, however, have always faced assignment much closer to the front lines – if not beyond them – even working alongside frontline SOCMs.

“It is very mission dependent how far forward the doctor goes; it has always been that way,” Farr notes. “Clearly, if a physician with more training can have the medics see patients first and select who comes back to him, that’s a good use of his expertise. But he will go as far forward as needed and wherever he thinks his skills are best used.

“We sometimes are supported by an FST (Forward Surgical Team) because our docs are doing the lifesaving care and want to turn those patients over to a surgeon at an FST or Level 3. But where we operate, it may be a very long way to that FST, so we may have to save the casualty’s life and then have a long way to get to that next level.”

In the military medical chain, Level 1 is the combat medic, Level 2 a casualty collecting point, and Level 3 a combat support hospital. The FSTs essentially are a piece of the CSH transplanted into Level 2, but the FSTs are still farther back than SOF doctors, who function exclusively as Level 1 and 2.

“We have a small Level 2 in our sustainment brigade – not an FST, but a holding hospital piece. We then get an FST to fall in on top of that to provide our surgical care. We use that to support ourselves and any other SOFs assigned to our task force,” Farr explains.

While the structure may differ from one service SOF component to another, under the relatively new SOCOM directives, there is close coordination among all Special Operations medical teams.

“There is complete cross-over in Special Ops,” Farr says.  “All our medics are trained to the same standards.  Within the command in Tampa, we have not only SOCMs and 18-Deltas, but Navy SEAL medics, PJs (Air Force Special Ops ParaJumpers), and 4N AFSOC medics, all trained to the same level. If you are fighting a SOF war and a PJ gets off the helicopter, you want to know he has the same training as an 18-Delta.”

Whatever a SOF medic can fit into his backpack may be the extent of his field supplies for days at a stretch, placing pressure on the services to find the best possible components – small, light, multifunctional, and, aside from mission-specific items, standardized and interoperable.

“For the most part, when we send medics forward, whether Special Ops Forces medical elements or PJs, they have to have the capability to be self-sufficient, with a small footprint, and operate for prolonged periods of time in austere environments without outside support,” notes Lt. Col. Michael Curriston, Air Force Special Operations Command (AFSOC) chief of operational medicine. “We train all AFSOC operators to be first responders, to provide triage capability.”

While the PJs are inserted, usually by helicopter, to provide medical care far forward, they are considered ground operators; every effort is made to limit their involvement in casualty evacuation (CASEVAC) to no more than one hour’s transport before they can return to the combat site.

“If there is a prolonged transport time, that’s when mission planning looks at establishing a transload site within an hour’s distance, where they would go to a Special Ops medical element for handoff. That is generally a flight surgeon, PA [physician’s assistant] and IDMT [independent duty medical technician] for prolonged flight transport as well as advanced monitoring and medical capabilities,” Curriston says.

“We also have a Special Operations Surgical Team (SOST) and Special Operations Critical Care Evacuation Team (SOCCET), which are similar to the conventional mobile field surgical team or critical care air transport team. The primary difference is additional training to work far forward for prolonged periods with a smaller footprint.  SOST is a couple of surgeons, a nurse anesthetist, EMS (Emergency Medical Services) for initial resuscitation after surgery; SOCCET is an emergency medicine physician and nurse as well as a respiratory therapy technician for ventilatory support in-flight.”

Butler says a lot of time and effort has gone into reducing the SOF medical pack and protocols to the fewest instruments and medications providing the greatest versatility of  use. For example, while a hospital can store dozens of different antibiotics to fight infectious diseases, SOCOM has narrowed that to a few broad-spectrum antibiotics that do not require refrigeration.

The SOF combat operations environment also affects those choices as well as training, including how best to deal with both trauma and non-trauma medical emergencies in a tactical setting.

“We expect our combat medics, if confronted in an austere environment with pneumonia or an allergic reaction, to have both the training and equipment to treat those. That is a capability that, at this point in time, is unique to SOF medics,” Butler says.

“Other things unique to SOF medicine include distribution of assets and a number of physiological aspects. If you are deploying to Afghanistan and operating at 9,000 feet, are you safe going straight from your flight to the field to your operating locale? Another is CASEVAC (casualty evacuation) – how do we do that, who flies the aircraft, what are the onboard care teams like – 18-Delta, SOAR medic, PJ, or 4-November – and what can all those different flavors of medic do on the aircraft?”

CASEVAC also is unique to SOF, which is about the only combat element for which immediate medical evacuation (MEDEVAC) – often within 30 minutes of being wounded – is unlikely due to their more remote (and often clandestine) operations. As a result, all SOCMs are trained to hold a patient for up to 72 hours before transport to a higher level of care. Those completing the 12-month training course also are taught to use platforms of convenience for CASEVAC, as well as how to develop a plan to turn civilian casualties over to the care of host nationals if they have to leave before evacuation is available.

The primary training center for all SOF medics is the Joint Special Operations Medical Training Center (JSOMTC), part of the Army JFK Special Warfare Center & School at Fort Bragg, N.C. Col. Kevin N. Keenan serves as both JSOTC dean and commander of the Special Warfare Medical Group (Airborne).

“We teach MEDEVAC in the first six months, CASEVAC in the second – and how to deal with both human and animal patients if no evacuation is possible,” he says. “We also teach how to carry patients on horses and mules – but not on camels or llamas – not only treating and diagnosing those animals but also loading patients on [horseback] (as opposed to camelback). We teach diagnosis and treatment of camels, but only PowerPoints on using them for CASEVAC as platforms of convenience, not choice.”

Keenan says the overall standards of proficiency and practice for SOF medical personnel has always been exceptionally high, but while 20th century medics were highly skilled and well-trained, today’s six-month graduates leave the school with a much improved knowledge base and skills proficiency.

“What we have changed in terms of training and the product – the SOCM – is tremendous improvements in the basic medic, SEAL corpsman, and aviation regiment medic. That six-month course is a tremendous improvement, reflecting improvements in civilian medicine for paramedics and in conventional force medicine, who have much greater trauma skills than those of prior wars,” he adds.

“The 12-month grad is not tremendously better because they were always great. What has changed is some of the equipment, which is lighter, more reliable, and provides more useful information. So the equipment is much more efficient, but the warrior is equally as superb in terms of Green Beret, independent duty SEAL, and independent duty Force Recon Corpsman.”

In some respects, it is not lessons learned from the ongoing war on terrorism and field operations in Southwest Asia that form the core of SOF medic training, but lessons learned from World War II operations by the Office of Strategic Services (forerunner to the CIA) that have evolved with changing technologies and improving medical knowledge.

While the civilian standard for conventional force medics is EMT-Basic, the equivalent for SOF tri-service medics is the more advanced EMT-Paramedic, plus additional trauma and primary care screening skills.

“That is driven by isolation, protracted evacuation time, and dispersal on the battlefield [distance from higher level care]. So we have additional training, especially in trauma,” Keenan says. “That tri-service standard is exceeded by Army Special Forces and some of the Navy SEAL IDCs and in the Marine Corps Force Recon community. Those three come back here for an additional six months of training beyond the six months SOCMs get.

“In that second period, we talk about families, children – more medical practice in an austere environment, because we think these warriors will work with populations – local villagers – who will never be evacuated. World War II also taught us that guerrilla or irregular fighters fought better, harder, and longer if they knew good medical support was available.”

As of March 2005, all SOF combatants – not just medics – are trained in TCCC, something conventional warriors do not get.

“The standard we aspire to is to have each combatant provide life-saving care for his teammate, so if three operators are on a mission and the medic goes down, the other two can care for him,” Butler explains. “That was mandated in response to a growing awareness, based on individual reports coming back from theater, that training medics in TCCC was a good and correct step, but an incomplete solution. There were multiple reports of individuals who had to have life-saving care rendered by a teammate when no medic was available.”

Neither JSOMTC nor the service SOCs provide special training for physicians, nurses, or PAs assigned to SOF units, but they are encouraged to become familiar with field medic operations.

“From a SOCOM standpoint, we have not tried to impose a standardized training package for physicians beyond the Joint Special Operations Medical Officer orientation course, which is taught at the Joint Special Ops University twice a year,” Butler says. “The new training instruction strongly encourages commanders to send their nurses, physicians, and PAs to this course, because most have no background in Special Ops and won’t get that in hospitals or medical school. So it is important to get a look at Special Ops force structure and some of the peculiar characteristics of SOF medicine.”

Among those unique aspects is who provides what level of care in the field. SOF non-commissioned officers are trained to use equipment and techniques only employed by medical professionals in conventional forces.

“They use ultrasound to look for blood in the belly; shoot, develop, and interpret their own X-rays,” Keenan says. “That equipment – similar to what you would find in a field hospital and used by physicians, nurses, or physicians assistants – is packaged in parachute-droppable containers to be deployed in theater for use by SOF NCOs. They also carry broad-spectrum antibiotics, narcotics, and interosseous fluid administration kits, which not all conventional medics carry.

“These are high-school graduates doing physician-level work. That’s the uniqueness, not special equipment. The equipment is standard, the soldier is the special part of the system.”

In addition to caring for local human and animal populations, SOF medics also are trained to repair a wide range of medical equipment – including older systems rarely found in U.S. hospitals or clinics. The end goal is not to use such host nation resources, which often are scarce, but to return them to use by local doctors and nurses. When their own supplies begin to be depleted, SOF medics will call back to their support chain and request parachute drops of “push-packs” – supply pallets they created prior to deployment.

As to the future, Butler says it will be a continuing evolution, combining lessons learned from every combat theater of the past with new techniques and technologies, creating an ever-more capable medical care system for Special Operators in remote, austere environments.

“If you look at what has happened since Vietnam and the original TCCC paper, there has been a recognition of the need to combine good tactics and good medicine. That led to the concept of three phases of care – under fire, tactical field, and CASEVAC,” he says. “Each phase has a gradual reduction of the threat from the enemy and an increase in the capability to do more advanced things for the casualty. You can do more while flying back on a helicopter than on a battlefield under fire, but in the past those differences were not defined in terms of what specifically could be done in each phase.

“The original combat casualty care paper also made a point of saying combat medics might need to return fire instead of render care, at least initially,” Butler continued. “There were those who said medics should be observant of the Geneva Convention and not carry automatic weapons. We researched that with Convention lawyers and found SOF combat medics are not afforded any special protections because they do carry weapons and do not wear a Red Cross. So they are considered combatants who know how to treat injuries.”

The distinction is not a mere technicality. Even as all SOF combatants are now being trained in combat casualty care to a level equivalent to Vietnam medics, so have all SOF medics become full-time warriors.

This article first appeared in The Year in Special Operations: 2006 Edition.