Every American warfighter now goes into combat with a personal first aid kit and Combat Lifesaver training to provide both personal and buddy medical care immediately. Only moments away is a Combat Medic, trained beyond the capabilities of previous battlefield medics, whose job is to stabilize the patient pending medical evacuation, often in a matter of minutes, to a field surgical care facility and, usually within 24 hours, back to Europe or the United States for top-level hospitalization.

Except special operators.

The current conflict in Southwest Asia has seen increased demands on the joint Special Operations Command (SOCOM) and its service components – U.S. Army Special Operations Command (USASOC), Air Force Special Operations Command (AFSOC), Naval Special Warfare Command (NAVSPECWARCOM), and Marine Corps Forces Special Operations Command (MARSOC). But just as special operators typically function alone with specialized equipment, so have they evolved their own brand of field medical care.

“We are unique, in that we are dropped into remote, austere locations, often surrounded by the enemy. You have to use whatever you can take with you to reduce the morbidity and mortality of your team, host nation personnel, and even enemy combatants,” noted Col. Jeffrey Kingsbury, dean of the Joint Special Operations Medical Training Center (JSOMTC). “If a special ops unit infiltrates an area where they do not want to be detected, they may have to hold a wounded warfighter for days until they can get him out.

“I have seen situations where evacuation simply cannot get to them and our guys are prepared for that. And that is when the tools and skill sets they have combine with their very good reachback capability [typically satellite communications – voice, data, and video – to specialists anywhere in the world], where they become the eyes and ears of someone who helps them deal with situations for which they were not trained. They also encounter conditions among the host nation population, such as skin problems, they have never seen before and local medicine cannot help.”

JSOMTC, located at Fort Bragg, N.C., is the centerpiece of SOCOM medical training, beginning with a 26-week course that produces a Special Operations Combat Medic (SOCM) – the minimum level of training for SOCOM medics.

“This is beyond the basic training and combat medic training that produces the 68W MOS [military occupational specialty] for Army Combat Medics,” according to SOCOM Command Surgeon Col. Virgil T. Deal. “Total training time for the 18D or medic assigned to a 12-man Special Forces Operational Detachment-Alpha – or A Team – may be up to over 40 months when language and other requisite training is completed.

“Even non-medical personnel now receive far more extensive training in the initial management of trauma than has ever been taught. In the late 1990s, Dr. Frank Butler, later SOCOM command surgeon, authored a paper that refocused our approach to casualty care in far-forward areas of the battlefield and led to our current training in Trauma Combat Casualty Care.”

A regular Army combat medic or Navy corpsman (who provides field medic services for the Marine Corps) completes a 16-week course that provides field skills at the EMT-Basic level of a civilian emergency medical technician. With a substantially improved medical kit, they can stabilize and hold a wounded warfighter during the “golden hour” before the patient can be medevaced to a higher level of care.

For SOCOM, the term “medevac” – traditionally associated with the use of specialized medical evacuation helicopters – does not exist. Neither do the specialized helicopters. Instead, special ops wounded await “casevac” (casualty evacuation) by whatever means may be available, whenever it may be available. That may be a resupply helicopter that arrives days after the injury – or even a horse, mule, or camel, if that is the only means of transport available.

“Our course for a Special Ops Combat Medic, our lowest ranking, is 26 weeks. Our special ops Independent Duty Corpsman – or 18D – is an additional 24 weeks of advanced training, including two one-month rotations: one during the basic course in Virginia or Tampa/St. Petersburg [Fla.] civilian hospitals – that includes two weeks on ambulance runs and two weeks at various assignments, from the ER to maternity to surgery – and one during the second, at one of 40 DoD [Department of Defense] locations around the nation, where they primarily will do more advanced work, such as dermatology, pulmonology, etc.,” Kingsbury said.

“For SOCOM, we teach them to the EMT-P [paramedic] level and how to stabilize patients until they can be casevaced. For the combat provider, trauma is 5 to 10 percent of what you do; the rest is taking care of pneumonia or skin infections. Our special operators work very closely with host nation personnel and will, on occasion, break bread with them, so they could pick up a GI infection of some sort.”

Dropped into remote locations, cut off from traditional support systems, perhaps unable to call for help due to the risk of revealing their location, special operators must take everything they need with them – including medical caregivers who can keep a wounded warfighter alive for several days. Due to the small size of special ops units, those medical personnel are considered warfighters first, medics second.

“Each operator is trained to the level of a Combat Lifesaver [a three-day annual course], who can stop hemorrhage, start an IV, do CPR – there is no real civilian equivalent,” Kingsbury said. “The next level is a Special Ops Combat Medic or Advanced Tactical Practitioner [ATP], which is more than an EMT-P in civilian medicine, sort of an EMT-P medic with additional training in trauma medicine [a graduate of the 26-week course]. This medic has the capability to hold a patient up to 72 hours.

“Above that is the 18D or Special Forces Medical Sergeant or Special Ops Duty Corpsman [Navy/Marines]; that I would describe as a wilderness physician. Like a civilian PA [physician’s assistant], they have the breadth, but not the depth – they have trauma capability and a broad spectrum of knowledge, and may be the only medical care a host nation patient sees, especially for uncomplicated cases. They have the capability to indefinitely hold patients who cannot get into our medical system or a host nation medical facility.

“Each special ops team has 12 members, two of whom are 18Ds. In addition, each company has six ODAs [Operational Detachment-Alpha] and each battalion has a doctor and a PA plus a couple of 18Ds. At the group level we have a doctor, a veterinarian, and a dentist. So a Special Forces Group typically has five doctors, four PAs and 160 18Ds; four-man special affairs teams have one ATP.”

What SOCOM does not have is its own hospitals – in the field or elsewhere.

“We don’t have anything above level-one care, so we do everything we can at the site of injury. For the most part on the battlefield, if it is going to kill you, death is immediate; otherwise, people will do fairly well if they get appropriate treatment immediately, which is what our guys are trained to do,” he added. “It takes time for dirt on the battlefield to cause infections, so our guys know what antibiotics to give for each type of injury. We have a pill pack containing anti-inflammatory drugs, Tylenol^®, and an antibiotic, which minimizes the risk of infection and minimizes shock by reducing pain.”

Special ops medicine actually is highly sophisticated, with equipment and capabilities even doctors in a typical late 20th century field hospital might have found remarkable.

“Our guys can do trauma and cardiac-plus on the battlefield. You don’t see regular medics trained in advanced cardiac support – that’s the difference between an EMT-B and an EMT-P,” Kingsbury explained. “The 18D, graduate of our 50-week course, can do his own lab work – bacteriologic studies, all bodily excretions, diagnose malaria by microscope.

“For example, I was working with medics in Afghanistan and they asked about a new FDA-approved test for malaria, which I didn’t know about. They said it was a serologic test, where you could spin down blood serum and test it for malaria. So what we’ve made are thinking medics, who have diagnostic capabilities and even veterinarian skills, because in some areas of the world, animals are as important as other members of the family. They also are trained in surgical tasks, from actual surgery to anesthesia to sterilization. So they can take advanced steps to save a leg or, if already amputated, clean it and greatly increase the likelihood of survival.”

The medical kit this new class of “medic” takes into the field today includes portable X-rays, with a solid-state plate developer, and ultrasounds to look for fluid or air under the diaphragm instead of cutting into the patient, which increases the potential for infection.

“We don’t have CT-scans or MRIs far forward, but the set kits and outfit are fairly robust, including microscopes and the ability to perform transfusions,” he added. “The set kits on two 18Ds is significant, probably an entire pallet by itself, in addition to other special ops requirements, such as ammunition and food. The lab set kit also is larger than it was 10 years ago – two boxes rather than one rucksack – but the R&D [research and development] people are looking at how to shrink that.

“And that does not only have value to special operations, it also can help those responding to natural disasters, such as hurricanes, where local infrastructure is disrupted. So what they do for us will be beneficial to the whole population.”

The SOCOM command surgeon oversees the coordination of special ops medical training, along with a requirements board that maintains a SOF interoperable combat medic critical task list that delineates the minimal knowledge and skills requirements for SOCMs. There also is a medical exam board that documents what is contained in the critical task list and on the tests SOCOM medics must pass.

“This school trains all Army, Marine, and Navy special ops ATPs,” Kingsbury said of the JSOMTC. “The only difference is AFSOC, which creates its ATPs at Kirkland AFB. But everyone takes the SOCM skills sustainment course here, a nine-day block of training every two years that refreshes all their cards – CPR, advanced cardiac life support, how to draw blood, etc. – and reviews all procedures. We put them through triage scenarios and all the different phases of care, using simulations to put them under stress and make sure what they are doing in the combat zone is done the way it should be done. We do that for everybody, including AFSOC.

“The requirements board is made up of all component members – USASOC, AFSOC, MARSOC, Navy surgeons, senior enlisted medics, and experts from throughout the world. We also do surveys at the unit level on what we are doing right and what is lacking, because they do know their mission sets. Special ops teams are in a large number of countries, such as Colombia and others with whom we have developed good relations over the years, working with host nation teams, doing medical capability studies, implementing vaccination programs, etc.”

Host nation efforts by SOCOM medics range from treating civilians and combatants under fire, stabilizing those who can be transported to a host nation – or U.S. – medical facility, often days later, to sometimes providing the only health care remote host nation citizens may see.

“When in a nation with a very rudimentary health care system, we treat a lot of host nation personnel,” Kingsbury said, adding they also try to raise the level of local medical care. “We helped train Afghan military medics, some of whom became very proficient, so we have created a residual, long-term benefit for that nation. Today, Afghanistan essentially has a very advanced medical provider, wilderness physician-trained, who understands immunizations as well as wound treatment. And years after we’re gone, they will still be providing care to their fellow citizens.”

For the most part, SOCOM relies on the four services, DoD, and civilian labs for R&D to improve current skills, medicines, and equipment applicable to their requirements. But they also maintain a small R&D budget to pursue those needs unique to their special circumstances.

“While others still think about the ‘golden hour,’ we are more likely to think in terms of the ‘golden day’ due to the unique remote and hostile environment in which special operators work,” Kingsbury said. “So that is the viewpoint SOCOM medical research tends to take, such as a way to slow metabolism to help them survive until they can reach a higher level of medical care.

“We are a member of the DoD medical community, but have to interface in an unconventional manner. However, with the conventional medical system, once we get there, we’ve found our care fits in nicely. So we are not doing anything outlandish, we just often have to hold patients much longer than the golden hour.”

Which, according to Deal, special ops medical personnel have succeeded in doing despite all of the hazards and restrictions under which they must perform.

“The survival rate for these conflicts [since 9/11] has been superb; that’s due to a number of factors, including body armor,” he said. “However difficult it may be to separate out the contribution of the SOF medic, there’s little doubt that the special operator is well aware that the medic fighting beside him is the best trained and equipped field medic that’s ever deployed. Our operators are going to take on whatever mission [they’re given] with or without great medical coverage, but there’s little doubt it is a morale boost to those in the field and waiting back home.”

SOCOM and JSOMTC also continue to advance the technologies of telemedicine and the ability of medics in the field, even under fire, to reach back for help.

“We’re currently looking at a cell phone-type capability that will provide the equivalent of an easily searched medical library that can also provide consultation,” Deal said. “Having an ‘onboard’ artificial intelligence computer – perhaps in the rucksack frame? – to mentor the medic in real time, perhaps even for combat wounds, without electronic connectivity elsewhere will remain the ultimate goal, but that’s a ways off. For now, our focus is on training the medic so he functions well in an austere environment with as little ‘reach back’ mentoring as possible.”

From the development of hemostatic agents now used to help control bleeding on the battlefield to efforts to diagnose and quantify traumatic brain injury as early as possible to techniques and pharmacologic interventions to help medics treat the severely wounded when evacuation is not possible for hours or days or not at all – those are among the areas in which SOCOM has been involved. And the future – driven by its unique requirements – will push the frontiers even further.

“We’re following with real interest the development of electronic simulations for training,” Deal noted. “Just as surgeons anticipate that one day every surgeon’s first case will be on a simulator, we look forward to the simulator that will recreate the realities of the battlefield, down to the feel of wounded tissue and the uncertainty of close combat for the SOF medic in training long before he ever deploys.”

While advanced technology and intensive training are the hallmarks of all SOCOM efforts, in the end it is the commitment and determination of the multitasking SOCOM warfighter medic that will make the greatest difference to those with whom he fights.

“The 18D is a combatant medic, not a medic. His primary job is a combatant who brings to the table special medical skills, so our guys can focus on the mission at hand, knowing if things go bad there is someone there who can increase their survivability with care far forward on the battlefield,” Kingsbury concluded. “And as part of their skill set, our medics also provide field training to their comrades, so everybody has a robust understanding of what must be done in care under fire, such as applying a tourniquet and then returning fire.

“Special ops personnel are expected to operate in non-linear, operationally immature environments, far forward of any support and typically requiring skills in excess of typical medical providers. They have to use casevac because there is no organized medevac. And they have to conduct good medicine in bad places, lacking any medical infrastructure.”

This article was first published in The Year in Veterans Affairs and Military Medicine: 2009-2010 Edition.