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The world of Special Operations medicine evolves and changes to respond to specific challenges encountered on the battlefield. It feeds off the lessons identified by thousands of providers that deliver medicine in the most dangerous and remote environments. Medical professionals, including doctors and medics from around the world, all contribute to this ongoing evolution. Whether the practitioners are affiliated with official military organizations, international committees, not-for-profit groups, or humanitarian missions, they all have the same goal and purpose – to show up prepared and save lives. When Operation Enduring Freedom and Operation Iraqi Freedom were at their pinnacle, Tactical Combat Casualty Care had been the focus of study for Special Operations medicine. This valuable research led to the significant reduction of preventable deaths on the field, saving countless lives at the tip of the spear in the field, but also through the Chain of Evacuation and beyond.

The end of the Global War On Terror coincided with the beginning of multiple small footprint operations carried out through a larger operational space. Due to the absence of complete service and support structure, combined with the tyranny of distance (Did somebody say Africa?), the concept of the “Golden Hour” became nothing more than a memory of the war in Afghanistan. New challenges and operational problems arose from this scenario, where a “scoop and run” model was not a feasible solution anymore.

Prolonged Field Care is the answer the “community” came up with. I do not think there could be a more appropriate word for it, considering an independent web page has been the main promoter of “patient field care beyond doctrinal timelines.” When it all started, Prolonged Field Care was considered to be “Spec Ops stuff.” Today the Expeditionary Combat Medic program is bringing PFC to conventional medics. A pretty clear sign of where the wind is blowing.

So, if PFC is the future of conventional forces, what is the future of Special Operations medicine?

Well, the answer has been there for more than sixty years.

Unconventional warfareActivities conducted to enable a resistance movement or insurgency to coerce, disrupt, or overthrow a government or occupying power by operating through or with an underground, auxiliary, and guerrilla force in a denied area. Also called UW. (JP 3-05.1)

If you are looking for a complete historical breakdown of UW medicine, Colonel Farr’s “Death of the golden hour and return to the future guerrilla hospital” is where you need to look (it is heavily referenced it in this article). There is no better resource out there if you want to understand that Special Operations medicine was born to support UW.

“Iraqification” was a consequence of specific conditions that are the exception in Special Operations medicine history, not the standard. It might be all that our generation of medics knows, but there is definitely more to it.

The definition of UW is pretty non-specific an umbrella term as it covers everything from logistical support to the top-secret, finite tactical details of the deep-jungle guerrilla fighters. This is only one of the reasons why coming up with a Medical Plan (Med Plan) in support of such operations is a pretty daunting idea.

You have to start from somewhere though, and I believe that we should do it by asking yourself the same questions you would for any other kind of operation. Maybe the answers are going to be different.

The four pillars of any Med Plan are the same, and they are not modified regardless of a UW operation:

Medical Intelligence (the Med Plan is based on this information)Treatment chain (the preplanned continuity of care)Evacuation chain (transportation from the point of injury to definitive care)Supply chain (sustainment of medical operations)

“Hey man, should we bring mosquito nets?”

It does not really matter if you are going on a vacation with your family or on a deployment with your team, each time you step into an unfamiliar territory you want to have an idea of what awaits you. Being a team medic carries its own set of duties and responsibilities, but at the end of the day, your guys, CoC and higher are ultimately depending on you for the success of the mission. No operation can be successfully carried out if half of the people/soldiers are stuck in bed with a high fever, right?

UW presents, by nature, a long-term commitment on the ground than other operations.

Besides, being embedded with the indigenous forces or the local population means that you would consume the same food and water as them. This would be radically different than living

inside a fully resupplied forward operating base and going out only to conduct operations. Because of all of these reasons it is safe to assume you will be more exposed to the environmental threats. Before it’s too late, start thinking about diseases and non-battle related injuries (DNBIs) since, as a SOF medic, those could easily be your weakest point.

The first step should be to assess what kind of endemic and environmental conditions can be found in the area. The research process might be different than what is expected since, if the nature of the UW operation includes a strictly need-to-know basis, conventional information channels might be precluded. Open source research could become the number one feed to this part of the Med Plan. Printing out a Wikipedia page is not enough! However, there are many resources available that you can research. There are expats forums (where and when available) that usually offer a language-friendly source of boots-on-ground information that can help to put the pieces of the puzzle together. Documentaries are also a good place to look and can be pretty reliable scientifically. All the data you gather must always be verified against multiple sources (when possible). If you have access to proper institutional medical intelligence packages, that would be your way to go, but some additional personal digging never hurts. An overview of the country general climate conditions can give you an indication of what diseases might be more threatening in the seasons you will be on the ground.

This initial data must be compared with your team’s immunizations, to promptly take care of additional vaccinations that might be needed.

The same information will influence the kind of drugs and medications you will carry in the area. Consider that there might be limitations to the logistics you are able to carry with you, because of space and OP SEC reasons. Research on what types of medications can be found on the ground might be a necessary step. Usually, underdeveloped countries offer easier access to prescriptions, but it is worth having a look at that beforehand.

Once you have figured out the environmental threats and have started to prepare accordingly, it is time to build the intelligence package that is going to feed the next steps of the planning process. This consists of an assessment of the global healthcare infrastructure in the country of interest. What level of general hygiene and health there is, what is the doctor to inhabitants ratio, which emergency medical services are, i.e., hospitals, and clinics. Will these facilities be available to us? Is the population likely to support our troops in case of need? Some of this information might be difficult to access, especially if the theatre in question is under political and/or technological isolation (Ie. North Korea). It is worth considering that the assessment of a target country health care system might be a UW mission objective on its own. Non-governmental organizations usually have open source reports on critical countries, so that might be a good place to start if you lack an official package of information on global healthcare in the country.

“Where do we go now??”

As you take in the exam the treatment chain within UW operations, you have to understand a fundamental notion immediately. The typical echelon structure (role 1/2/3) of a mature theatre will most likely be unavailable in this kind of austere, unpredictable environment. If feasible, it may not be located within doctrinal timelines or even accessible through conventional means of transport (see evacuation chain). Furthermore, it is important to remember that being embedded with local forces would probably be something to expect. This would mean that you may not only be responsible for providing indigenous troops with medical care, but you may be forced to

depend, or partially depend, on their healthcare structure, as well- assuming they have one, of course.

In fact, medical support to partner forces is not a new concept. International Security Assistance Force and Operation Inherent Resolve demonstrated the importance of such support to boost troops’ morale. This would be exponentially relevant in a UW context, and you can quickly realize how much the medical side of things could influence the outcome of such an operation. Assuming that a full-scale combat support hospital within the range of the Golden Hour is not going to be an option, you should identify minimum mission-specific requirements. The medical intelligence can come in handy at this point to evaluate capabilities and accessibility of the country’s own infrastructure.

Surgical capabilities usually represent the most critical part of the chain, especially when it comes to trauma. Requesting some form of surgical support from our own forces might represent a necessary step, keeping in mind that even the slim and sleek Special Operation Surgical Team might be too “heavy” or virtually impossible for the logistics of the UW operation. Such a resource would represent a force multiplier when considering the impact on indigenous forces. Plenty of examples in history, mainly through WWII.

Did someone mention prolonged field care?

One of the first rules of PFC states that it should never be a pre-planned option but rather a contingency. At the same time, a scenario like the one we are war-gaming here might easily rule out any possibility other than PFC. It has been the reality these days in places where own forces held air superiority, would it be such a surprise in a situation where airspace is not under control?

Smooth integration between the surgical capability and PFC could be a solution to this potential problem. If we identify the surgeon and the anesthesiologist as the essential elements of a SOST, bridging the OR nurse and the OR tech with experienced 18Ds or SOCMs will not be a long shot. Figures such as surgical PAs with SOF experience (former medics who upgraded their qualifications maybe?) could indeed be crucial for this beyond-the-wire employment.

DNBIs are likely to represent the toughest challenge to handle as they sit in the “grey” zone: dangerous enough to be a concern but not enough to justify the security breach of a whole operation. Indigenous forces might be deferred to the host country health care system for anything that is not combat-related and does not raise flags. Our own members may not even qualify for this local treatment, especially if they are not even supposed to be in the country in the first place. No matter what kind of support you can arrange on the field, definitive care is always the end-state. Considering friendly adjacent countries could be a solution for that, to shorten transport times and streamline the whole system.

“…country roads, take me home…”

Once the continuum of care is determined, it is time to understand how to deliver a patient from the point of injury to definitive care. Aeromedical evacuation has been the primary platform for the past 15 years of operations combining speed, access to any terrain and the possibility to deliver high-quality medical care on board. Unfortunately, it is highly dependable on air supremacy- something that does not necessarily exists in UW operations.

The deeper into non-permissive territory with an absence of air supremacy by our forces, the more likely you will have to rely on improvised means of transport. At least from the point of

injury to a “cold” or less hostile part of the area of operations. Casualty Evacuations (CASEVACs) carried out through commercial vehicles such as vans (maybe set up to provide medical care en route) or donkey rides through high mountain roads.

The sooner you step away from the idea that DustOff is going to pick your patient up in twenty minutes, the more quickly a whole world of possibility will unfold before you. Improvise, adapt, overcome, isn’t that the entire idea behind SOF?

When, and if, an air asset does become available, it does not necessarily have to be a rotary wing. Short Take Off and Landing aircraft (STOLs) disguised as tourism shuttles might offer a better solution in term of safety and autonomy, maybe from the target country to a safe hospital in a friendly nation.

All of these options will be highly dependable on the indigenous forces’ infrastructures and underground nets, as it is improbable that a small team will be able to pull off a long distance ground movement through a semi/ non-permissive environment.

“Doc, we ran out of…”

In instances of longer-term operations, resupply options must be considered, especially when medical support is delivered to a large number of forces. As briefly mentioned, the biggest issue that a group may face is the traceability of the supplies themselves. If your presence in the country is not exactly overt, going around distributing North American Rescue first aid kits might not be the smartest move.

So, instead, we go back to medical intelligence, trying to figure out what we can find on the ground, how to access it and what we necessarily need to “import” from the outside. In all cases, unconventional solutions need to be explored. Newer tools such as 3D printers can be used to create critical surgical equipment on the ground, spending the time to teach local people how to manufacture tourniquets, or maybe just buying local medical equipment could all be viable options depending on the scenario.

Other solutions could involve smuggling equipment through land borders or set up clandestine airstrips or resupply drop zones.

“Ehm… this is it??”

I really hope that right now you are staring at the screen with a huge question mark over your head. The purpose of any planning process is to raise questions in the first place, then to answer them. As was mentioned at the very beginning, Unconventional Warfare embraces a broad spectrum of operations which would probably create questions that have not been answered before.

The exact nature of Special Operations as they were intended. Hopefully, should you ever find yourself in these circumstances, this might be your starting point.

Adaptive and agile; Anytime, anywhere- Just like our company’s motto. If your Medical Plan reflects those features, you will be set up for success!



-Unconventional Warfare in the Gray Zone Joseph L. Votel, Charles T. Cleveland Charles T. Connett, and Will Irwin, National Defense University Press, 1 January 2016

-Unconventional Warfare, Unconventional Medicine: The Role of Tactical Emergency Medical Support in CBRNE /HAZMAT Events

-The Death of the Golden Hour and the Return of the Future Guerrilla Hospital by COL (R) Warner D. Farr

-Department of Defense Dictionary of Military and Associated Terms United States Department of Defense



Mike T. Husband, trauma junkie, adrenaline freak. A NATO Special Operations Combat Medic serving with an high-readiness European airborne unit. Devoted to the delivery of the best patient care in those places where only a few can venture, on a perennial journey towards self improvement. He graduated the Australian Diploma of Paramedical Science (PLAR) and is now a student at the prestigious University College of Cork.

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