The Changing Face of Battlefield Medicine

At the end of the runway, an idle firetruck sat near a massive petrol-fed inferno. Flashes of light and rainbowing tracers played among the hangers, followed half-a-second later by thumps and clatters. Overhead, attack helicopters launched rockets that landed far too close.

"The bad guys are on the wrong side of the fence," Matt Komatsu thought. "Inside the fence."

Komatsu and Dan Warren looked at each other and then at the rest of their team, tightened the lashes on their body armor and rifles, and then one-by-one took off running for a line of armored vehicles closer to the fight. Burning aviation gas lit their way.

It was September 14, 2012. Taliban had successfully breached the wire at Camp Bastion in southern Afghanistan. But Komatsu and his team weren't primarily in search of insurgents. There were looking for wounded. Lieutenant Colonel Komatsu is an Air Force combat rescue officer. Technical Sergeant Warren is a PJ, a pararescue airman. Their job is trauma medicine on the battlefield. Shooting guns is just part of the commute to work.

"And to think," Komatsu would reflect when it was all over, "only a few years before, this wouldn't have been our fight. We wouldn't have even been forward deployed to that base at all."

Even as technology like drones and Stuxnet viruses have made war more remote and data-driven, there's a bigger expectation than ever for battlefield medical response. Specialists like Warren and Komatsu are moving ever closer to the fight, bearing a hospital emergency room's latest devices and know-how.

The only special operations units dedicated to rescue missions are Air Force PJs, known by their callsign Pedro. Officially, their primary job is personnel recovery. They carry equipment to flip overturned trucks, cut through armor plating, and patch up the victim formerly trapped inside. Warren described pararescue work as "the most self-actualizing rewarding job in the world. I don't want to toe the company line, but it is. You get to use every skill in the inventory—dive, jump, shoot, trauma medicine—to save somebody's life."

Former Air Force Chief of Staff General Norman Schwartz has referred to PJs as "the angels of the battlefield."

Earlier this year, PJs retrieved two Saudi pilots who crashed at sea while bombing Yemeni positions. And in February, PJs were staged in northern Iraq, to rescue ground and air units fighting ISIS in Syria. But the availability of such a quick pick-up has not always been so assured or ubiquitous, and it took years of soldiers bleeding out, waiting for helicopter evacuation, to breed the military's rescue culture.

***

It is perhaps counterintuitive that even as the industrial and information revolutions have made war more deadly, even as machine guns and tanks and drones have made killing more efficient, the chance of any individual soldier surviving their wounds has increased dramatically.

In World War II, when the infantry wore helmets and little else and men landed on beaches in swarms, the ratio of American wounded to killed was only 2.1. The ratio increased to 2.7 in Korea, as helicopters became available to medically evacuate, or medevac the injured to Mobile Army Surgical Hospital, or MASH units. In Vietnam the ratio improved again, to 3.3, and in Iraq, where soldiers wore body armor and drove V-hulled armored vehicles and rarely strayed far from the world-class trauma hospitals at their main bases, the ratio was an astounding 9.1. Only one soldier in ten died of their wounds.

But Afghanistan, vast and mountainous and downright medieval, reversed the trend. From 2001 until 2008, the ratio of wounded to killed was only 4.1. Soldiers who arrived alive at the main hospital at Kandahar had a survival rate well above 90 percent, but few soldiers could get there; in 2005, there were only 12 dedicated Army medevac helicopters in the entire country, and PJs were largely on the sidelines.

The Air Force pararescue program began as the Air Rescue Service in the late 1940s, and focused almost exclusively on retrieving downed pilots. In Korea and Vietnam they added a ground combat function, to recover pilots shot down behind enemy lines. The training "pipeline," as it is known, consists of airborne, free fall, dive, mountaineering, survival, and battlefield medicine schools.

Less than 3,500 men (though that may be changing) have ever completed the pipeline, and there are only about 500 total PJs operating today.

Even well after 9/11, their focus remained on saving aircrews and the special operations forces within which they were embedded.

"There we were," Warren said, "three Millennium Falcons [CV-22 Ospreys] flying over south Sudan in broad daylight, and they open up on us. 7.62, 12.7, 23mm, RPGs. And they come through the floor, and guys' water bottles are splitting in half. Four guys in the other bird get hit, and not a one of us. None of the PJs. That's a scenario where I can thrive, and four minutes later, we're drawing blood out of the SOF team leader and putting it directly into a team member. And they all lived."

Good for the special operations teams they worked with, but average soldiers were left without. Being stuck on the sidelines left many PJs frustrated. "I wanted to be a part of the war," Warren said. "Is it an entire childhood spent reading comic books? Maybe. I've been drawing pictures of Superman since I could hold a pencil."

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Komatsu had a longer, though similar view. "When you're in a job like this, the pinnacle is the combat scenario," he said. "You keep wanting to go back for another taste of it. In the 80s and 90s, guys went twenty years without an opportunity to do it for real."

There were plenty of opportunities, but mostly to rescue standard patrols. In Iraq and Afghanistan, fighting a war that looked nothing like what prompted the creation of the old Air Rescue Service, there were few downed pilots.

The pivot occurred in late 2008, when Defense Secretary Robert Gates, at the urging of families of fallen soldiers, made a major policy change. He instituted a new goal to transport all battlefield wounded within the "Golden Hour," a civilian emergency medical concept that notes survival rates increase dramatically when patients enter trauma surgery in less than 60 minutes.

The military was achieving a Golden Hour standard in Iraq, but casualty transit times were twice that in Afghanistan. Gates deployed significantly more medevac resources, additional Army helicopters but also Navy units and Air Force PJs.

No longer dedicated only to pilots and special ops, PJs began running standard medevac missions, and the change to battlefield survival rates was enormous. Between 2009 and 2012, the wounded to killed ratio improved dramatically to 9.7, better than the overall Iraq rate, and double the previous Afghan rate. And while many additional factors undoubtedly contributed to this rise—more hospital resources, more armored vehicles—this increase in survivability remarkably occurred against the backdrop of a significantly bloodier war. During the same time period, the Surge in Afghanistan, the number of wounded increased 700 percent.

PJs brought an array of technology onboard the aircraft, some not fielded with standard medevac teams: Jaws-of-life to open jammed vehicle doors. The latest Zoll monitors that track heart rhythms and automatically send defibrillating shocks. Video laryngoscopes to make precise intubations and open a patient's airway.

But for Komatsu, the technology came secondary.

"Bandages are bandages," he said. "Tourniquets are the same torture devices from the Spanish Inquisition. It's the human systems that are the most important part."

The PJs proved their worth when medevac calls grew into something more. On November 14, 2010, Komatsu was stuck flying a desk at the headquarters planning staff in Afghanistan, distributing PJ teams around the country like puzzle pieces on a jigsaw board, making sure Gates' Gold Hour was always followed. That night, Komatsu heard one of his teams, fellow comrades from his unit in Alaska, had fallen into a meat grinder in the Hindu Kush. A unit requested a simple helicopter medevac for two wounded soldiers. Upon arrival, the PJs found a platoon nearly overrun, stuck in the bottom of a valley and surrounded by hundreds of Taliban.

By the time the six-hour mission was over, dozens of airstrikes had been called in, and Master Sergeant Roger Sparks, the PJ team leader on the ground, had medically treated nine soldiers and earned a Silver Star.

The deployment of armed combat-effective medics worked so well that in 2012 several families would file a formal complaint to Congress, to get the Army to change its own policy. Army medevac helicopters bear noncombatant red crosses, and require an armed escort. The families charged this slowed the rescue process, as medevac missions sometimes had to wait for gunships to become available.

Air Force PJ helicopters, by contrast, fly armed with .50 caliber machine guns, carry no red crosses, and require no escort.

The Gates "Golden Hour" has set a new expectation. As long as there are soldiers on the ground to get hurt, they and their families will be looking for the timely specialized medical extraction. Drones don't do rescues, for now.

***

Fourteen years of war and counting, and the whole time we've maybe been playing the wrong video games.

Twenty times more Americans have purchased Call of Duty than served in the Afghan War, but despite its popularity, the dominant first-person shooter genre misses the point for plenty of veteran soldiers. And yet there's only one first-person rescuer game, the out-of-print "Combat Medic Special Ops" for the PC. It gets only 2.5 stars on seven reviews at Amazon, and the screen shots suck too.

They might not have a video game, and until late in the Afghan War, they only did a few limited and specialized missions. But when PJs finally joined the main effort, they made a huge impact, and still affect the way we are fighting ISIS today. A big part of that has to do with what makes these high-tempo rescuer-types tick, medevac or not.

Ross Ritchell, former Ranger in the famed 75th Ranger Regiment and author of the war novel The Knife, served in Iraq during the Surge, kicked doors on nightly raids and snatch-and-grab missions.

"There is no cap for the testosterone in that environment," he said. And yet explained that staring over the barrel of a rifle isn't the important part. "People think we're addicted to killing, but we're not. We're addicted to not dying."

Senior Master Sergeant Paul Horton has also done rescues, of the explosive kind, and has been rescued via medevac twice himself.

Horton is an Explosive Ordnance Disposal (EOD) technician, a leader in the military's bomb squad, and over a nearly 21-year career he deployed seven times, including two tours to Iraq and two to Afghanistan. He found satisfaction in competence—"I was extremely good at horrific combat situations"—but he also said doing a rescue is different than normal missions.

In 2010, he responded to a scene where two armored vehicles had become trapped in a minefield of improvised explosive devices. The wounded were stuck inside the trucks, and "you could tell they had written themselves off, they thought no one could get to them," Horton said. "But you clear a path in, and you see the looks on people's faces, like 'where did you come from,' and the fact that somebody came for them means so much."

He paid a price for pursuing this sense of meaning. Horton has two Purple Hearts, and was blown up a total of six times.

Saving a life—the rescue—that's what sticks with those who do tour and after tour in Iraq, Afghanistan, Syria, Africa, beyond. On two occasions, Horton was the one rescued by medevac.

"It's intoxicating, but it's also enriching," Komatsu said of doing such missions. "We're in the business of saving lives, so there's an altruism to it. If other guys are volunteering to go risk their lives, I want to have their backs."

***

During the attack at Camp Bastion, Komatsu and Warren needed no helicopter insert. They were one of the puzzle pieces, already deployed forward to southern Afghanistan to daily pick up Marines wounded on patrol in Helmand Province.

But that night, they treated casualties on their own base, fighting their way past burning aircraft toward the breach in the wire.

"PJs are like climbers," Komatsu would tell me later. "There are old climbers and bold climbers, but no old and bold climbers." And yet here he was, running into the gun fire.

Warren found and treated five casualties, severely wounded by an RPG. Komatsu joined a team of Brits and assaulted a bunker designed for Americans to ride out mortar attacks. On the way, he patched the wounds of two Marines he found running around in boxer shorts and carrying M-16s. By the end of the night, Komatsu would coordinate helicopter strafing runs on insurgents huddled near Harrier jets on the runway, Warren would shoot another insurgent hiding among the aircraft shelters, and both would escort the remains of the Marine commander killed in the fight.

This is how we medevac in modern war.

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