0:01

It's hard to practice battlefield

0:03

medicine without, you know, a

0:05

battlefield. And when the U.S. launched its

0:08

invasion of Afghanistan and Iraq in the early 2000s, it

0:10

had been a decade since

0:12

a full-scale deployment of American troops. That's

0:14

why when the wars started, a

0:17

lot of the medical corps' experience came from big

0:19

city emergency rooms. This is the closest thing to

0:21

being in combat that you can get without actually

0:23

being in combat. That's an Army

0:26

surgeon named Tom Noof at Miami's Jackson Memorial

0:28

Hospital speaking to NPR in 2003.

0:30

But a few years into the wars,

0:33

the military was facing hundreds of casualties

0:35

each month between Afghanistan and Iraq. Military

0:38

surgeons were seeing wounds requiring double amputations,

0:40

the kind of thing you might never

0:42

encounter before serving in a war zone.

0:44

I could probably count on one

0:46

hand how many double amputations I'd had to take care

0:48

of or do. And now how many?

0:51

I don't even know. It's a lot. It's

0:54

pretty regular. That was Lieutenant Colonel

0:56

Rachel Haidt talking to NPR's Quill Lawrence at

0:58

the Joint Theater Hospital on Bagram Air Field

1:01

in 2010. By that time,

1:03

the military had turned all this real-world

1:05

experience with traumatic injuries into breakthroughs in

1:07

care. Some of them were

1:09

simple tweaks, like pop-up surgical teams that set

1:12

up close to the battlefield designed to get

1:14

care to wounded troops faster. Here's Colonel Chris

1:16

Benjamin, the commander at the hospital back then.

1:19

The soldier out in the field that

1:21

encounters an explosion or a gunshot wound,

1:23

the most important part of his entire

1:25

chain of survival from the explosion until

1:27

we can get him to Walter Reed,

1:30

is what his his battle buddy does. The

1:32

guy in the next vehicle or the guy

1:34

who was 50 meters away. Over

1:36

the course of the wars, small innovations

1:38

like this tripled the survival rate for

1:40

the most critically injured troops, according to

1:42

one study. Now

1:45

that the post-9-11 wars have ended,

1:47

some veteran military doctors say those

1:49

gains are at risk. Consider

1:54

this. The Pentagon has tried to

1:56

cut its health care costs by outsourcing medical

1:58

care to the private sector. And

2:01

that could hurt battlefield medicine in a

2:03

future war. From

2:10

NPR, I'm Ari Shapiro. Don't

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saatva.com/NPR. When

3:01

the economic news gets to be a bit

3:03

much... Listen to the indicator

3:05

from Planet Money. We're here for you,

3:07

like your friends, trying to figure out

3:10

all the most confusing parts. One

3:12

story, one idea, every day, all

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in 10 minutes or less. The

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indicator from Planet Money, your friendly

3:19

economic sidekick. From NPR. It's

3:27

considered this from NPR. Even

3:29

before the wars in Afghanistan and Iraq had

3:31

ended, the Pentagon had activated a plan to

3:33

cut health care costs for its millions of

3:36

troops and retirees and their families. NPR

3:39

Veterans Affairs correspondent Quill Lawrence has been

3:41

looking into the consequences of that plan,

3:43

and he picks up the story from

3:45

here. War is the mother of

3:47

invention, and the 20

3:49

years of U.S. deployments in Iraq and

3:52

Afghanistan produced a lot of medical advances,

3:54

including people, battle-tested doctors

3:56

and nurses. a

4:00

vascular surgeon, professor of surgery at the

4:02

Mayo Clinic, in Rochester, Minnesota. The Air

4:04

Force put Rasmussen through med school. For

4:06

that, he owed them several years of

4:08

service, and then he figured he'd go

4:11

into private practice. He started

4:13

a few weeks before September 11th. We

4:16

were only about eight miles from the Pentagon.

4:18

You could sort of see smoke from the

4:20

Pentagon, and I think from my perspective, I

4:23

thought, boy, my military career as a surgeon

4:25

would be vastly different than what I expected.

4:27

Rasmussen switched to trauma surgery as casualty numbers

4:29

lifted to the highest rate since Vietnam. At

4:32

first, the way patients arrived so quickly

4:35

from the war zone amazed him. They'd

4:37

been severely injured, you know, five or

4:39

6,000 miles away, just three

4:41

or four days earlier. The wonder wore

4:43

off, though, because patients weren't getting care

4:46

soon enough. They arrived with contaminated wounds too

4:48

late to treat. It's hard to admit we

4:50

could have done better, but I think maybe

4:52

the only thing worse is not admitting it.

4:54

And the military did do better, getting

4:57

surgery done inside what's known as the

4:59

golden hour after injury. At

5:01

first, they improvised, tent hospitals where

5:03

patients arrived with tourniquets made from

5:05

cargo straps. As the

5:08

war ground on, newly designed tourniquets

5:10

became standard gear. Units

5:12

of whole blood seemed to work miracles. By

5:15

2005, about when he had planned to

5:17

be going into private practice back home,

5:20

Rasmussen deployed to Iraq and saw

5:22

the innovations in real time. I

5:24

remember one US service member who

5:27

came to us from the front

5:29

lines in Fallujah, and he had

5:31

been operated on by a small group of

5:34

surgeons near the front line. I

5:36

think the assumption was that

5:38

we would need to amputate. The doctors near the

5:41

front line had used a temporary shunt in a

5:43

new way. Basically, they stuck

5:45

a plastic tube into the thigh to

5:47

keep the blood flowing around the wound

5:49

and save the foot. Then we said,

5:51

wait a minute, we can actually fix this

5:54

because of what the surgeons have done in

5:56

their creativity and

5:58

skills, sort of put the amputation. saw

6:00

away. Rasmussen deployed six times between 2005 and

6:03

2012. On the last one in Afghanistan,

6:07

he operated in a fully equipped

6:09

hospital with new concrete floors and

6:11

access to MRI and CT scans.

6:14

Then the wars wound down and

6:17

Rasmussen noticed a drastic change.

6:19

There were efforts to outsource

6:22

beneficiary care from

6:24

the military treatment facilities to

6:26

civilian institutions which emptied

6:28

out and hollowed out storied military

6:31

medical centers like Walter Reed. That

6:33

outsourcing was planned. In the past

6:35

decade, the Pentagon tried to tame

6:37

its massive health care costs by

6:40

pushing medical care, especially for family

6:42

members, into the private sector. The

6:45

result was a sort of spiral. Military

6:47

hospitals lost the numbers of patients they

6:49

needed to keep doctors in practice. Because

6:52

of that, and also the pandemic, many

6:54

clinicians left the military. And the

6:56

cuts kept going, says Rasmussen. Then

6:59

lastly, even you know what I would, in

7:01

my own words, call like crazy ideas, you

7:03

know, that were floated to close the Uniformed

7:06

Services University. Right? I

7:08

mean, why do we need a

7:11

military medical academy? The Uniformed Services

7:13

University is the military's medical school.

7:15

Okay, I'm Dr. Art Kellerman. For

7:17

seven years, I was the dean

7:19

of the Uniformed Services

7:21

University in the Health Sciences. Art

7:23

Kellerman was a leading voice against

7:25

downsizing the system, especially the university,

7:27

which he says preserves and supports

7:29

all the military medical advances from

7:31

the past 20 years and

7:33

many of the doctors who made them.

7:36

They achieved the highest rate of survival

7:38

for battlefield wounds in a history of

7:40

warfare. They were able to

7:42

save people that would have died in

7:44

any prior conflict. That, as much as

7:47

a helmet or flak jacket, gave US

7:49

troops confidence, Kellerman says, to rush

7:51

into a firefight knowing they

7:53

would probably survive. US allies

7:55

joined the fight knowing that an American

7:57

medevac would fly to the rescue within...

8:00

30 minutes if they got blown up. And

8:03

that they'd not just survive, but live

8:05

well, Kellerman says. They dramatically

8:08

improved their ability to rehabilitate

8:11

wounded warriors after being injured and many of

8:13

them were able to return to duty and

8:15

others were able to return home to

8:17

be with their families and to function for the

8:19

rest of their careers. Some of them today are

8:21

members of Congress. Kellerman says America

8:24

needs that same ready medical force for

8:26

any future conflict. And the

8:28

Pentagon now seems to agree. A Defense

8:30

Department internal memo obtained by NPR

8:32

found that outsourcing didn't actually save

8:34

money, but did hurt readiness. The

8:37

memo directs the Pentagon to reverse course

8:39

to bring more medical care back to

8:41

its hospitals on base and increase medical staff.

8:44

But the next war may be very different. In

8:47

Iraq and Afghanistan, the golden hour was

8:49

possible because the U.S. had air superiority.

8:52

The enemy had no planes or helicopters.

8:54

Sooner or later, somewhere, we're not going

8:56

to have air superiority. And I don't

8:58

care if we think we are, we

9:00

should plan for not having it. Dr.

9:02

Sean Murphy served 44 years retiring as

9:05

Air Force deputy surgeon general. He's

9:07

thinking about Ukraine, two conventional

9:09

armies squared off with massive

9:11

casualties being evacuated by ground,

9:14

or even more extreme, a possible

9:16

conflict with China around Taiwan. What

9:19

we realize when we start looking

9:21

at a theater like the Pacific

9:24

and the distances and a

9:26

peer-to-peer fight, there is

9:28

no way we're going to get to the

9:30

golden hour. The solution, says Murphy, is to

9:32

make every soldier and sailor a medic. To

9:35

do that, he says, the Pentagon needs

9:37

urgently to build back its ready medical

9:40

force. Dr. Todd Rasmussen

9:42

agrees. The most important fighting

9:44

system or weapons system we have is

9:46

the human system. It's

9:48

not a plane or a ship or a tank. Rasmussen

9:51

says he saw that again and again when he

9:53

served. That's the most lethal

9:55

and most important fighting system we have

9:58

on the battlefield. And

10:00

that human system is only optimized

10:02

and cared for if there is

10:04

a robust and expert military health

10:06

system. And I think degrading that

10:09

risks our national security. Rasmussen retired

10:11

after 28 years, and he is

10:13

finally a civilian vascular surgeon at

10:15

the Mayo Clinic. He still

10:17

mentors military doctors, though, and the

10:19

ones who do join give him great hope. That

10:23

was NPR's Quill Lawrence. This episode

10:25

was produced by Walter Ray Watson

10:27

and Connor Donovan with audio engineering

10:29

by Stu Rushfield. It was edited

10:31

by Andrew Sussman and Courtney Dorning.

10:33

Our executive producer is Sami Yennigan.

10:36

And one more thing before we go, you

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can now subscribe to The Consider This newsletter,

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