In Iraq and Afghanistan, casualty treatment and evacuation were faster and more successful than in any previous conflict.1 The “golden hour” policy, enacted in 2009, improved the survival rate of injured service members by providing access to airborne evacuation and resuscitative surgical care within 60 minutes from point of injury.2 Having rapid access to care helped save lives.
The success of the golden hour policy has been attributed to U.S. air superiority and the enemy’s inability to interfere with the vast medical infrastructure put in place across the battle space.3 Looking to the next major conflict, however, the Marine Corps likely will face a sophisticated enemy that can contest air, land, and sea superiority.This will challenge current medical doctrine and the capabilities that enabled the rapid evacuation and treatment of casualties. It could take hours or days for a wounded service member to reach higher levels of medical treatment and resuscitative surgery.4
The Marine Corps’ health service support system needs to incorporate prolonged field care training into predeployment requirements for hospital corpsmen assigned to Marine Corps company- and platoon-size units.
Prolonged Field Care
The Marine Corps operating concept (MOC) presents battle-space scenarios in which forces will be operating in an antiaccess/area-denial environment, in smaller disaggregated units, and threatened by sophisticated new weaponry. Forward resuscitative surgical units, airborne medical evacuation, and patient-holding capabilities could be vastly reduced or nonexistent. Medical force signatures and energy sources will need to be reduced to remain agile and limit detection by enemy forces.5 To support the strategies and tactics presented by the MOC, unit-level medical capability must be increased.
One option is to provide additional, sustained training to corpsmen assigned to Marine Corps units. Prolonged field care training will enable Fleet Marine Force (FMF) corpsmen to keep injured Marines alive long enough for transport to a higher level of care.
Prolonged field care is defined as field medical care applied beyond “doctrinal planning time-lines” by a combat medic. It uses limited resources and is sustained until the patient can be transferred to the next appropriate level of care.6 The prolonged field care curriculum is an Army special operations resource, and until recently, it has been available solely to members of the special operations community. The only Navy and Marine Corps personnel who receive this specialty training formally are special amphibious reconnaissance corpsmen and naval special warfare personnel.7 All FMF corpsmen should be included in this training to develop and maintain the critical skills they will need for the future operating environment.
In the Marine Corps, FMF corpsmen and self or buddy aid at the unit level provide the first medical care at the point of injury. Corpsmen assigned to Marine units have completed three major training certifications: Corpsman Basic School, the Field Medical Training Course, and Tactical Combat Casualty Care (TCCC). When issued deployment orders, they are required to complete additional phased training, but that is dependent on the deployment location and platform.8 In general, this additional training includes surgical team training with a focus on trauma and traumatic brain injury treatment.
Upon successful completion of the prescribed courses, FMF corpsmen are fully qualified for combat deployments. However, current training revolves around immediate treatment of trauma-related injuries and short-term management of those injuries—to keep the patient alive long enough to be evacuated to surgical intervention. Because of the golden hour policy, most corpsmen have only had to apply immediate lifesaving measures before the patient was evacuated within minutes to higher-level care. In the future operating environment, this capability might not be available, and corpsmen will be expected to keep patients alive outside current doctrinal planning time lines.
Because of the nature of their operations—in austere and remote environments where resupply or patient transport might take days—the special operations community has been trained in prolonged field care for many years.9 Its use in real-world settings has shown high survival rates. For example, in a review of 54 cases of prolonged field care lasting four or more hours, 90.7 percent of patients survived to the next level of care.10
Despite the importance of this training and prolonged field care’s proven success in helping to save lives, it has not yet been standardized for unit-level FMF corpsmen.
Addressing the Opposition
Opponents of implementing prolonged field care training for unit-level corpsmen believe forward surgical teams of specialized doctors and nurses should be responsible for this capability. However, although there is evidence that decreasing transport time to surgical care allows more severely injured patients to present to care alive, it has not been demonstrated that overall outcomes are improved by initial presentation at far-forward surgical teams.11 Nevertheless, the Navy still is allocating resources to surgical capabilities that have little to no post-surgical holding capability—meaning the teams can provide surgical care in remote and austere environments, but patients then must be evacuated as fast as possible because there are not enough supplies or space to hold them. If these surgical teams were expected to provide prolonged field care, more equipment and personnel, as well as a redefined mission, would be needed.
Unit-level medical providers do not have surgical capability, but recent research from the Joint Trauma System and U.S. Central Command has determined that certain surgical and pharmaceutical practices can be implemented by unit-level providers using prolonged field care practices.12 Prolonged field care is not intended to create holding or surgical capability, but instead to bridge a training gap that becomes apparent when corpsmen must hold casualties on site when surgical intervention or evacuation is unavailable.13
In addition, there are too few forward surgical teams and capabilities to support every individual unit or austere environment.14 Navy Medicine provides the FMF with 32 forward resuscitative surgical systems.15 Considering worldwide deployments, dwell time, and training, the current surgical capability of the Marine Corps health service support system will struggle to support all missions across a dispersed battle space. Budget constraints also mean these programs have lagged the needed modernization that would allow them to be fully functional in a dispersed and contested environment. Instead of increasing the demand for these teams and capabilities, efforts should be pushed down to the unit-level assets that can provide some of the same capability through application of prolonged field care.
A golden hour mind-set centered on access to forward surgical teams is not a realistic policy against a peer competitor who can contest all domains of the battle space. The Navy and Marine Corps must make a change from how they fought and healed in Iraq and Afghanistan. Instead of bringing the patient to the best casualty care, it is time to explore ways to bring care to the patient. The best way to do that is to increase medical capabilities down to the lowest level of unit care.
1. Tanisha M. Fazal, Todd Rasmussen, and P. K. Carlton. “How Long Can the U.S. Military’s Golden Hour Last?” War on the Rocks, 8 October 2018.
2. Russ S. Kotwal, et al., “The Effect of a Golden Hour Policy on the Morbidity and Mortality of Combat Casualties,” JAMA Surgery 151, no. 1 (2016): 15–24.
3. Fazal, Rasmussen, and Carlton, “How Long Can the U.S. Military’s Golden Hour Last?”
4. T. E. Rasmussen, D. Baer, B. Doll, and J. Caravalho, “In the Golden Hour,” Army AL&T Magazine, January–March 2015, 80–85.
5. Marta Kepe, “Lives on the Line: The A2AD Challenge to Combat Casualty Care,” Modern War Institute at West Point, 30 July 2018, https://mwi.usma.edu/lives-line-a2ad-challenge-combat-casualty-care/.
6. Special Operations Medical Association, “Prolonged Field Care Resources,” www.specialoperationsmedicine.org/Pages/pfcresources.aspx.
7. MAJ Matthew J. Gross, USAF, “Damage Control Surgery and the Joint Solution,” fellowship paper, U.S. Air Force Medical Service, Defense Health Headquarters, June 2017.
8. Bureau of Medicine and Surgery (BuMed) Notice 1500, “Phased Medical Readiness Trauma Training Requirements,” 19 June 12018, www.med.navy.mil/directives/ENotes/NOTE 1500 - PHASED MEDICAL READINESS TRAUMA TRAINING REQUIREMENTS.pdf.
9. Sean Keenan and Jamie C. Riesberg, “Prolonged Field Care: Beyond the ‘Golden Hour,’” Wilderness & Environmental Medicine 28, no. 2 (2017): S135–39.
10. Erik DeSoucy, et al., “Review of 54 Cases of Prolonged Field Care,” Journal of Special Operations Medicine (Spring 2017): 121-29.
11. Mary J. Edwards, et al., “Army General Surgery’s Crisis of Conscience,” Journal of the American College of Surgeons 226, no. 6 (2018): 1190–94.
12. Andrew D. Fisher, et al., “Joint Trauma System Clinical Practice Guideline,” (2018), and Mary Ann Spott and CAPT Zsolt Stockinger, “U.S. Central Command Theater Trauma System Assessment Report” (2018).
13. Max, “Prolonged Field Care for the Combat Medic,” Next Generation Combat Medic, 9 September 2017, https://nextgencombatmedic.com/2017/06/15/prolonged-field-care-for-the-combat-medic/.
14. Keenan and Riesberg, “Prolonged Field Care: Beyond the “Golden Hour.”
15. Bureau of Medicine and Surgery, “Naval Operational Medicine Capabilities Handbook,” 2015 edition.