Combat Trauma -- Placing Surgeons to Save the Most Lives

Small mobile surgical teams attached to maneuver units save lives in the initial stages of major combat operations. But in the later phases of an operation, consolidating surgical capability will save more lives with fewer resources. This is because surgical care can be initiated sooner, the variety of specialists can be increased, and fewer complications are likely. The problem is that tactical commanders resist moving surgeons away from their areas of responsibility, even when it will provide timelier, more comprehensive care to their wounded. This problem of resistance and its complexity are well known. The objectives of this paper are to discuss the reasons for this resistance and to provide recommendations for overcoming it. The author contends that when conditions permit in late Phase 3 or beyond, small surgical sites should be consolidated into a theater trauma system that provides rapid evacuation, increased surgical capability, and surge capacity for mass casualty events. Although the benefits of this restructuring can be shown empirically, the resistance to moving surgeons off the battlefield is high. This resistance exists because of the emotional attachment of leaders to their wounded, and because keeping surgeons on the battlefield is a common belief passed down through generations of military personnel. The author analyzes the intense emotional attachment of leaders to their men through excerpts of conversations with tactical commanders during Operation Iraqi Freedom OIF. He then discusses three misunderstood concepts driving line officer opinions on surgical placement the Golden Hour, the Capability-Proximity Paradox, and the Surgeons Mentality. Data from civilian trauma literature and from OIF surgeons experience are provided as supporting evidence. The author concludes with recommendations for maintaining premier surgical care on a dynamic battlefield.