/image%2F3692661%2F20191002%2Fob_eae8ee_usa-news.png)
American troops believe they will get world-class care if they’re injured; the military’s own surgeons disagree.
A medic with the U.S. Army gathers equipment after finishing a mission in southern Helmand Province, Afghanistan in 2011.
SURGICAL READINESS IN the Military Health Service is fraying fast. A nine-month U.S. News investigation has uncovered mounting evidence that military medical leaders are squandering a valuable wartime asset: the surgeons and surgical teams that save lives on the battlefield and back home.
The investigation is the latest chapter in a continuing U.S. News probe of militaryhealth care. Interviews with more than two dozen active-duty and retired military surgeons and a confidential survey of Army surgeons and Pentagon records obtained by U.S. News have found:
- Severe shortages of skilled surgeons, especially trauma surgeons, on active duty and in the reserves.
- Army field hospitals that "are not staffed with appropriate specialty capabilities for a combat theater."
- An active-duty patient population that rarely needs surgery, with the end result that in the majority of the nation's 48 military hospitals, surgeons struggle to practice their craft. Many moonlight in civilian hospitals to keep their skills from eroding.
- Lengthening deployments that keep surgeons out of the operating room for months at a time, sapping hard-earned and highly perishable surgical skills.
The documents reveal that members of the military's Joint Trauma System and other military medical leaders repeatedly warned Pentagon officials, including former Surgeon General Nadja West, about the crisis in surgical care. West could not be reached for comment.
West retired in December according to the Army and her deputy, Maj. Gen. R.Scott Dingle, was appointed in July to replace her. The Senate confirmed his appointment in September. Unlike previous surgeons general, Dingle is an administrator with no medical degree or clinical experience. He is out on emergency family leave and could not be reached for comment, Army public affairs officer Maura Fitch said.
Each year, the Military Health System invests $50 billion annually in a network of hospitals and clinics to serve the routine health care needs of healthy, young, active-duty personnel, their families and some retirees.
The military justifies the expense of funding the MHS by asserting it provides a training ground for military health personnel to hone their skills until they're needed on the battlefield.
The U.S. News investigation indicates that the reality is often the opposite of what is intended: military hospitals sap surgeons' skills because most surgeons spend so little time in the operating room.
Civilian surgeons at busy medical centers may perform as many as 500 operations per year; military surgeons perform one fifth of that number, and, in many cases, even fewer, according to published studies of surgeons' case logs.
The situation is so dire that many surgeons view the military hospitals where they're assigned as a form of confinement where they watch their training – which costs taxpayers approximately $500,000 per surgeon – atrophy.Deployments, months spent in austere conditions often doing little or no surgery, are even worse.
Congress has accepted the Pentagon's assurances that military hospitals can keep surgeons' skills fresh. House Armed Services Committee staff, briefed on the U.S. News findings, did not respond to a U.S. News request to interview the group's chairman, Rep. Adam Smith (D-Wash), or other committee members. Smith did not respond to a request for an interview conveyed to him via his Twitter account.
Surgeons and other trauma care specialists are among the harshest critics of the current system and its failure to ensure that military medical teams are prepared to care for wounded warriors. A military that is ill-prepared and ill-equipped to perform surgery, they say, can't fulfill its solemn promise to provide life- and limb-saving care to those who are injured serving their country.
So many Army surgeons have become disenchanted with their military careers that "a surgeon insurgency is building," one says in an email obtained by U.S. News. To gather information firsthand, U.S. News reached out confidentially to approximately 140 U.S. Army surgeons.
Almost two dozen responded, providing detailed information on their surgical caseloads and experiences. The respondents answered a set of standard questions and most agreed to be interviewed. They spoke to U.S. News on condition of anonymity, asking that their identities be withheld to guard against retaliation from superiors.
In frank comments, surgeons shared serious concerns about the state of military surgery, about the complacency of commanders, and about the lack of awareness among young combatants who believe that, if they're wounded, they'll be well cared for.
"Parents who send their kids to war should be worried about the care they'll get if they're wounded," says one Army surgeon who has cared for scores of injured combatants. "I would be."
"These 20-year-old kids think they're getting top-notch care," says another. "They're not. And it's nobody's fault but the Army's."
The Surgeon Pipeline Is Running Dry
At latest count, of the 4,500 physicians in the Army, just two dozen are trauma surgeons.
The U.S. military fields 1.3 million active duty troops, with another 865,000 in reserve. Surgeons, and the teams they lead, are combatants' best hope of surviving catastrophic injuries.
Combat casualty care depends on expert surgery performed hundreds of miles from sterile, high-tech operating rooms. Military surgeons operate in small teams under challenging conditions, often in tents or hovels without running water or bright light.
Skilled surgeons are essential for high-quality trauma care. They can definitively treat severe injuries – stop the bleeding, cut away damaged or infected tissue, extract bullets or bomb fragments, manage complex wounds and debride burns, especially in such critical areas as the head, neck and torso. Military surgeons are famed for improvising new procedures in challenging settings that revolutionize civilian medicine.
To achieve those gains, the military needs a reliable pipeline of skilled surgeons, technicians and nurses. But, in the all-volunteer military, surgeons are in short supply – and caught in a tug of war between military hospitals that need their services stateside and combat commanders who need them to care for troops who fight wars.
Vice Admiral Raquel Bono, who retired in August as director of the Defense Health Agency, which governs military hospitals, told U.S. News that the military's surgical crisis is exacerbated by a private-sector surgeon shortage that will make it difficult, if not impossible, to fill gaps by recruiting civilian surgeons. "We're very much a microcosm of what's happening in the rest of the health sector in the United States," Bono says.
Col. Jason Hiles, MD, general surgery consultant to the Army Surgeon General, offered this explanation in a Feb. 19, 2019 update on coming changes to Army surgery for his fellow surgeons:
"I cannot get a single [surgeon] to assist recruitment command in recruiting general surgeons. Nor can I make myself do it," Hiles wrote in the memo obtained by U.S. News. "How can you recruit people to not operate and deploy where they will not operate?
"Surgeons who have operative experiences," he continued, are "rare as unicorns."
Hiles did not respond to requests for comment.
The surgeon shortage has already manifested during wartime.
During Operation Iraqi Freedom, U.S. Army Gen. Peter Chiarelli found himself waging a separate and unexpected battle to stop the Army from recalling one of two U.S. neurosurgeons in Iraq. It was July 2004, and the battle for Sadr City was raging.
Chiarelli's men were suffering devastating head injuries from the enemy's latest weapon of choice, improvised explosive devices. Soldiers with traumatic brain injuries need expert care that only neurosurgeons can provide. But the Army had other priorities.
"I went crazy," says Chiarelli, now retired from the military and an adviser to the George W. Bush Presidential Center. "I fought to keep two neurosurgeons there. The day I left the country, they went down to one. That's when I realized we had a problem." Without another neurosurgeon, Chiarelli says, more men would die or risk suffering lasting brain damage.
Military planners say these conflicts could be far more savage than those experienced during the wars in Iraq and Afghanistan. They will likely also be fought on much more challenging terrain.
"The next battlefield is going to be unlike anything we've seen in the past 18 years," says Michael Heimall, a former Army officer who served as director of the Walter Reed National Military Medical Center in Bethesda, Md., from 2015 to 2017. "We've had the real luxury of taking the capabilities of places like Walter Reed and Landstuhl (Regional Medical Center in Germany) into large bases in Iraq and Afghanistan. We've brought the modern medical center to the battlefield.
"Because of air superiority, we've had the ability to fly wherever we want, whenever we want, to move people around rapidly on the battlefield and also out of theater," Heimall says. "A critically wounded patient could leave the battlefield and be back at Walter Reed Medical Center in 96 hours or less sometimes."
"We likely won't have that luxury on a battlefield in Eastern Europe, the Balkans, Africa, or the Pacific Rim, when near-peer competitors [such as China and Russia] are involved," he says.
With unrest escalating worldwide, experts say, the U.S. Military Health System must be ready to deal with the carnage that is likely to occur in even a limited conflict. The improvised explosive devices that were the terrorist's weapon-of-choice in Afghanistan and Iraq may cause catastrophic injuries, but their range is limited, affecting only those within the blast radius.
In contrast, high-tech weapons such as the thermobaric bombs deployed by Russia in Syria – which use oxygen as fuel and ignite the atmosphere – can devastate hundreds or thousands. A nuclear conflict with North Korea or Iran would produce unimaginable suffering and destruction, Cancian says.
"We're facing a level of threat and casualty generation that's orders of magnitude greater than anything the military dealt with in Iraq and Afghanistan," says one leading Pentagon expert, who, like most active-duty and Department of Defense personnel, agreed to speak on condition of anonymity.
It takes a certain kind of surgeon to operate out of a backpack, solo. Experts say these surgeons should be highly experienced and accustomed to working in challenging settings."We take young graduates just out of training and they get the far-forward deployments," says the combat trauma care specialist. "They put you in a dugout with half the people and half the backup."
Military surgical leaders have also warned that downsized forward surgical teams often pair out-of-practice older surgeons with newly trained younger surgeons in situations where they may be required to juggle several soldiers with catastrophic injuries at once, without sufficient support.
In one published case report, an Army surgeon offers his own experience as a tragic lesson in what can go wrong. The surgeon had been assigned to a Forward Surgical Team a two-hour drive south of Baghdad with one other surgeon. Suddenly they found themselves caring for four soldiers with catastrophic wounds caused by an improvised explosive device.
"So here I am, three years out of residency, used to taking calls two to four times a month at a relatively slow, level II trauma center," the surgeon said. "In that time, I had performed maybe four or five blunt-trauma related operations…and only a few penetrating trauma cases from Afghanistan. Now I had to simultaneously care for four wounded, multi-system trauma patients with one other surgeon, who was less than a year out of residency."
Not realizing that the soldiers could have been transferred to a bigger hospital 17 minutes away by air for more definitive care, the surgeons did their best to repair the damage, according to the account in a 2016 report on "Essential Medical Capabilities and Medical Readiness" by the Institute for Defense Analysis.
Their decision, the surgeon says, cost precious time – and one patient a leg. Had the surgeons responded differently, amputation might have been avoided.
"We could have simply applied secure tourniquets to this guy, resuscitated him, and sent him on his way."