In Tension

Death Ignores the Golden Hour

Welcome to Ridgway’s Notebook, your home for airborne PME. We offer penetrating essays on military history. Through the World War II experiences of General Matthew Ridgway and the 82nd Airborne Division, we illustrate some of the similarities between the questions asked by officers of the 82nd yesterday and today—and dissect how they came to be.

The future of Ridgway’s Notebook is bright. Our weathervane will soon be reoriented to sharpened battle concepts that the infantryman longs to command and unfold on his enemy. But before that shift in the wind, putting the medical services at our backs, I want to engage with a piece in Military Review, “Death Ignores the Golden Hour.” It is emblematic of the crossroads the Army is bearing down upon. Or is bearing down upon the Army.

Dispersion and scale, the two things the Army is embracing, are in tension. Like an invisible rip current, it’s only felt when one wades in. Yet this tension is betrayed by the way the authors build words up into ideas. They correctly advocate a change in structure, yet I was struck by a feeling of looseness. There were were no bold statements, no precision in what their design should be able to absorb. We’ve faced the same dilemmas before. We’ve asked the same questions. We’ve done this before. Take the following two paragraphs:

1. In LSCO, the tasks of far-forward surgical assets will not change, but considerations governing their deployment will. Planning will need to calibrate a mission’s operational importance and unmitigated risk. Surgical assets execute early stabilizing interventions and conduct expert far-forward triage. This expertise interdicts preventable combat mortality and allows casualties to be reclassified as lower evacuation priorities, enhancing the efficiency of a restricted medevac system.

2. [T]he choice lay between (1) sending the [surgical] teams to the [division] clearing stations where they would see the casualties early but under poor working conditions and (2) keeping the teams back in the hospitals where they would be properly equipped but at a considerable distance from the front. In the absence of any precedent, General Blesse and Colonel Blatt decided to try both methods. In the Tunisian campaign which was now rapidly taking shape, teams would go forward as far as the clearing station but they would also work at the surgical hospital and the evacuation hospital.¹

Distill the Army legalize out of paragraph one, and you get paragraph two.

What struck hardest about the article was the absence of any number. Scale is applied liberally throughout, but the interpretation of scale is at the will of the reader. A dose of history can enlighten. Like the authors of “Death Ignores…” the 82nd Airborne wisely surrendered to the need for surgical teams forward — they had two in Operation Market Garden, and contested evacuation. In the first ten days, the division saw 1,368 battle casualties in their clearing station — Role 2, in the parlance of the Army and article² — and the two surgical teams conducted 400 operations; by mid-October the number of operations was flirting with 1,000.

The authors of “Death Ignores…” write:

The optimal location of surgical team employment should be as close to the potential casualty producing site as tactically feasible, targeting an interval from injury to surgery of no more than twenty minutes.

Dealing with this level of scale requires a precise industrial assembly line, which the 82nd Airborne developed. At their best, they got patients on the table within an hour and a half. In periods of high volume (such as the first 10 days), the surgical teams saw patients an average of six to eight hours post-injury. They were 9 km from the farthest regimental aid station over good roads.

To accomplish the low mortality achieved at the clearing station (the Role 2), they yielded to something else the authors acknowledge:

A far-forward surgical element will always be constrained in the volume and duration of its capacity to hold casualties and its depth of expendable [medical supplies].

A field hospital platoon air-assaulted with the 82d to work alongside the clearing station. This became a war-wide standard following the outcome of the Tunisian campaign’s dilemma. General Blesse found, “Clearing stations still require an adjoining unit for non-transportables and immediate operation of serious cases of that type.” One hundred surgical patients per day could be handled with the setup. It had neither wasted capacity, historian Sanders Marble writes, nor need substantial acreage near a road.³ And here seethes gently the tension between scale and dispersion:

In LSCO, the availability of large medical elements is restricted by exposure to enemy fires and hybrid threats. Casualty evacuation, meanwhile, is subject to ground-centric movement schemes stemming from a contested air domain.

The tension was brought to full light in the comments section on the MSC Leader Development page. A couple excerpts:

1. First, putting a highly-trained and unreplaceable surgeon right behind the front line seems reckless at best.

2. If you can’t protect and sustain a medical unit of action, you are only sending more casualties.

3. With improvements in our near-peer/peers ability to fight (long range precision fires, drones, etc.), how much risk are we ready to impose on highly-specialized capabilities, in which we cannot easily replenish? A significant loss in surgical personnel would also be sobering, highly catastrophic, and demoralizing.

Large scale combat begets large scale casualties. To cope with the wholesale of tragedy in Market Garden — a large scale combat operation — these instillations were necessary, and they were forward where they were demanded. One gets the impression from the comments of an inversion of the process; they are attempts to design something unhinged from something greater. To properly tailor what is needed for the Army of 2030 — like the marriage of the field hospital platoon/surgical team/clearing station was tailored for Europe — the direction of the Army must be determined. Where will it fight? How will it fight? What kinds of numbers should a Role 2 be expected to absorb during LSCO? (The number will be larger than you think.) Even if one disagrees with USMC’s Force Design 2030, you have to give them credit: everyone knows where it’s going to fight, and how. It’s a design linked to strategy. Some clarity on this point will make a more precise prescription for how the Army medical services need organize. As we saw in “Under Canopy,” the same structure can be concurrently sound and unsound: it just needs to know where it’s fighting, and grasp the scale it needs to absorb.

📚READ OF THE WEEK📚

Hans von Seeckt - Generaloberst Reichswehr

1. Clifford Graves as quoted in Sanders Marble “Forward Surgery and Combat Hospitals: The Origins of the MASH,” Journal of the History of Medicine, Volume 69, January 2014. (This is a highly recommended read.)

2. Using the definitions of the NATO Logistics Handbook, the closest equivalent today would likely be a Role 2+; the WWII clearing station was not quite a Role 3, but slightly more robust than a Role 2.

3. Marble, “Forward Surgery and Combat Hospitals.”