How The 'Golden Hour' Created A Crisis In Care For The Deployed Warfighter

The Long March
U.S. Navy corpsmen with Black Sea Rotational Force 18.1 and British Royal Air Force medical personnel with British 135th Expeditionary Air Wing move to assist notionally-injured Marines and civilians after arriving via U.S. Army UH-60 Black Hawk helicopter during a medical evacuation (MEDEVAC) drill at Mihail Kogalniceanu Air Base, Romania, Aug. 16, 2018.
U.S. Marine Corps/Cpl. Abrey Liggins

In 2009, the Department of Defense introduced the so-called 'Golden Hour' mandate.  This led to the development of systems that ensured the injured warfighter access to surgical care within 60 minutes of injury.


This led to massive infrastructure being created in Iraq and Afghanistan, including the deployment of forward surgical teams, extensive medevac capabilities, and the in-country availability of advanced and specialized medical care. Undoubtedly, this saved many lives and has led to the expectation is that this is the standard.

But is this the future or even the present? The environment of conflict currently and in the coming years seems likely to look very different.

In the last few years, in order to maintain operational flexibility while still meeting the golden hour mandate, smaller versions of forward surgical teams  (20-30 people and multiple surgeons) have developed. These include GHOST-T (Golden Hour Offset Surgical Treatment Teams) and ERST (Expeditionary Resuscitative Surgical Team) made up of a perhaps a single surgeon and less than 10 people.

With forward deployments consisting increasingly of embedded advisory and support roles rather than large missions with occupying forces, the demand for these teams have grown and the operation tempo has increased.

Therein lies the issue: Surgeons are being deployed to areas and in teams where their skills, experience, and ingenuity are expected overcome poor facilities and equipment and support. Because of their small size, in order to keep surgical capacity available for the warfighter, the deployed surgeon plays primarily a standby role with little operative experience. Unlike surgeons deployed in more robust settings who maintained skills in part by operating on host country nationals and providing some humanitarian care. Like in sports, practice is what makes perfect.

Frequent deployment without much operative experience combined with low volume, low acuity care when stateside makes military surgery increasingly unattractive. Surgeons, like athletes, want to be on the field and playing the game rather than sitting in the stands. This combined with the low surgical volumes of most military surgeons compared to their civilian counterparts and one can question how competency can be maintained.

Senior surgeons are leaving the Army in large numbers. Indeed, more than half of highly experienced general surgeons are reportedly leaving by retirement or separation in the coming year.

The number of citizen soldier surgeons in the reserves are also well below authorized numbers, resulting in little surge capacity and requiring active duty surgeons to cover this mission as well.

In short, surgeons with increasingly limited operative and trauma experience are expected to care for patients with potentially the most horrendous injuries, with minimal access to technology, equipment, and personnel to assist them.

What are the solutions?

First, the Mission Zero Act (H.R. 880) which will fund the embedding of military trauma teams into civilian trauma centers awaits passage through Congress. Also, expand the Military Health System Strategic Partnership American College of Surgeons (MHSSPACS) program, allowing increased civilian-military partnerships that support combat readiness. Explore new partnerships with humanitarian organizations and non-governmental organizations that may have resources on the ground in many current forward areas of operation. Contracted surgical assets may be another avenue to consider.  And encourage and support the involvement of deployed surgical assets in the surgical care of host country nationals in order to maintain readiness in the deployed setting

What we need to do is balance the spirit of “Golden Hour” mandate, with its call for zero preventable deaths and public expectation of providing the highest possible quality of care regardless of location, with the reality of smaller footprints, immature deployments in nonpermissive environments, much less logistical infrastructure and a paucity of evacuation assets

Kai Engstad is a board-certified general and cardiothoracic surgeon. He is experienced in working in austere environments and conflict areas, including Kurdistan and Myanmar. He is interested in the intersection between military and civilian surgery in conflict zones.

Todd Robinson's upcoming Vietnam War drama, The Last Full Measure, is a story of two battles: One takes place during an ambush in the jungles of Vietnam in 1966, while the other unfolds more than three decades later as the survivors fight to see one pararescueman's valor posthumously recognized.

On April 11, 1966, Airman 1st Class William H. Pitsenbarger (played by Jeremy Irvine) responded to a call to evacuate casualties belonging to a company with the Army's 1st Infantry Division near Cam My during a deadly ambush, the result of a search and destroy mission dubbed Operation Abilene.

In the ensuing battle, the unit suffered more than 80 percent casualties as their perimeter was breached. Despite the dangers on the ground, Pitsenbarger refused to leave the soldiers trapped in the jungle and waved off the medevac chopper, choosing to fight, and ultimately die, alongside men he'd never met before that day.

Decades later, those men fought to see Pitsenbarger's Air Force Cross upgraded to the Medal of Honor. On Dec. 8, 2000, they won, when Pitsenbarger was posthumously awarded the nation's highest decoration for valor.

The Last Full Measure painstakingly chronicles that long desperate struggle, and the details of the battle are told in flashbacks by the soldiers who survived the ambush, played by a star-studded cast that includes Samuel L. Jackson, Ed Harris, and William Hurt.

After Operation Abilene, some of the men involved moved on with their lives, or tried to, and the film touches on the many ways they struggled with their grief, trauma, and in the case of some, feelings of guilt. For the characters in The Last Full Measure, seeing Pitsenbarger awarded the Medal of Honor might be the one decent thing they pull out of that war, remarks Jackson's character, Lt. Billy Takoda, one of the soldier's whose life Pitsenbarger saved.

There are a lot of threads to follow in The Last Full Measure, individual strands of a larger story that feel misplaced, redacted, or cut short — at times, violently. But this is not a criticism, quite the opposite in fact. This tangled web is part of the larger narrative at play as Scott Huffman, a fictitious modern-day Pentagon bureaucrat played by Sebastian Stan, tries to piece together what actually happened that fateful day so many years ago.

At the start, Huffman — the person who ultimately becomes Pitsenbarger's champion in Washington — wants nothing to do with the airman's story, the medal, or the Vietnam veterans who want to see his sacrifice recognized. For Huffman, it's a burdensome assignment, just one more box to check before he can move on to brighter and better career prospects.

The skepticism of Pentagon bureaucracy and Washington political operators is on full display throughout the movie. When Takoda first meets Huffman, the Army vet grills the overdressed and out-of-his-depth government flack about his intentions, calls him an FNG (fucking new guy) and tosses Huffman's recorder into the nearby river where he's fishing with his grandkids.

Sebastian Stan stars as Scott Huffman alongside Samuel Jackson as Billy Takoda in "The Last Full Measure."(IMDB)

As Huffman spends more time with the grunts who fought alongside Pitsenbarger, and the Air Force PJs who flew with him that day, he, and the audience, come to see their campaign, and their frustration over the lack of progress, in a different light.

In one of the movie's later moments, The Last Full Measure offers an explanation for why Pitsenbarger's award languished for so long. The theory? Pitsenbarger's Medal of Honor citation was downgraded to a service cross, not because his actions didn't meet the standard associated with the nation's highest award for valor, but because his rank didn't.

"The conjecture among the Mud Soldiers and Bien Hoa Eagles is that Pitsenbarger was passed over because he was enlisted," Robinson, who wrote and directed The Last Full Measure, told Task & Purpose.

"As for the events in the film, Pitsenbarger's upgrade was clearly ignored for decades and items had been lost — whether that was deliberate is up for discussion but we feel we captured the spirit of the issues at hand either way," he said. "Some of these questions are simply impossible to answer with 100% certainty as no one really knows."

The cynicism in The Last Full Measure is overt, but to be entirely honest, it feels warranted. While watching the film, I couldn't help but think back to recent stories of battlefield bravery, like that of Army Sgt. 1st Class Alwyn Cashe, who ran into a burning Bradley three times in Iraq to pull out his wounded men — a feat of heroism that cost him his life, and inspired an ongoing campaign to see Cashe awarded the Medal of Honor.

There's no shortage of op-eds by current and former service members who see the military's awards process as slow and cumbersome at best, and biased or broken at worst, and it's refreshing to see that criticism reflected in a major war movie. And sure, like plenty of war movies, The Last Full Measure has some sappy moments, but on the whole, it's a damn good drama.

The Last Full Measure hits theaters on Jan. 24.

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Editor's Note: This article originally appeared on Business Insider.

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