No ‘golden hour’? How Army medicine is changing for the next war

An infantry company is taking casualties and a medic has no good options. As the wounded pile up, the golden hour — the standard of modern medical care that moves a soldier from the battlefield to surgery within 60 minutes — comes and goes.

The battlefield is bristling with modern air defense weapons, artillery, and a dug-in enemy. Medevac helicopters can’t land and even armored field ambulances are blocked by shattered, dangerous roads.

The combat medic must keep patients alive for at least a day or maybe two. Or maybe four.

The golden hour standard may not be realistic going forward

Those dire conditions, resembling the landscape of Ukraine more than any battle in Afghanistan or Iraq, are what medics of the future must be prepared for, says the general in charge of the Army’s medical research arm.

“You may have previously heard a discussion of the ‘Golden Hour’,” said Brigadier General Anthony McQueen, the commander of the Army’s Medical Research and Development Command. “We’re moving more to a ‘golden window of opportunity.’”

McQueen’s command oversees the Army’s network of medical labs and R&D facilities scattered around the globe, from Africa to the top of Pikes Peak, Colorado. Speaking at a June 14 symposium of army medics, doctors, researchers, and commercial vendors, McQueen addressed five areas that his labs view as gaps military medicine would face in future large-scale combat operations: time, blood, oxygen, the Arctic, and disease.

The threat of large-scale combat operations, or LSCO, against militaries as large and as technologically advanced as US forces, said McQueen, means future medics must change their approach in all five areas. The most fundamental shift, he said, will be in “the tyranny of distance” where quick air evacuation is not available across large distances, leaving wounded far from surgical care.

“The majority of us that are all working in this space probably only have the past two decades of experience,” McQueen said. “That primarily has been a [counter-insurgency] fight.”

McQueen’s remarks came in the keynote speech at the Medical, Biomedical, Biodefense Support to the Warfighter Symposium in Chapel Hill, North Carolina, hosted by the NC Military Business Center.

“I’ve had pushback from folks and they’ll say, ‘Hey, that Golden Hour is a standard and we’ve gotta have it,” McQueen said. “I don’t think anyone’s denying that we would all love to have a surgical capability for our service members within that hour. But based on the conditions that we’ve potentially think could exist in the future battlefield, I think it’d be irresponsible for us not to be looking at ways on how we still sustained the life of a service member.”

A need for whole blood transfusion on the battlefield

First on the list, said McQueen is blood.

Special operations medics carried whole blood on battlefields for a significant portion of the Afghan and Iraq conflicts. Still, the permissions and logistics of getting it to regular units have been slow going.

Sgt. Maj. Chris McNamara, a Special Forces medic now with the 3rd Operational Support Group, told Task & Purpose at the symposium that any focus on future LSCO events will need a huge increase in US-based blood supplies, likely through blood drives.

“The amount of blood in US stores right now is for natural disasters,” said McNamara. “They’re not built for large-scale operations. So it would require a national effort of blood drives.” 

The supply chain is also an issue, McNamara said.  

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“No longer is anybody pushing back on it. You are getting some people saying, ‘Is the juice worth squeeze,’ though? Their question is not, ‘Blood or no blood?’ It’s ‘I don’t have all the infrastructure to use blood.’

McNamara said that whole blood products usually face a 21- or 28-day expiration, but only if transported and stored properly, which is costly and cumbersome. He noted some commanders in the field argue “‘My medics don’t have cold storage capability, and they don’t have the power to rewarm it.’ So essentially, it’s not gonna get used.”

Future solutions, McQueen said, will need to include smaller cold storage solutions and synthetic or partially-synthetic blood.

And while blood will always be needed for combat care, army researchers are finding that wounds suffered by soldiers in Ukraine differ from Afghanistan and Iraq, McNamara said. US medics grew used to wounds from IED explosions and burns, while in Ukraine rifle fire, artillery, and air attacks are constant threats.    

“New kinds of weapons are being used,” McQueen said. “I mean, all you have to do is turn on the television and you see what’s going on in Ukraine and Russia. Are they creating different types of injuries? We need to make sure that we’re linking up with those from a treatment standpoint and from a wound care and bandage care standpoint.”

When artificial intelligence meets large-scale combat operations

Extended care also means oxygen, McQueen said, which requires two technologies: producing and storing it, and delivering it to critical patients in transient field hospitals, which the Army calls Role 2 facilities. 

“So if we’ve got currently two ventilators at a Role 2, do we need 20 at a future Role 2 to sustain that 72 to 96 hours in that space?” McQueen said. “If you’re going to get 20 more ventilators, you’re not going to get 20 more soldiers to run the ventilators, but how can we execute them with an AI capability?”

Another front that 20 years of Middle East combat did little to prepare for will be arctic operations. 

“Our medics are trained to perform triage and immediately treating,” McQueen said. “If you’re in an arctic environment, you’re gonna have to get that casualty back to a space where you can be safe that you’re not gonna become the casualty even before you start triage and performing the treatment.”

And supplies — from IV fluids to battery-powered monitors — will have to be rethought.

“How does our current materials perform at -30, -45-type temperatures?”

Disease care, including pandemics, McQueen said, are also threats that will change in the future. If another pandemic arrives, how will the army respond?

“It’s not like we can just develop something in a year or less,” he said. “We’ve got to constantly be looking at what those threats are and have things on the shelf and ready to go.”

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