Clearing the Table: Reviewing Dr. Regan Lyon’s thesis “WHEN THE ‘GOLDEN HOUR’ IS DEAD: PREPARING INDIGENOUS GUERRILLA MEDICAL NETWORKS FOR UNCONVENTIONAL CONFLICTS”, by Teddy Bear (D.O.)

TL:DR

• Treatment stages are care-based, not equipment-based
  • 1 – TCCC (medic)
  • 2 – PFC (medic)
  • 3 – DCR/DCS (physician/surgeon)
  • 4 – definitive surgery, rehabilitation, return to duty (physicians and surgeons)
  • The highest available level of care will vary; something the Guerilla Chief must plan for
• Tangible limitations are
  • trained personnel (training lead times vary based on role and existing capabilities)
  • hospital capacity (does not have to be all in one place)
  • blood supply (walking blood bank?)
  • evacuation assets (w/ or w/o medical personnel)
• UW/GW considerations
  • medical personnel should be trained in tradecraft, EW, fieldcraft, and tactics
  • evacuation of casualties is a compromise risk
  • telemedicine is a compromise risk
  • blue-tooth or cell-phone (ultrasound, EKG) based devices are a risk
  • caches are key
  • existence of safe zone is not guaranteed, nor does its existence guarantee success

Note: italics are quotes, and bold is my emphasis added.

The Problem

Much like “guerrilla” or “recce”, the term “medical” has become a frequently used buzzword in the  community of armed prepared citizens. Usually “medical” refers to nothing more than an Individual First Aid Kit (IFAK) hopefully built around solid trauma first-aid principles as outlined for Tactical Combat Casualty Care (TCCC). This is all well and good, so far as it goes. Say what you  like about folks who like to ape modern shock troops, they at least stumbled into carrying decent means of hemorrhage control…usually. Again, this is fine and dandy for overt, white-side activities, wherein rapid access to definitive care is nearly assured, without the fear of subsequent arrest and detainment. But what about a  casualty in a non-permissive environment? What happens after picture perfect execution of the MARCH algorithm? In other words, where is the guerilla’s hospital?

This last question is what Lieutenant Colonel Lyon, MD, (USAF) explores in her thesis for a master of science in defense analysis, published December 2021 via the Naval Postgraduate School. Dr. Lyon is an emergency medicine specialist, with experience working in Special Operations environments. Early in her discussion, she cites the work of Colonel “Rocky” Farr, MD, “Death of the Golden Hour” 2017 monograph as the starting point for her own research. Very briefly, the problem that the US military and its allies are facing is that it is no longer fighting a non-state actor without air assets or electronic warfare capability. Very pertinently and even more recently than Dr. Lyon’s research, we can see this playing out in real time. Having fled Afghanistan in disgrace, the US military is trying to learn what it can via proxy war being fought in eastern Europe, nominally between Ukraine and Russia. As Col. Farr points out, without control of the airspace and the ability to guarantee (weather allowing) injury to surgery times within 1 hour, an entirely different approach has to be taken maintain the fighting force.

“The establishment of a guerrilla combat casualty care system is no small task. Guerrilla forces are classically limited on resources and are rarely of a demographic with extensive medical experience. In addition, the practice of austere resuscitation and surgery requires additional training for even the most qualified U.S. medical professionals. And finally, training and coordination of the full spectrum of necessary medical assets requires more than a few short certification courses. Consequently, mission commanders may be reluctant to entrust care of U.S. forces to a guerrilla medical system, and the potential time horizon for establishment of an indigenous medical system is disillusioning to stakeholders and strategic planners.

 “Although valid concerns, these potential objections are based on the assumption that the end-goal for every guerrilla or unconventional conflict is to establish a complete full-spectrum medical system, no matter the available resources or initial operating standards. In reality, a resistance medical network will be tailored to the complex circumstances of the resistance. This will cause variation in the level of trauma care provided within the network while decreasing the casualty death rate of the resistance without medical support. Therefore, it is the goal of this research to determine how SOF can prepare a resistance medical network to optimize casualty care for future unconventional conflict.”

It is important to note that the thesis we are discussing was written with the assumption of US and allied backing of unconventional warfare in a foreign land. The logistics, training timelines, and operational tempos that are assumed will be less applicable the fewer of the basic assumptions are met. For example, Dr. Lyon includes a limited access to helicopters for evacuation, having to overcome language barriers, and reconcile various countries’ legal and medical establishments. For an unsupported American citizen defending his country in his own homeland, these considerations are not likely to be relevant. Nevertheless, there are many important lessons to be learned, if one approaches the topic with an open mind.

A Solution

Before we can theorize about the future, we must understand the past. The US military has its medical system divided into 5 Roles based on their capabilities. These Roles range from buddy care, self-aid, and trauma first aid provided by the medic at Role 1, all the way up to Role 5, such as a military level 1 trauma center hospital back in the US. Every Role is expected to also have the capability to perform the duties of all the Roles below it. This means, that higher the level of care, the less mobile and covert it can be. What Dr. Lyon proposes is a different way of looking at the problem:

“stages focused on treatment goals, rather than asset capabilities.” In other words: “in the denied, hostile environment of UW [unconventional warfare], the more important objective of a medical system is to improve battlefield mortality statistics by addressing preventable deaths. The dangers of non-urgent evacuation for non-debilitating or non-lethal injuries can cause increased risk to force, which in turn, may increase casualty numbers. It is unlikely that a tactical unit will have to worry about where the nearest x-ray facility is located.”

A fundamental difference in approach between the Role system and what Dr. Lyon has termed Casualty Treatment Stages (CTS 1, 2, 3, & 4) is the move away from emphasizing evacuation due to its inherent risk of compromise in a non-permissive environment. In her words,

“To minimize movement in theater, evacuation should only be performed if a patient is combat ineffective, and to what asset they are evacuated is determined by whether they have an immediate, treatable life-threatening condition. So long as an asset meets the expected objective for their assigned stage without increasing their vulnerability to compromise, variability regarding what tools they use to accomplish that objective is irrelevant.”

“Rather than thinking in a linear evacuation process from one echelon of care to the next level, the continuum of care is based on the type of medical intervention necessitated by the patient’s condition.”

• CTS 1—Battlefield care provided through self-aid/buddy care or battlefield medics and based on the foundational principles and procedures of TCCC. This stage intends to address acute,life-threatening injuries with the exception of noncompressible torso hemorrhage requiring surgical control.

•  CTS 2—Prolonged battlefield care [PFC] provided by battlefield medics for extended periods of time and based on the foundational principles and procedures of PFC and damage controlresuscitation. This stage intends to provide more advanced and prolongedmanagement of serious casualties in a field or austere setting with limited resources.

 (“PFC offers more advanced care than TCCC, addressing ongoing shock rather than only immediate life-threats.”)

•  CTS 3—Damage control resuscitation and surgery provided by forward, mobile Austere Resuscitative and Surgical Careteams. This stage intends to address acute, life-threatening injuries, especially noncompressible torso hemorrhage.  Per the  2018 5^th revision of “Emergency War Surgery” Ch 12: “Damage Control Surgery is defined as the rapid initial control of hemorrhage and contamination, temporary abdominal closure, resuscitation to normal physiology in the ICU, and subsequent reexploration and definitive repair after normal physiology has been restored. Damage control techniques can also be applied in vascular, thoracic, orthopedic, and neurosurgical procedures.”

If you ever watched M*A*S*H, this is what they meant by “meatball surgery.”

•  CTS 4—Definitive surgery, recovery, and rehabilitative care provided by medical personnel at sites suitable for longterm care. This stage intends to provide definitive surgery to address subacute issues, prevent and treat shock and infection, and recover patients to return to duty. “It is important to note that although terms such as ‘hospital,’ ‘ICU,’ ‘inpatient,’ and ‘beds’ are used to describe a Stage 4 location, it should not be assumed that a Stage 4 facility must look like a traditional hospital with all these treatment areas in one confined space. The guerrilla hospital, for example, may have a surgical suite and trauma bay and use auxiliaries or citizens to provide post-surgical nursing care in the surrounding area.”

“By linking levels of care to TCCC, PFC, damage control resuscitation, and damage control surgery, a system can more effectively reduce the number of potentially survivable combat deaths.”

Across all four CTSs, “the most significant tangible limitations: trained personnel; hospital capacity; blood supply; and evacuation resources.”

Creative thinking and an acceptance of limitations with gratitude for what is available will get us further than trying and failing to reproduce the medical system we are used to.

The Environment

In conventional peer or near-peer conflict as pictured above, each side has approximately evenly matched resources and network density on the ground. Where elements of these networks come into contact, there is conflict. Conventionally,  this results in literal battle lines being drawn.

In unconventional or guerrilla warfare, the insurgent projects force into areas of higher enemy density for the duration of his mission. So while he may be able to have relative advantage in his immediate area, he is at a huge disadvantage in the larger scheme and is vulnerable to compromise.

Above is a map showing the part of Belarus that saw active operations of the “Forest Brother” partisans of WW2. Forest Brother networks are in blue, occupying forces networks are in orange, and major  insurgent attacks/missions are marked with a red star. This map is an illustration of how the guerrilla projects power out of his area of relative strength and into the area of relative enemy strength in order to achieve his goals. This strategy places casualties far from where they need to be to maximize their chances of survival and recovery.

While the guerrilla can sometimes secure an area temporarily through a combination of local relatively higher firepower and avoiding detection of larger enemy forces, this should not be confused with a safe zone. In fact, the existence of a safe zone is not assured. (To define our terms: secure –  countermeasures are in place against a known threat; safe – there is no known threat.)   The further we can get our casualties away from the point of conflict, the more we can do for them and the better their chances are.

 For the purposes of the thesis, Dr. Lyon defines available evacuation platforms in the following terms:

• Casualty evacuation (CASEVAC) … any platform that does not have medical treatment capability (i.e., no medical personnel on the platform)
• MEDEVAC … any platform that does have medical treatment capability.”

“Decreased freedom of movement caused by increased opposition force density mandates medical teams to be more mobile, to decrease their footprint, to set up supply caches, and to rely on the clandestine movement of patients and supplies by the underground and auxiliary supporting networks.”

Inevitably, the regime will seek to strike back at the guerrilla, and it is critical that the guerrilla withdraw and avoid contact. For the medical system, this could mean a geographical collapsing back (see following figure) on a safe zone or at least an area of higher density in the friendly network (forward support). This does not necessarily require a physical relocation. In fact, since movement draws attention and the risk of compromise, collapsing back of the medical system may simply mean a reduction or cessation of activities for a time. Network medical assets would go into isolation from one another for a time, to be reactivated and reorganized by prearranged signal at the ground commander’s discretion. This once again illustrates the need for medical staff to have some exposure to tradecraft and clandestine means of communication, to at least a basic level. An understanding of patterns of life, cover for action, environmental baseline, dead-drops, et cetera, is essential to the long term survivability of medical support assets.

To participate in a covert medical system, healthcare professionals will need to unlearn a lot of their dependence on high technology, due to their inherent electronic warfare vulnerabilities.

“Medical innovations and technological advancements provide more effective medical care in comparison with that of historical guerrilla medicine. However, the operational environment requires greater light and sound discipline, reduced access to electricity, and reduced electronic signatures from Wi-Fi or Bluetooth connections. Telemedicine capabilities may be incredibly beneficial to remote medical teams but may compromise the guerrilla force’s proximity to the enemy.”

“U.S. [or American partisan] medical teams expected to support special operations [or guerrillas] need to receive training in UW and clandestine skills to improve survivability.

“To avoid compromise, clandestine practices obscuring identity, affiliation, and purpose are required. These movement restrictions and requirements to “blend in” with clandestine

procedures underscore the need for strong relationships with underground and auxiliary. … The development of these relationships requires forward planning and building trust to strengthen commitment in a situation of high uncertainty. … building of these relationships will be instrumental in optimizing a medical support system.”

If you are a healthcare professional, you need to go get training on tradecraft, electronic warfare, fieldcraft, and small unit tactics. If you can’t find a qualified instructor such Brushbeater, Combat Studies Group, SOARescue, etc, look for learning media from S2 Underground, Garand Thumb’s mountain series (not for EW), Alpha Charlie Concepts, Brent0331, etc.

While riflemen can be trained fairly quickly, there are long training timelines for medics, and even longer for physicians (as well as NP and PA). Realistically, existing medical professionals would need to be recruited and trained up. Short of US government support, providers holding medical licenses and/or DEA registrations are the only folks who can legally purchase any kind of necessary medical supplies in preparation for defense of the homeland.

“Although the phases of UW accounts for training of partner forces, depending on the baseline medical capabilities of an indigenous population, the time requirement for training medical personnel can vary significantly. Figure 39 is a graphic representation of the estimated time requirements for establishing each treatment stage, primarily determined by the training of personnel.  … Green time ranges are for a force with a baseline medical capability, and orange time ranges are for forces with no established medical support. … These time horizons were estimated based on my professional experience, knowledge of traditional training timelines, and involvement with medical education.”

“Stage 3 and 4 both require a skill level of a trained physician, specifically a surgeon. Operating in an austere, clandestine environment, however, requires unique tactical and medical decision-making skills not inherent in medical training. Austere medicine and clandestine skill training could take up to 6 months. Since Stage 3 is closer to the point of conflict than Stage 4, training for even established surgeons used for Stage 3 care will take longer than training for Stage 4.”

“Evacuating outside the theater is not realistic in a denied environment, but treatment through local hospital systems not considered part of the GW medical system would likely lead to compromise and/or capture of that patient.”

Note: while this is generally true within these United States, it is my opinion that certain faith-based, religious-affiliated, and tribal hospitals might prove exceptions.

“Planners who are trying to develop a medical system for a GW/UW conflict must have realistic expectations regarding the level of care possible for that system. … The lack of required skills and time to train those skills will ultimately dictate the best possible level of an indigenous medical system able to be reached.”

“It is expected that the denied environment will increase the likelihood of death and battlefield mortality, but failure to create a complete medical system comes at a cost. For each treatment stage not achieved, the CFR for a medical system increases, with significant increases if surgical care (Stages 3–4) is absent. … The other limitations discussed in this research, such as medical supplies, blood, and evacuation, still hinder the ability to treat patients, independent of the medical skills of personnel.”

Physicians trained in the unique aspects of austere medicine and UW can help to identify indigenous medical personnel with required skillsets or cache requirements that may not be appreciated by non-physicians.”

Final graphic is flowchart for determining the highest level of attainable care. Where are you on it?

While I wish that this thesis review had all the answers to the problems of guerrilla medical systems, it does identify challenges in a defined way, with concrete starting points for attacking this problem set.

Disclaimer

Teddy Bear holds a Doctor of Osteopathy (D.O.) degree, and is a general medical practitioner. As a hobby, Teddy collects various state’s medical licenses. Having entered medical school specifically with a coming collapse in mind, Teddy appreciates the opportunity to educate, viewing it as a form of caching. However, the information contained in this article does not constitute medical advise, and does not create a patient-physician relationship between the reader and author.

Financial disclaimer: All provided links are for educational purposes or representational examples only. At the time of this writing, there are no financial associations with any product, service, or business mentioned or linked. All products are examples only without personal knowledge of how they perform, except where noted.