The military is moving away from its long-standing policy of getting wounded troops to sophisticated surgical care within 60 minutes. The "Golden Hour," as it's called, has itself become a casualty of modern warfare, where battlefields increasingly are ruled by unmanned aircraft.
By some estimates, more than 80% of casualties in the Ukraine war are caused by drones, mostly the small attack type. Both sides are making and destroying several million a year now and treating them basically as ammunition, to be destroyed in one-way attack flights.
Meanwhile, surveillance drones blanket the battlefield, finding them targets.
Combat medical troops at Fort Bragg got to hear what that means in real terms recently, thanks to a UNC Health program that brought in a Ukrainian combat surgical team.
"We'd be more than happy to have the golden hour, but we're more happy sometimes to have a golden day," said Taras, a Ukrainian military surgeon who asked to be identified only by his first name to prevent Russian intelligence making him a target. "In these cases, a person can be without any type of aid, even medical aid, for a week."
He and four other members of his surgical team gave a seminar at Bragg. Their audience of more than 400 included Army medics and others involved with combat casualty care.
The visit was organized by Carolina MEdiC, a UNC Health military-civilian partnership that trains military medical personnel. It was funded with federal money.
The Ukrainians described a battlefield where casualties sometimes couldn't be evacuated for several hours or even days due to the swarms of small attack drones and surveillance from other drones.
"Here are the results of a delayed evacuation," said Taras, looking back over his shoulder at a slide showing a soldier with toes blackened by frostbite. "The enemy is constantly monitoring the sky and the situation and is ready to strike with drones at any time, strike the vehicle that is performing the evacuation."
It was 12 days before the man could be brought from the front lines to the makeshift forward field unit where Taras' team was working. By then he had developed gangrene and his leg had to be amputated, but he survived.
Another slide showed a wounded soldier with a tourniquet on his thigh to keep him from bleeding to death. Major limb injuries are common from attack drones, which drop explosive charges or explode after diving into their targets. The standard medical goal is to get tourniquets off within two hours. But this one was in place for seven, and Taras said sometimes they have been left on for days.
"When we see that the positions are under fire and there's a lot of drones in the sky, then nobody will arrive there at this moment because nobody will risk additional lives," he said. "The evacuation will only happen when the sky has cleared or it has been cleared up."
For years, the U.S. military has been preparing for conflicts with sophisticated adversaries such as China. That sort of major conflict with a near-peer foe would mean challenges similar to those the Ukrainians described — including difficulty evacuating wounded troops and getting medical supplies to the front lines.
"The nature of warfare has unquestionably changed, especially with the drone threat, and also that enemy actors don't always follow the Geneva Convention," said Colonel Jennifer Gurney, an Army surgeon who leads the Pentagon’s Joint Trauma System, which is tasked with improving combat casualty care. "So I think that we have to change our tactics, our procedures, our mindset about how we approach the new battlefield, which is definitely a drone-infested, drone warfare battlefield."
She said three key aspects of casualty care increase battlefield survivability: transportation, meaning the ability to quickly evacuate the wounded to the next level of care, controlling blood loss, and early blood transfusions.
The Joint Trauma System has been working with Ukrainian battlefield medical personnel, gleaning their hard-learned lessons. Since surveillance drones make the combat zone essentially transparent, it's become crucial to hide medical facilities, typically underground, and keep them as dispersed and nondescript as possible.
And a key focus, Gurney said, is shifting more onto front-line health care providers such as medics, making sure they have the training, equipment, and supplies — including blood — to keep patients alive not just for minutes, but hours or days.
A potential front-line source for blood is the troops themselves, so they’re now being screened as possible donors before deploying.
"Of the three things that have been data driven, proven to save lives, blood is a huge part of that," Gurney said.
U.S. forces also have taken notice of the Ukrainians' reliance on smaller surgical teams pushed close to the front lines to help speed blood transfusions, hemorrhage control, and other types of higher-level care.
Gurney said the largest single problem for the U.S. is not having enough medical personnel. She said among other things, the military is short on surgeons, medics with the right training, anesthesia providers, and nurses.
"I do think that Congress and senior leaders need to hear that our military health system and the number of critical wartime specialists that we have is low," she said.
At Fort Bragg, those in the audience for the Ukrainians' presentation said it drove home the value of the changes the U.S. military has been working on.
"I think that really speaks to where our prolonged casualty care guidelines are going and really reinforcing what we already know to be true," said Sgt. Major Clark Hitchcock, senior medic for the Fort Bragg-based 18th Army Corps, which hosted the event. "It's very encouraging to hear the practices that we're looking at are actually in play in Ukraine right now."
The UNC Health military-civilian partnership helps train military medical troops, including special operations medics, at Fort Bragg and Camp Lejeune. It also is working with a non-governmental organization to create a program in Ukraine to train surgical teams, with the goal of Ukraine eventually taking over the program itself.
Nate Stokes, a former Army medic himself, is the UNC program's manager. He said the approaches to the problems the Ukrainians describe aren't coming as a surprise to the Pentagon.
"We have to get better at providing better care closer to the front line for longer periods of time, and then we have to force protect that that care, because we're not going to be able to get the patients away as often or as quickly as we'd like," Stokes said.
He agreed that locating medical facilities underground, as the Ukrainians suggested, is becoming an important planning consideration.
"How do we build mini hospitals we can bury in the ground and bring patients to, to minimize that the risk of drones?" Stokes asked. "How do we take our existing hospitals and decentralize them so they don't have the big tent footprint we're used to seeing? How do we power things without having to have generators running?"
Generators or other sources of heat, like vehicle engines, show up on the thermal vision some drones are equipped with.
Stokes' program brought in the Ukrainians mainly for a major training exercise involving the Bragg-based 44th Medical Brigade. But they also gave presentations at UNC-Chapel Hill's annual trauma conference and a special operations medical conference.
While drones are creating many of the new problems, they also may be at least a modest part of the solution. The Ukrainians now are using some to deliver medical supplies and in some cases even using armored ground drones to evacuate the wounded. And Gurney said using drones to move supplies, including blood, was already on the radar screen.
Hitchcock, the 18th Corps senior medic, also spent time with the Ukrainians before the program. He said the lessons they offered weren't surprises, but it was sobering to hear real-life case studies that brought home what it means to not be able to rely on the Golden Hour any more.
"I think that's something that we've already kind of taken a look at and acknowledged that the Golden Window is in, the Golden Hour is out," he said.
This story has been updated with comments from Colonel Jennifer Gurney, who leads the Pentagon’s Joint Trauma System.
This story was produced by the American Homefront Project, a public media collaboration that reports on American military life and veterans.
