Medical Support to Resistance: Special Warfare Article

This article first appeared in the Jul-Sep 2019 Special Warfare Magazine which can be found open-source at




Hope is a primary driver of resistance movements, and the best way to keep hope alive...

This article first appeared in the Jul-Sep 2019 Special Warfare Magazine which can be found open-source at




Hope is a primary driver of resistance movements, and the best way to keep hope alive in a resistance movement is to keep people alive. There are many aspects to enhancing survivability of a resistance movement, and medical support is one critical part. Doctrinal military health service support constructs, such as combat support hospitals or forward surgical teams, will be wholly inadequate to support resistance movements in a peer conflict in Europe for the primary reasons that they are overmanned and under trained. This article will discuss a whole-of society approach to preparing military and civilian medical resources that will build readiness and resiliency of our allies or partners, improve casualty mortality rates and enable both resistance members and allied forces to sustain the fight to regain territorial sovereignty against an illegal occupation. Medical infrastructure is vastly different in peacetime Europe than in more austere areas frequented by U.S. Special Operations Forces. Medical evacuations begin with calling 112, the European 911 equivalent, ambulances arrive to provide pre-hospital care, sometimes with physicians onboard, the patient is transported to a trauma center, and medical care is generally comparable to U.S. standards. If peer conflict occurs again in Europe, medical infrastructure will be severely degraded and significant obstacles to medical support will immediately arise, especially regarding extremely prolonged evacuation times and scarce resource availability. The U.S. military has not faced as severe a challenge to provide medical support since World War II. The SOF medical community has been bracing for the regression of medical support in emerging conflicts since at least November 2017 when U.S Army COL (Ret.) Dr. Warner “Rocky” Farr published The Death of the Golden Hour and the Return of the Future Guerrilla Hospital; yet the existential threat facing Eastern Europe poses the worst case scenario for medical support to resistance. The restricted mobility for friendly forces in territory occupied by a peer adversary will severely limit external medical support to U.S. SOF and our allied partners, including the resistance. The isolation of U.S. and allied forces in a denied environment will by necessity convert the delivery of medical care from a linear progression of medical evacuations from point of injury to higher echelons of care outside the combat zone, to a cyclical progression of evacuation, treatment, convalescence and return to duty, all completely within occupied territory.

A resistance scenario in Europe presents a unique risk to U.S. SOF supporting resistance movements, as organic capabilities will not be able to provide required medical support in this tactical environment. Recent exercises have demonstrated that U.S. SOF surgical teams will be severely restrained and may not be survivable in a denied environment, and conventional medical forces will likewise be absent. U.S. SOF medics are highly capable within their scope of practice, but over-inflation of their ability results in commanders miscalculating risk; a medic’s ability to reduce serious risk is often predicated on access to definitive care. The Maquis in occupied France and Partisans of Yugoslavia faced similar challenges in World War II but were still able to provide medical support despite great odds. The relevance of these historical precedents might be limited, however, by exponential advances in technology over the last 75 years. Providing medical support to U.S. SOF and resistance forces will be immensely challenging, but there is one great advantage over historical precedence: there is time and space now to enable ourselves and our allies and partners to be prepared to provide medical support to resistance prior to conflict, instead of reacting after a violation of a country’s national sovereignty.


In early 2018, SOCEUR conducted a multinational SOF exercise focused on irregular warfare and resistance in the Baltic region of Eastern Europe. Key medical lessons learned from the exercise were that medical evacuation in restricted areas during peer conflict is incredibly challenging, and U.S. SOF surgical teams as currently configured and trained will have low, if any, chance of survival in occupied territory. It was evident that planning medical support solely using only a U.S. military doctrinal construct was impractical and ineffective; civilian medical resources were identified as, and will necessarily be, the center of gravity for medical support to resistance. Resistance doctrine was turned to as a possible solution to the way ahead, but existing doctrine was found to be largely inadequate for the range of potential operational environments in future conflicts against a peer adversary in Eastern Europe. The focus of U.S. resistance doctrine on unconventional warfare and resistance movements assumes that conflicts have already begun or are ongoing. Furthermore, reverse engineering resistance constructs prior to conflict is difficult because it is impossible to forecast who and what will survive the initial invasion. The whole-of-society approach advocated by the Resistance Operating Concept was embraced as a potential solution for addressing critical gaps in providing medical support to resistance.


The SOCEUR Surgeon’s Office has developed a whole-of-society approach to enable medical support to resistance (Figure 01) as a tiered approach to improve trauma care from point of injury through surgical intervention, convalescence and return to duty. Additionally, it aims to increase medical interoperability with Allies and partners in preparation for a resistance scenario in Eastern Europe.


The core of this approach begins with increased readiness for U.S. SOF. If peer conflict in Eastern Europe occurs, U.S. SOF medics will be required to treat casualties on extended timelines with limited supplies. Proficiency in Prolonged Field Care improves the SOF medic’s ability to do this, but is dependent on the medic’s ability to transfer casualties to higher echelons of care for definitive treatment or required convalescence. SOF surgical teams may be part of the solution, but will require manning changes and additional training in order to improve survivability in peer-adversary occupied territory.

Previously, the SOCEUR Surgeon’s office developed and conducted a course in UW medicine for surgical teams. This training was conducted as a proof of concept in Fall 2017, and was subsequently turned over to U.S. Army Special Operations Command with a request to further develop UW training for SOF surgical teams. Currently, the SOCEUR Surgeon’s office is continuing to develop Trojan Footprint as an opportunity for U.S. SOF medical units to practice UW medical tactics and techniques in a major exercise. The command is developing training opportunities for U.S. SOF medics and surgical teams to work in partner-nation trauma centers in Eastern Europe. This aims to achieve multiple objectives including enhanced interoperability of U.S. medical personnel and potential partners, information sharing regarding medical materiel and techniques and potentially to raise standards of trauma care as best practices are shared between allies and partners. The strong relationships that would be created by this course of action would be mutually beneficial. These types of training opportunities may be expanded beyond U.S. SOF to other U.S. military medical personnel, further increasing interoperability and alliance building. SOCEUR is also assisting USSOCOM to define the Special Operations Forces Baseline Interoperability Standards for medics and surgical teams. These efforts attempt to link SOF medical requirements to National Defense Strategy priorities in order to develop the force for the future, and not simply to fight the last battle. Finally, current U.S. SOF doctrine on medical support to resistance appears to have gaps in Eastern Europe’s potential operational environment, especially with regard to preparing Allies and partners to conduct resistance prior to conflict. Working with USASOC’s medical teams will help develop future iterations of doctrine in order to prepare U.S. SOF for best success in an extremely challenging environment.


A key focus area for the SOCEUR Surgeon’s office is supportive relationships with European partners. Effective relationships with partner SOF medical leaders builds shared vision and enables work toward common goals. The majority of partners’ SOF medical personnel are intertwined with their conventional military Health Service Support, similar to U.S. military medicine, and efforts with conventional HSS are required in addition to work with SOF medical leaders. Investments in relationships now with partner nations’ medical capabilities will pay dividends in a peer conflict and resistance scenario, even though partner’s military HSS will likely be diminished. Partner SOF medics, military medical personnel, and home guard units will serve as medical cadre in local resistance movements and save lives through application of their medical skills and knowledge. Special Operations Forces Institution Building is a primary line of effort that aims to improve interoperability. The near term plan is to promote Tactical Combat Casualty Care (as the base standard for all allied SOF medics and enable partners to conduct internal training without external support. An additional goal of this initiative is to assist North Atlantic Treaty Organization Special Operations Headquarters to develop doctrine for NATO and partner SOF medics and SOF surgical teams. This aims to make allied medical enablers similar, with improved interoperability. The SOCEUR Surgeon’s office is currently working with partners to develop a medical annex for the ROC to serve as a guide for medical support to resistance in Europe. The emerging medical annex is focused on key components of medical resistance networks, treatment and triage considerations and planning medical stay-behind capabilities. Major exercises like Trojan Footprint are opportunities to test the viability of potential medical resistance networks and competencies in a controlled setting, while identifying areas for improvement. SOCEUR aims to increase involvement of key European SOF medical enablers in order to further improve combined medical preparedness as an interoperable allied force.


Civilian personnel are anticipated to provide the majority of medical support to resistance, as most military medical capabilities are likely to be exhausted during an invasion. While there is no doubt our Eastern European allies have robust, capable trauma systems, a significant gap in our collective medical preparedness for resistance, however, is understanding the available civilian medical capabilities. Investing time and resources to better understand and cooperatively increase the trauma capabilities of civilian medical institutions will enhance our collective ability to provide medical support in a resistance scenario. Creating a medical common operating picture will identify where gaps exist and inform planning priorities for greater resilience in trauma care now, as well as prepare for medical support to resistance. First responders are the critical bridge from POI to higher levels of care. Sharing lessons learned from decades of combat with partner civilian first responder systems will improve initial survivability of resistance members and enable better chances of successful evacuation to higher levels of care. U.S. Allies in Eastern Europe are already preparing themselves. In Lithuania, for example, new regulations were recently passed to enhance the scope of paramedics in the event of disaster. The new training for these paramedics closely mirrors TCCC guidelines, which have saved many lives from combat trauma. In most resistance operations, bystanders will be the first on scene, just as they are in everyday life. Treatment of combat casualties at the POI by first responders improves the likelihood of survival until casualties can be treated by qualified medical personnel. Because it is impossible to predict who will be first on the scene in a resistance scenario, the potential target for training on POI care might be as large as a country’s entire population. There are precedents for whole-of-society programs for POI care in recent years due to terrorist acts against innocent civilians. In 2015, the U.S. Department of Homeland Security launched the STOP the Bleed campaign in order to cultivate a grass roots efforts to train, equip and empower bystanders to help in a bleeding emergency before professional help arrives. In the United Kingdom, London Ambulance provides life-saving first responder training to taxi drivers. Conducting large scale campaigns like these in Eastern Europe would undoubtedly save lives in future resistance scenarios. Finally, trauma systems and medical facilities are critical for definitive treatment of trauma casualties. Trauma center subject-matter expert exchanges would facilitate sharing of best practices and development of strong relationships. These relationships could be at a medical center or university level. Enduring institutional relationships would enable medical interoperability and could be expected to advance the efficiency and effectiveness of trauma systems bilaterally and multilaterally. A whole-of-society approach to enhancing trauma system capabilities is beneficial not only for resistance scenarios, but also to increase preparedness for, and improve response to, a host of contingencies. Trauma systems nest within broader emergency response systems, which must be prepared for natural disasters such as earthquakes, fires or floods, man-made disasters such as industrial accidents or chemical releases, disease outbreaks or terrorist attacks. Well-prepared, effective emergency response systems increase national resilience to adverse events and build hope.


Observations from recent theater level exercises by the EUCOM Surgeon’s office closely parallel the SOCEUR Surgeon’s office’s lessons learned from focused exercises: modern conflict modeling and casualty estimates reveal that military medical resources may be rapidly depleted, such that civilian medical infrastructure, when present, will be critical for medical support to Allied operational forces in various Eastern European conflict scenarios. The EUCOM Surgeon and staff, along with Service Component Surgeons’ staffs, have begun efforts to address the identified need for a whole-of-society approach to preparing for the potential medical scenarios associated with contingencies in Europe. EUCOM is working with the Defense Health Agency’s Joint Trauma System to establish a Combatant Command Trauma System, which aims to set a common baseline across U.S. geographic combatant commands for standards of trauma training and components of trauma systems. This effort ensures that U.S. military HSS capabilities are optimally poised to be ready for response to contingencies, providing the best possible care from POI through surgical care. It also acknowledges the need to better integrate partner nation systems into a theater-wide trauma system. EUCOM has begun to develop a MEDCOP that will provide EUCOM and Component Commanders, Surgeons, and medical planners with increased awareness of military and civilian medical, and specifically trauma resources in Europe. Ideally, this MEDCOP will be developed corroboratively with partner nations, and shared for common operational benefit. EUCOM’s Global Health Engagement activities with Allied and partner nations over the last several years have focused primarily on military-to military activities that aim to support partner nations’ achievement of NATO standards for expeditionary medical capabilities. These have included cooperative training on TCCC and other trauma care standards, as noted above. Recognizing the importance of civilian medical capabilities in a variety of operational scenarios, EUCOM is updating its GHE strategy to increase U.S. engagement with partner nation civilian health systems, medical centers and personnel. This, of course, must be approached with a great deal of coordination: with U.S. Embassy country teams for synchronization with other U.S. government health efforts; with partner-nation military and civilian health leaders; and with multilateral organizations, such as NATO, as appropriate. One approach to enhancing understanding of partner nation trauma systems and developing institutional relationships is to capitalize on the State Partnership Program. This program, executed via the National Guard Bureau, pairs U.S. states with partner nations. There are 22 such partnerships in the EUCOM area of responsibility. Military-to-military activities, such as training and exercises, often lead to military-to-civilian and civilian to-civilian interactions with enduring personal and institutional relationships. CONCLUSION Medical support to U.S. SOF and partner resistance forces will be extremely challenged in the European theater in a resistance scenario. Specifically, medical evacuation will be severely restricted and U.S. SOF surgical teams, as currently designed, will have low survivability. The SOCEUR Surgeon’s office is targeting a whole-of society effort to enable medical support to resistance across multiple spheres of influence, including U.S. SOF medical forces, partner- nation military HSS and partner-nation civilian medical institutions. A whole-of-society approach is critical for uniting efforts of U.S. medical equities now in steady state operations, which will improve capabilities and increase options for medical support of U.S., allied and partner forces in the event of peer conflict in Eastern Europe. EUCOM recognizes the value of this approach and is developing a strategy toward end states of enhanced military and civilian trauma capabilities, and increased interoperability between civilian and military capabilities, both within and between nations. Embarking now on these collective steps will save lives and, should the worst case happen, enable better trauma care at every level, which will help keep hope alive.


Sgt. 1st Class Jake Hickman, U.S. Army, is a SOCEUR Medical Operations Sergeant.

Col. Jay Baker, U.S. Army, is the SOCEUR Command Surgeon.

Lt. Col. Elizabeth Erickson, U.S. Air Force is the EUCOM Chief of Global Health Engagement.

Acknowledgments: We extend a special thanks for review and comments to Col. (Ret.) Dr. Warner “Rocky” Farr, Col. (Ret.) Sean Keenan, Maj. Michael Weisman and Maj. Adrien Adams.


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