Page 156 - JSOM Winter 2018

responding to the absence of explicit acknowledgement of and thinking about SOCMs’ relationship to death in austere set-
medical training for death in current Tactical Combat Casu- tings. On one side, SOCMs ought to do nothing; on the other
alty Care (TCCC) and PFC documentation. side, they ought to do everything. The reality lies somewhere
in the middle and is captured by the following commonly used
military medical adage. There are rules of war. Rule 1, young
Modern Medical Assumption About Death
men die. Rule 2, doctors cannot change rule 1. If this is true,
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Military medicine influences and is influenced by broader then SOCMs providing care without the benefit of a quick
sociocultural values and politics concerning healthcare. One medical evacuation will face death. To establish why expli-
assumption is that death is the enemy to be combated by med- cating death is important, I begin by investigating how the
ical interventions. As Atul Gawande, a civilian physician spe- SOCM’s role could change in the future.
cializing in trauma surgery, explained, “Our textbooks had
almost nothing on aging or frailty or dying . . . the purpose The SOCM’s Roles in PFC
of medical schooling was to teach how to save lives, not how PFC researchers are interested in moving away from the tra-
to tend to their demise.” 2(p1) When death is avoided as a med- ditional “echelons of patient care,” because of the need for a
ical reality, the practical result is that dying is understood as “more comprehensive list of capabilities . . . across a wider
a failure of medical competency. Gawande related that when spectrum of operational realities.” 5(p78) To achieve the most
he encountered death, he felt he had killed his patients—that efficient and effective combat casualty care, PFC research
he had failed. 2 is turning the doctrine of traditional echelons of care on its
side and investigating ways of performing medical care that
Elizabeth Kubler-Ross, the pioneer of contemporary research have typically been performed at Level II or III facilities. Con-
on death and dying in medicine, said the singular focus on sequently, care of the injured warrior may last “for days or
life-saving procedures creates more fear of death, making it even weeks” in the field. 6(p84) In SOF, the focus of prehospital
more taboo, gruesome, lonely, mechanical, and dehumanized. trauma care has never been immediate evacuation; it has been
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If the modern medical collective consciousness is deeply death management of life-saving interventions.
averse, then SOCMs facing death in austere settings are im-
plicitly asked to be countercultural, because they cannot hide Because the SOCM is the main source of prehospital trauma
death behind medical technology. Anxiety and distress could care in austere settings, it seems reasonable to infer that the
be made more poignant for the SOCM if there is a lack of SOCM’s role in providing life-saving care will expand to in-
familiarity with the dying process. Without training, SOCMs clude management of severe injuries, something that doctrin-
are unlikely to have the wherewithal or knowledge to confront ally would happen at a Level II or higher facility. The SOCM’s
the subtle forces of death denial. They are more likely to main- role will also include determining which casualties can best
tain the status quo by avoiding the dying warrior. Avoiding be treated with the available resources, which requires deter-
the topic of death sets up potentially challenging consequences minations about starting, withholding, and withdrawing life-
for the SOCM in terms of care in the field as well as how the saving care. Realizing that the unprecedented survival rates for
SOCM manages her or his reality upon coming home from combat casualties is linked to rapid evacuation and damage-
deployment. control surgery, it is likely that more injured warriors will die
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in the care of the SOCM. As such, within austere care, I see
Objections to Exploring Death Care three logically distinct categories of medical care provision in
The normative thrust of my article assumes a few things to which the SOCM will have to function: life-saving care, with-
which readers might object. First is that death is a reality in holding or withdrawing care, and death care. I make these
combat. Although a few people might take issue with my first three distinctions because the type of competency required to
assumption, I believe the reader will concur that death is a achieve each category is different, the cadence in which the
strong possibility. I also assume that death, as well as the pro- SOCM will operate is different, and the way of interfacing
cess of dying, ought to be viewed as a medical reality over with the injured warrior is different.
which SOCMs have some level of responsibility on the bat-
tlefield, especially in austere settings once fighting has ended Technical training for life-saving skills will remain a necessary
or in the nonpermissive environment. This assumption is con- requirement within combat casualty care. Although the types
tentious on many levels. I discuss two points of contention. of medical interventions might expand within PFC, this mode
First, it could be argued that military medicine solely exists to of care generally remains focused on aggressively and swiftly
support the combat mission and focusing on the dying process doing everything to ensure that an injured warrior will sur-
is antithetical to conserving the fighting force. The SOCM, or vive. In life-saving interventions the SOCM primarily attends
any military medical professional, should only be concerned to patterns of injury and ways of performing damage control
with ensuring tactical effectiveness by treating warriors to put to ensure survivability. Determining which casualties will need
them back in the fight. The dying warrior is, at best, a dis- to have care withheld or withdrawn moves into the realm of
traction and, at worst, a misallocation of resources. After all, both medical and moral decision-making. This deliberative
SOCMs are known as combat life savers. Second, others argue role requires the SOCM to perform risk-benefit calculations,
that those involved in military medicine, especially the SOCM make determinations about resources, consider operational
who is close to his or her comrades in arms, should do ev- priorities, and evaluate the ethics of refusing care. The SOCM
erything possible to save every warrior because anything else will have to slow down to engage high-order cognitive func-
would be tantamount to giving up on them, which strongly tions that rely on the ability to conceptualize and rationalize
contradicts community values. various conflicting pieces of information. Moving into death
care requires the SOCM to connect into the subjective reality
Although these arguments are defendable on their own terms, of the injured warrior’s pain, needs, and desires. This role en-
taken together, they create an intractable ethical polarity when tails a broad set of intra- and interpersonal skills that require

154 | JSOM Volume 18, Edition 4 / Winter 2018