Page 118 - JSOM Fall 2025

occurred during World War II when the Yugoslavian Partisans While tactical and political considerations are human vari-
resisted Nazi occupation. ables, other operational considerations that force a DFC strat-
egy are out of human control—weather and disease. In their
Nazi dominance required creative methods for delivering final campaign in 1944, Merrill’s Marauders paid dearly with
healthcare to both the resistance and civilian population. Static 980 soldiers evacuated for illness and 955 evacuated for in-
locations were often in hard-to-reach geographic locations jury. Burmese jungle roads became impassable with the rainy
10
requiring patients to be carried for miles across rugged and season deluge, and movement was equally difficult for both
treacherous terrain. Geographic features were taken advan- the Allied and the Axis armies. Mosquito and waterborne ill-
1
tage of, including gorges and caves, to provide cover and con- nesses were rampant. Merrill’s Marauders had a very limited
cealment for medical operations. At times, underground wards evacuation plan. The Office of Strategic Services (OSS) had
were constructed, often dug by hand, near a water feature. no practical means of evacuation, and the local Kachin fight-
Utmost secrecy was maintained regarding all these locations, ers were never getting evacuated (Lew Kolodny, MD, Personal
as the Nazis specifically targeted healthcare facilities, killing Communication, December 1996). DFC was their only option.
both workers and patients alike. Despite tactically proficient
2,3
fieldcraft being utilized, the always advancing enemy forced These operational conditions are seen regularly by humani-
the operating theaters, post-operative recovery wards, and tarians working with oppressed people groups. In Afghani-
convalescing patients to relocate often. Surgical care in this stan during the Soviet invasion, a small civilian surgical team
environment was challenging at best. 4,5 utilized disguise and frequent movement on bicycles to avoid
detection by Soviet forces. The team never stayed longer than
8
Following WWII, the implementation of DFC was also uti- eight hours in a location and thus postoperative recovery and
lized by several non-governmental organizations (NGOs) in follow up were limited. Despite the challenges, outcomes were
Afghanistan during the Soviet invasion from 1979–1989. surprisingly good, demonstrating that surgical care, even with
6–8
While there are many more examples of definitive care less than optimal conditions, saves lives.
throughout history, there is one important shared aspect of
healthcare delivery—definitive care was always provided at With appropriate planning, implementation of DFC may make
the time of the initial surgeon-patient interaction because this attaining care within the Golden Hour more likely. Rather than
interaction was often the first, last, and only interaction. delaying definitive surgical care or damage control surgery as
described in PCC/PFC, the DFC pathway is implemented as
soon as it is deemed reasonable. What small amount of liter-
Operational Considerations
ature there is available describing DFC-like conditions, sug-
Restriction of movement is the the driving force behind the gests that suboptimal conditions for surgery are less evil than
use of a DFC strategy. While there are numerous reasons for delaying a critical surgery. The DFC plan accepts some risks
restrictions of movement, without movement, normal evacua- inherent to the environment while mitigating others.
tion chains cannot be utilized. The tactical and political envi-
ronment are the two main considerations driving restriction Risk Tolerance
of movement. As war is a continuation of politics, there will
always be a population of people that are not politically con- During DFC, the accepted risk tolerance will be higher than
venient, or maybe even politically detrimental, to evacuate. A PFC/PCC. As of the writing of this manuscript, there are over
medical element supporting such a population by definition forty conflicts globally. It has been said that the world is at
11
are in a DFC strategy. war, though it is not yet a “world war.” The majority of these
12
conflicts are due to terrorist insurgencies, ethnic conflicts, and
For example, the Viet Cong were restricted to using the Cu Chi civil wars, the combination of which has led to an increase in
tunnels. There was no evacuation plan to a higher level of care irregular war environments (IWE). Many of these conflicts are
9
for these casualties. The providers sent were the DFC. Even in the most remote and poverty-stricken areas of the world,
within Operation Enduring Freedom, Operations Freedom compounding the difficulty of providing medical support to
Sentinel, and Operation Iraqi Freedom, there are examples the combat elements, as well as to the civilians who are often
were local forces partnering with the United States were not directly attacked as terror targets (Box 1). Additionally, many
able to be evacuated to higher levels of care, let alone evacu- of the actors in these IWEs are ideologues and not subject to
ated for Role 5 care in the United States, as this would have and refuse to abide by Geneva conventions.
been impractical. In this situation, the U.S. provided some level
of care, and if and when able, casualties moved to definitive In order to provide care in many of these conflict zones, dis-
care locally or “on the economy.” creet humanitarian or government entities are needed. The in-
dividuals in these elements, and their patients, face different
In the case of an intervening country supporting a resistance risks and mitigation strategies. These risks include disease as
element, echelons of care are likely different for intervening well as battle and non-battle injuries. The increased risk also
force casualties than for their local partners. Additionally, applies to facilities, infrastructure, tactical commands, and
wounding patterns may drive a partial DFC strategy in which politicians engaged in the conflict. Accepting these risks is a
all patients with extremity injuries are managed locally, but necessary part of implementing and understanding DFC as a
those with penetrating abdominal trauma are evacuated when primary strategy. Despite these increased risks, it is being ac-
possible. When there is no hope for any evacuation, there is tively carried out in parts of the world today.
likely to be a significant shift in decision making; for example,
the role for direct amputation versus limb salvage, or the de- Providers in these locations are subject to the same risks as
cision to resuscitate a patient with a significant burn or trau- the resistance forces. Neutrality is not an option in IWEs
matic brain injury (TBI) versus expectant management. where ideologues and dictators often dominate the political

116 | JSOM Volume 25, Edition 3 / Fall 2025