I have some friends who live across the country, and we have a recurring joke about catching up with each other in a few years somewhere in the South China Sea when we’re drafted to serve in a hot war with China. The exact venue varies: sometimes it involves us being pinned down on a Taiwanese beach, or facing an incoming drone swarm on the deck of a destroyer, or returning injured to the American mainland. It’s a dark bit and not especially funny, but very serious people spend their time preparing for that last eventuality.
Today, we spoke to Dr. Jeffrey Freeman, who directs the National Center for Disaster Medicine and Public Health (NCDMPH). Dr. Freeman leads a team that Congress has tasked with studying something called the National Disaster Medical System, which would coordinate how we treat casualties in the event of a hot war with a peer. He worries that if we don’t prepare now, our on-paper system for distributing patients is likely to collapse once the shooting starts.
Timestamps:
(00:18) Working with INDOPACOM
(3:55) 1,000 casualties, every day, for 100 days
(11:27) What private sector hospitals can expect
(23:43) Preparing for situations you can’t predict
(37:32) What happens when digital systems go down?
(44:19) What’s the potential scale of a conflict like this?
Tell me about the National Center for Disaster Medicine and Public Health.
The NCDMPH is an interagency organization that looks at strengthening our military and civilian health systems to respond to the medical requirements of a large-scale combat operation, with a peer or a near-peer.
In that situation, there's going to be a large number of both military and potentially civilian casualties. If folks are returning home from an overseas war, we're going to have to ensure that they can receive care.
As a consequence, we have a lot of bosses, including folks from the Departments of Defense (DOD), Health and Human Services (HHS), Homeland Security, Transportation, Veterans Affairs (VA), and State.
You were recently out at U.S. Indo-Pacific Command (INDOPACOM). What was that visit about?
When we visit a site, particularly when we're going to an area of a geographic combatant command like INDOPACOM, we speak to folks who represent all of those groups. We go to Tripler, which is the military treatment facility on-island in Oahu, and talk with folks from the major VA medical center and also federal, state, and local partners: HHS, FEMA, and the local hospital systems such as Queens Medical Center, the only Level I trauma center in Hawaii. We let them know why we’re here and try to better understand their situations, because our work requires their cooperation.
At an institutional level, what are you doing talking to folks at INDOPACOM?
If war broke out in certain areas in the Indo-Pacific, and we're having to move folks from theater back to the United States to receive definitive care, it’s complex. INDOPACOM is the geographic combatant command in which the hostilities are occurring, so our partnership is essential. Other non-geographic combatant commands, like Transportation Command: that's going to have to carry a lot of the weight in moving people and stuff.
There are the DOD military treatment facilities, both in Hawaii and back home, that will have to receive some of these folks, plus VA medical centers. There are also about 1,800 civilian hospitals that have signed an agreement with the Department of Health and Human Services to support this mission. Understanding all of those partners and how folks will flow from theater back to care is a monumental challenge.
My understanding is that you set an institutional benchmark for yourselves: caring for 1,000 casualties daily for 100 days. Can you contextualize that number for me?
That number is an unclassified, notional scenario based on the number of casualties that were returning home and needing care during World War II. There are classified scenarios, some that have already been developed, and others that are in development now based on what we're learning from recent conflicts. Those classified scenarios are much more specific in terms of not just the number, but the nature of the injuries themselves, which is going to be quite different than what we observed, say, in Iraq and Afghanistan.
That 1,000 per day over 100 days is a fair benchmark on the high side. And that unclassed notional scenario is both easy for folks to understand, and also large enough that it's going to stress the system in the ways that we would expect a true conflict with a peer or near-peer to generate. That’s why we use it, especially when working in an unclassified setting, which this mission requires.
If the nation goes to war with a peer, it's not a whole-of-government thing. It's a whole-of-nation and maybe even a whole-of-the-world, when we consider some of our partners and allies that would likely be involved.
Will you give me more detail on the step-by-step for getting casualties home?
Let's say I'm on a naval destroyer around the South China Sea, and I have a serious but not life-threatening injury. Eventually I end up, hopefully, in Hawaii? And then potentially back home on the mainland.
How do I get there?
Even Hawaii is a debated step. With a casualty downrange, first you're going to have to get that person and evac them out of the theater. In the cases of Iraq and Afghanistan, the U.S. had absolute air superiority. We could get people out quickly and back to what we refer to as a role 4 care, which is definitive care in a major hospital or MTF, meaning a military treatment facility. In conflict with a peer, we're not sure we'll have air superiority.
In addition, there's only so many military resources that can actually move people. A lot of those resources are going to be occupied with moving the things that are needed to carry out, execute, and hopefully win a conflict. But there are what we would refer to as flights of opportunity, where planes are needed to return to restock, get critical supplies, and be sent back to the fight. We anticipate that folks will probably be loaded onto some of those planes that are, of course, equipped for moving casualties.
Those planes will fly them back from theater to what we refer to as a core casualty reception site — these are designated military installations where very large military planes can land, unload those casualties, restock, and return. Maybe you stop in Honolulu or not; maybe that's a fuel stop. Maybe you have to stop operationally or strategically. Those considerations are all really wartime considerations.
We can plan as best we can. Certainly, there are plans around what routes to take and where and where these folks would go. Take everything with a grain of salt. There’s a phrase — no plan survives first contact. But there are some things I can say that are pretty sure.
They are going to land at one of those core casualty reception facilities. How do we then move them through this broader process? We have a system that we refer to as the National Disaster Medical System, or the NDMS. This construct was actually created back in the ‘80s during the Cold War. The concern was: if we go to war with the USSR and we have large numbers of casualties, how are we going to provide care for them?
What that amounted to is a partnership between Defense, Veterans Affairs, and Health and Human Services. Within that construct, you've got military treatment facilities that fall under the DOD, VA medical centers under the VA, and then you have those civilian hospitals under HHS ASPR, the Administration for Strategic Preparedness and Response. When you have casualties, the idea is to flow those folks through these places.
After landing at core casualty reception sites, a Federal Coordinating Center will try to identify where we can send them. Are there open staffed beds at MTF’s VA facilities, or at civilian hospitals? From there, the decision is made as there is some availability. Then we have to transport them. That’s another challenge because military vehicles will probably be forward-deployed. Then we have to look at civilian assets. There are things like the national ambulatory contract that FEMA owns.
What is that?
That's a contract with a number of different emergency medical services companies, a resource-sharing compact that FEMA manages.
Let’s say a hurricane hits Florida really hard. We could potentially pull in EMS ambulances and other sorts of capacity from a neighboring state. That model works pretty well because there's not a lot of EMS capacity in the country. If you're talking about a natural disaster, that is a bounded, acute, and geographically limited event.
But in the case of war, we're talking about a protracted and geographically unbound event. So a contract that relies on sharing, when everybody's having to deal with the same resources, is probably going to reach its limits quickly.
So what are the next steps there? Let's say military vehicles are largely off the table. The ambulatory contract is stretched. What's next in the chain?
That's an open question. There are other commercial contracts that we could look at that could potentially help people move. Air is one way to think about moving people from point A to point B, beyond just an ambulance or helicopter.
We might have to be more creative. In Europe, in World War II, they used trains, and they've converted trains into hospitals now in Ukraine. That might also become a requirement for this sort of mission. That being said, it's not easy to outfit a train, as they’re currently outfitted, into a hospital that is capable of moving trauma patients, for example. We’d have to look at many options to accomplish something at this scale.
In prep for this interview, I looked at a report that summarizes what military medical professionals worry about in a situation like this. Here’s one worry that surprised me: close to two-thirds of these interviewees are “very worried” that private sector hospital leaders may not be aware of their partnership with NDMS.
That was really striking to me. Are there lots of hospitals that don’t realize they’d have contractual obligations when war hits?
That is not just a very valid concern for some of our colleagues. We've observed that directly executing this NDMS pilot program — the project that is explicitly looking to assess and strengthen our military and civilian health systems to meet the requirements of this mission. We have pilot sites across the country where we're looking at these key gaps, challenges, seams.
In all of those sites, where we engaged with the civilian side of this mission set, very few people fully understood that their hospital had even signed the memorandum of agreement with HHS to support this mission. When they had, there was a pretty large lack of understanding of what their actual role would be and how they would execute that mission.
And what does that look like? Hospital administrators just don't realize that they're signed up or that they have certain commitments?
The hospital administrators may be totally unaware that in a prior administration, years ago, someone may have signed the memorandum of agreement with HHS ASPR.
This basic agreement says: In the event of war, natural disaster, or other health emergency, if we need to leverage beds and staff from your hospital, we would expect that you would provide them. As a benefit to that, when you move in NDMS patients, you are given a sort of guaranteed reimbursement. Under the memorandum of agreement, it was roughly 110 or 115% of CMS.
That has changed now. They've actually increased that to 125% to incentivize hospital participation.
Even if they did know, what does that look like? They naturally ask: “How are we going to adjudicate large numbers of casualties coming in?” Because the NDMS, since its creation in the ‘80s, has really only been used for natural disasters and smaller events, but it has never been activated at scale.
And what you're describing as a whole-of-nation response to a protracted war hasn't happened in living memory, right? You wouldn't describe anything since World War II as meeting that bar.
No. Vietnam was certainly a large-scale combat operation, Korea was large, but none of those were at this scale. And in neither of those instances did the U.S. homeland come under attack. There's a reasonable expectation that if we're at war with a peer, we probably can't assume a sovereign homeland.
In the same way that we probably can't assume air superiority in theater, a war at that scale is going to look very different. The kind of thing we are preparing for now is something closer to the scale of World War II.
What are the institutional muscles that have atrophied in that time? What would we have to relearn?
There are a few things. Let’s start with the National Disaster Medical System, the thing we’ve spent most of our time on.
It was created in the ‘80s to do this kind of mission, but it's not constructed in such a way to meet those requirements. There are roughly 3,400 intermittent federal employees, folks who can be activated and become a fed at that moment. You have a number of different DMAT — Disaster Medical Assistance Teams — that can be deployed.
They rotate in. They're really adept at doing what they have done for 20 years, which is responding to natural disasters and other critical events.
But in a war, a staff augmentation model is not going to meet the very large delta between where we are and what we need.
Is that a pure quantity constraint? That with this scale of casualties coming back every day, increasing the staffing just doesn't get you there?
It's both a quantity and a design constraint. Quantity because there are only so many staffed and available beds in this country. Most hospitals operate with a very fine margin.
What is that margin, typically?
Most hospitals are anywhere from 85% capacity to, for many of them, over capacity. The hospital in Hawaii, for example: Their steady state is above capacity.
And that's a function of the economic constraints the hospital finds itself in, that you can't just leave capacity sitting around all the time and operate?
The analogy I use is that our military and civilian health systems operate much like a restaurant after the dinner rush. If your listeners have not had the great privilege of working in a restaurant, as I have: restaurants are really only fully staffed during a few hours of any given night.
That’s just during the dinner rush when most people come in to eat. After things begin to slow down each night, they'll cut a bunch of their staff, servers, bussers, hosts. They can't afford to have a bunch of people standing around with nothing to do.
But sometimes, after those cuts have been made, a school bus pulls up, and it's got a high school band or soccer team on it. It just breaks the kitchen, because you're running a skeleton crew in that restaurant.
Our health systems are exactly the same way. They can't have a bunch of doctors, nurses, other clinicians, technicians — or even medical supplies, as we observed during COVID — sitting around in the event that the proverbial pandemic bus pulls up, or in this instance, war. They've got to maintain a really razor-thin financial margin.
In addition, one trend that limits our ability to respond is that our health system spent the last 20 years optimizing itself: trying to become more efficient, more optimal in the way in which it’s set up. The problem with this is it means we have much leaner systems and much more vulnerable systems. If you introduce a major perturbation into the requirements upon which a system has been optimized, you will break that system. If we have a war, if we have a next pandemic, a more severe pandemic, or any other catastrophic event on the homeland, there's just very little margin available to us anywhere in this country to meet those demands.
So getting all the way back to the NDMS — they can do staff augmentation, they can send DMAT teams, but that only gets you so far.
Will you describe that optimization trend over the last 20 years? What does that mean for hospitals?
Fundamentally, they try to reduce their inputs. They want to get more use out of the clinicians that they do have. They want fewer clinicians providing the same services wherever possible.
They also want to hone their healthcare delivery model such that it finally meets the expected patient demand, at any given moment. Now, that looks different over the course of a year. There's flu season. There are other sorts of things that matter. When you introduce changes to that expected demand, you can cripple the healthcare system.
During COVID you might remember the term tripledemic. RSV, flu, and COVID all hit kids at once when they started to return to school. The reason that was so problematic is what happened during the shutdowns. Kids weren't at school or in daycare, so they weren't spreading all the illnesses that they normally do. They were also not in hospitals needing care for more severe ailments. Since kids are pretty healthy for the most part, they’re typically pretty ill when they do show up in hospital. During COVID, those patients were not in hospitals anymore, and instead they were replaced with relatively lower-cost COVID patients.
Hospitals lost a lot of money during that time. So they made cuts, which led to burnout as they ran lower staff footprints. Then kids went back to school and daycare and started to get sick at higher rates again. Some of those kids started to show up in hospitals, but we had essentially crippled our pediatric intensive care system across the country.
Nobody intended for that impact to occur, but it gives you a sense of how optimized our health systems are for only the expected demand. Anything out of the ordinary is really problematic.
Beyond tightening staffing, how else has that hospital optimization occurred?
Some of the ways are very good. Optimizing the delivery of care to patients recognizes that patients are different. They might use electronic health record systems combined with advanced analytic approaches to acknowledge differences in a patient who is 70 versus one who is 40, a patient who is 70 and obese versus a patient who is 70 and not obese, and other sorts of comorbidities that patients and individuals may have.
If you can individualize care in a targeted way, then those folks don't necessarily have to remain in the hospital as long, and when they are discharged they’re less likely to come back. If you just think about sheer throughput from a hospital financial perspective, you really do want to maintain consistent throughput if you can.
How do you build an institution like the NDMS so that you’re ready to go in the event of fundamentally unforeseeable events? Because the nature of war, as you've outlined, is that your plans don't exactly survive. You're going to have to adapt on the fly.
There's a three-dimensional approach that you have to take to prepare for or respond to any major, large-scale, potentially catastrophic event. The first is where the government traditionally has spent most of its time, asking, “What can we do to strengthen the response capacity or even approach to respond to the events, as it exists today?” That may be increasing the number of intermittent employees. It may be our Disaster Medical Assistance Teams changing their models. Instead of staff augmentation, maybe they can serve as a staff multiplier. That dimension is within our control.
The second approach, policy changes, is for our colleagues on Capitol Hill. How can we improve the systems of tomorrow? We need to inform Congress on the fundamental changes that they need to make to prepare our nation.
Some are simple policy changes or authorities. What additional resources need to be given to FEMA's national ambulatory contract? What additional authorities might need to be given to the president or cabinet secretary or a particular agency or organization to meet these requirements? There will be many.
But Congress doesn't have a silver bullet. And that gets to the crux of the issue: no matter what we do in those first two dimensions, we're never going to bridge the delta all the way to the massive requirements that would be required in a wartime scenario. We're going to have to build an immense amount of capacity at the moment, on the fly. And importantly, we're going to have to do that in an environment where the mission will trump everything. The rules as we know them, as well as our assumptions, the things that we've learned throughout our careers, just may not apply. We saw a little bit of that in COVID. But in a wartime scenario, you'll see a lot more of that.
The third thing that the government has to do along with its partners, at every level, is think about how we build capacity more quickly, more effectively, on the fly, than we ever have before. We refer to it as “building on the fly by design,” where the mission trumps all and the rules do not apply.
Go into more depth on that for us. What does that look like in practice?
It basically requires you to walk the dog, so to speak. Step one in building on the fly by design is to imagine the requirements that would be derived from the worst-case scenarios: a large-scale combat operation overseas, combined with a cyberattack on the homeland, combined with the emergence potentially of an infectious agent, whether intentional, accidental, or natural. What are these worst-case scenarios that we're going to see, and what are the requirements of that? Is it moving X number of patients? Is it providing what composition of care to individuals?
But that's only piece one, and government has done that, traditionally speaking. It does a lot of worst-case scenario types of planning, but it's the second and third things that become really important. Step two: given the requirements of the worst possible things we can imagine now, let's imagine what solutions, capability, or capacity could be developed, refashioned, or re-vectored at that moment to meet those requirements. We're not talking about things as they exist today. We're asking, “What could be done if the rules do not matter?” You can be boundless in what you might imagine.
But that too is not enough. You have to then move to step three, saying: “If this is what you want to do, in a rules-flex environment, here's how you operationalize that.” That is a critical piece, because in health and medicine — and really across government — we do not plan or prepare for operating in an environment where the rules don't apply to us. That's antithetical to how we work, and so we never get to the development of that plan. We don't plan, for example, for how we would do a thing that otherwise would actually be unlawful. But I'll give you two examples of what this could look like. One is a pandemic example, the other is for wartime.
When we were distributing vaccines and actually trying to get shots in arms, what we used under the federal government was the PREP Act to allow pharmacists to start giving vaccinations in pharmacies. For the most part, that was fine. But you could imagine a more severe pandemic where we need to get shots in everyone's arms as quickly as possible. If you think about something like an intentional infectious attack, then we're probably going to need more than pharmacists.
Well, what about veterinarians? My wife's a veterinarian. This was a point of contention for her throughout COVID. The point that she made to me is, and I'll use her words, “Exactly who do you dummies think are more effective at sticking a mammal with a needle? A pharmacist, or a veterinarian?”
That's not a knock on the pharmacists: they are also quite effective at sticking mammals with needles. But there was an untapped capacity of veterinarians that we eventually used, but only after fourteen months into the pandemic.
If you were going to prepare for that worst-case scenario, that third step of the operational plan becomes really critical, because we need to answer fundamental questions, like: How many veterinarians are there in this country? Are people going to go to vet clinics to get their vaccines? How do they feel about that? Are vets going to go to pharmacies or hospitals to stick people? Also, how disruptive is using veterinarians to what they do on a day-to-day basis, the care that they provide to the country?
The wartime example is much more severe. The biggest constraint we have in providing care to our wounded warriors and also to our civilian casualties, should we be so unfortunate as to incur those, is that we don't have enough clinicians in this country. They're not available. A lot of our military treatment facilities are not fully staffed. A lot of civilian hospitals are understaffed. It's an enormous challenge. You see this in Ukraine as well. There’s probably going to be a need for people who would not traditionally provide life-saving care to provide it.
In Ukraine, people who are non-clinicians provide life-saving care. When our options become either to let people die or to become more flexible in how we deliver care, one solution might be to apply the military's supervisory medical model to a civilian hospital. That allows clinicians to operate at the very top of their medical license. In some instances, they’ll do something that they otherwise would not be licensed to do. And some folks may even actually have to provide care in the absence of a license altogether.
Saying that is one thing. Executing it is different. There are legal considerations: What’s the authority under which we could do that? Can POTUS do that? Can the HHS Secretary do that? Can a governor? Beyond just the policy itself, how do you execute that? Who are the right people to give the freedom, under a supervisory model, to provide care and also who's going to supervise?
I mentioned the shift in the NDMS model from staff augmentation to staff multipliers. Maybe your DMAT teams are no longer just augmenting a hospital. Maybe they're supervising the transition of that hospital into a more supervisory model.
But we have to work out all of these things. If we try to do them on the fly at that moment, having not thought about these more severe instances, it's going to be chaotic and will probably do more harm than we would otherwise accept.
But make no mistake about it. We're going to have to do it, even if it doubles or triples the risk of death to the individual patients we are caring for. A double or tripling of the risk sounds really bad, doesn’t it? But compare that double or triple risk to certain death. Does it sound bad then? That’s what we would have to weigh.
Let me go back to that survey of military medical professionals, on weaknesses in our current response system. Close to 90% of respondents agree that “IT systems are inadequate to coordinate patient care across the federal and private sectors.”
Explain that worry for me. What's the problem there?
There are a few. When we originally set up this pilot program, we had five pilot sites: Washington D.C., San Antonio, Denver, Omaha, and Sacramento. One of the first things we did was an IT landscape study to ascertain how many IT systems in those five pilot sites are involved in patient movement and care in this mission set?
We found 77 systems, just at those five sites. Those 77 are not interoperable. They do not share data or information, and they largely cannot put together the type of information we would require to execute that mission.
At the federal level, if we're talking about just patient movement, there are two really important systems. The DoD has a system called TRAC2ES, which provides the sort of information on those casualties as they move. And HHS has JPATS. Those two systems do not interoperate and do not share information.
We also don't really have, at the federal level, a finger on the pulse of the nation's health systems. Some disparate systems exist that provide us an indicator. For example, there's emergency department data that's fed up through what's referred to as the National Syndromic Surveillance Program at the CDC. That’s pretty good, except for the fact that California doesn't report that data to the CDC. In the middle of a response, you're not going to use a system that doesn't have California data for a national level event.
There was something referred to as the unified hospital data set, but that only existed because of COVID, and a bunch of hospitals were essentially forced by a Medicare and Medicaid mandate to report bed capacity, staffing, and those sorts of needs. But that's going away, and is replaced right now by a smaller scale pilot in a few select locations. So we don't have the data. We know we don't have it.
Even if these systems all did interoperate in a wartime scenario, the movement of hundreds of U.S. military casualties and where they ultimately end up is going to be classified, because if that was leaked it's essentially a targeting map for our adversaries.
So we have to think about high-side to low-side integration. How do we deliver actionable information from the federal government to the civilian hospitals that need to provide care, without simultaneously introducing a threat to our warfighters, right? These are huge concerns and problems under this mission set.
So what do you tell hospitals? You're going to have to communicate, “You've got 40 people incoming,” etc., right?
We don’t know. I've thought about pulling in our intelligence community partners. Are you familiar with homomorphic encryption?
No.
Homomorphic encryption is a way to share information without sharing data. You could take patient data and encrypt it. Then you could produce an output of your computation, still having never used the de-encrypted, patient-level data. It's possible we could apply something like homomorphic encryption to compute the high-level numbers, such as numbers coming in, type, etc. The output of that is only the actionable information that would be necessary for those hospitals to prepare and receive.
Exactly what that information looks like and how we prevent adversaries from extrapolating back the number and nature of who's coming in — Are they military? Are they civilians? — is still an open question, but that’s what we’re thinking about. At the end of the day, if we don't figure that problem out and the nation goes to war, we still have to tell the hospitals. It may be just one of those things where we accept the vulnerability. That's a decision above my head.
I'm imagining another related concern is that a lot of these systems may be non-operational at all in a wartime scenario: they may be hacked or compromised such that the whole digital tracking system isn't working.
That’s 100% a concern. Our adversaries are probing our critical infrastructure all the time anyway, both governmental and non-governmental. Why would we expect a war would result only in kinetic warfare and not cyber or infectious or anything else? If we prepare strictly for kinetic, we're going to be in for a rude awakening. I can assure your listeners, we are preparing multidimensionally.
There's another layer there as well if electronic health record systems (EHRs) are knocked out. 15 years ago, the federal government was super concerned about getting hospitals to adopt and implement EHRs. But a lot of our young clinicians now have never worked in an environment that was paper-based.
If you knock those systems out, as we did a couple months ago by what was essentially not an attack, you will immediately lower the capacity of your facility, because they're not used to operating in that environment. HHS is now asking, as a contingency plan, about how we train clinicians around the country to revert to a paper-based, non-digital environment, should those systems go out during any major event. It doesn't have to be a war.
Can you talk about any details of potential casualty scenarios we might see in a hot war with a near-peer? You mentioned classified scenarios. I'm looking at a RAND Corporation wargame. It doesn't get into numbers. But in the wargame, conflict over Taiwan kicks off a hot conflict, and the U.S. loses assets in theater “very quickly.”
And they have some striking language here about casualty rates. Can you say any more about the boundaries of a potential scenario here?
I can't talk about any sort of specific numbers or scenarios or even specific nations. But I can tell you that the scale of these events is enormous. They represent a scale that has every possibility of overwhelming our military and civilian health systems, quickly. Previously released unclassified information says the 1,000 per day would overwhelm our system writ large in about 14 days. No war is going to end in 14 days.
We fully anticipate that the kinds of injuries that we're going to see are going to be very different from what we saw in Iraq and Afghanistan. Some research from RAND as well as the Ukraine war show that as well.
In both Iraq and Afghanistan, we usually had more folks to provide care than we needed. In a World War II scenario where we're having to triage and make decisions not on who's most severely injured, but who's most likely to survive, the clinicians that are having to make those decisions are really going to struggle. It's what we refer to as moral injury. That leads to burnout, attrition, and other long-term impacts that will ultimately degrade our ability to sustain a wartime posture.
I've seen a big debate about the nature of casualties coming home. What do we have to prepare for? There’s one camp that says, “If you're able to get these folks out of theater and all the way back, they're probably stable enough that we're not going to be dealing with severe trauma.” Yet a lot of our attention focuses on trauma care.
But if they can cross the Pacific, presumably they’re somewhat stable, right?
That’s probably true for the folks that make it back. But if we're at war with a peer, we're probably also taking direct hits here, and the direct hits here would be immediate trauma care. So another camp says — we have to focus on trauma.
We actually have to be prepared for both and we would encounter both. The complexity of that kind of scenario greatly concerns us, because no matter how we slice it, we know we're not prepared. That’s why Congress mandated this program in the first place. It's why so many folks across the interagency are moving so aggressively to try to address these gaps.
One last point: We hope that a lot of the preparedness that we do prevents hostilities from occurring in the first place. Preparation might be a deterrent.
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