History of Military Emergency Medicine
Barry Wolcott, MD
GSACEP commissioned this interview with Dr. Barry Wolcott as part of its History of Military Emergency Medicine project. Dr. Wolcott held numerous positions throughout his Army career, including commandant of the Uniformed Services University of the Health Sciences. After retiring from the military he has continued to further the field of medicine through multiple medical ventures in the private sector. Here, he discusses the early days of USUHS and the evolution of combat medical education for military physicians into the types of training we all recognize today.
GSACEP: Tell me about what this looked like in the beginning.
WOLCOTT: The first time I went to visit Dr. Sanford in Washington, the Uniformed Services University of the Health Sciences was on the second floor of a three-story building in Bethesda above a drug store. Piled all around were samples of fabric and bricks and stuff like that, because Jay was, in addition to everything else, helping pick out all the materials to build the building. The first classrooms were in the Armed Forces Institute of Pathology in what looked a lot like a Victorian opera house with red velvet curtains and so on. By the end of the first two years, they had built the first building at the current campus. “Let’s paint the barn and put on a medical school.” That’s how they did it.
GSACEP: I want to come back around to the 12-week course and some of the other elements of that. Tell me about the lab work. I understand you used animals? Tell me about the ballistic labs. What are some other elements that you wanted to make sure you incorporated into that capstone class?
WOLCOTT: Well there were two animal labs. This is at a time when animal labs were a routine part of civilian medical education, as well. One lab was taught at Bethesda, and we did a lot of different procedures that even today I don’t really think you could do with mannequins. We felt they needed to be trained to do these procedures. And they needed to know what the procedures did to, in this case a dog, but by extrapolation to a human. What happens when you have a penetrating wound to the heart, what does it look like? What happens when you have a ruptured spleen, what does it look like? How fast does it bleed? When you look at it bleeding, you can get an idea how long it’s going to take the dog to bleed to death. That’s why you don’t bleed to death from your spleen right away. Usually, you die slowly. But if you get a hole in your heart, it goes a lot faster. We also had a suturing lab and practiced splinting; everything that today would be taught to an EMT. Now, this is before the advanced trauma life support course existed. If you consider that advanced cardiac life support was only a couple of years old at this time, you can see this is all new ground that we were plowing with these kids. How do you load a helicopter? How do you load a crackerbox ambulance? How do you strap somebody down to a litter? How do you strap somebody down to a backboard? How do you get somebody out of a vehicle? How do you put out a vehicle fire? How do you get people up a hatch in a ship? How do you take a blood pressure in a helicopter? It’s really noisy, how do you do that? What are the limitations in the back of an ambulance to what you can do? These questions were a critical piece of training. So that was the lab and hands-on part of it. The other part is the clinical pieces, and then the five-day capstone course.
GSACEP: [Now] we get the five-day capstone course; what do you have to tweak once this is in practice?
WOLCOTT: The first thing was each of the surgeon generals came to Dr. Sanford, because their people had attended this first course. They were under huge pressure from Congress to show that their physicians were being trained to take care of the upcoming war. There was a lot of publicity coming out and a lot of investigative journalism saying that with a huge number of casualties, the military medical system was going to be overwhelmed. And so they were really on the spot with Congress. Their representatives came to this field exercise we put on and went back and said, “This is marvelous; we need to do this for everybody.” Each of the surgeon generals basically came to Dr. Sanford and said, “Can you put one of those on for our doctors?” And Dr. Sanford said, “No, but I’m not in the training business, I’m in the university education business. But I will put on a one-week, educational course for your interns, as long as it’s all services. I’m not going to do one for the Army, and one for the Navy, and one for the Air Force. I’m going to do one together. And I’ll do one and if you like it, then you can put together the staff that’d be necessary to run it after that. The university will provide the academic credentials for the course, so that you can send your interns to it.” That looked like a pretty good deal to them, so they made that decision to do what was going to be called the Combat Casualty Care Course in January of ’80. We were to run two iterations each with 130 students in San Antonio, and it was to be modeled after the field exercise that we put on for the University students. It was a little bit different, but it was essentially the same thing.
There was a lot of concern that this was going to be incredibly unpopular. Doctors just didn’t go live in the woods and do stuff like this. It was unheard of. I had several general officers tell me that they expected that large numbers of the students would either refuse to show up or would just go AWOL. I didn’t think that was true because they were thinking about the drafted doctors that were like Hawkeye Pierce. I realized these were all people that had volunteered to the Health Profession Scholarship Program, to be in the military, at least for three, or four, or five years. They knew they needed to learn enough about it, and they might actually get sent to go help fight the Russians, so I didn’t think that was going to be a problem. But that was the environment - the “Oh, we’re expecting this to be a total disaster.”
True story. Four nights, three nights before this thing was supposed to start, came the news of Jimmy Carter’s raid into Iran to try to rescue the hostages where everything went belly-up and two helicopters crashed and a bunch of people got killed and so on and so forth, big to-do. So that’s going on, and now the students are showing up in San Antonio to go to this one-week course. It was clear that in their mind, they were going to go from this course to go fight in Iran. They actually believed that this course had been put together because somebody knew that we were going to go to war with Iran. So they really paid attention to everything we were trying to teach them. And it was a huge success. Students loved it, the people that came down to look at it from all the different services said, “Oh, this is wonderful.” The second week was equally wonderful, and the services decided to put the resources in to make it run once a month for the rest of time. And it still goes on, it’s still called the Combat Casualty Course, and it’s still down in San Antonio.
It’s a pretty reasonable statement to say that almost every doctor in the military has gone to that course or gone to the one at USUHS. So Dr. Sanford’s contribution is something that 40 years later, is still going on.
GSACEP: Wow, that’s quite a legacy. So let me ask you, did you ever consult doctors who were in Vietnam for any part of any of these systems?
WOLCOTT: Yes, I did. What I used them for was to help me put together the conditions, the medical conditions, and the surgical conditions that made it as far as the battalion aid station. And what did the students need to know in order to be able to function at that level as doctors.
I consulted lots of guys that were still in the Army, or guys that had been in the Army, and had been in Vietnam. But the fact of the matter is that for what we were trying to do, most of their experience was far less relevant than I thought it was going out be. Because most of them had hospital-based experience, and we were focusing this at the battalion aid station and forward. The best information came out of the history books from the people that had run battalion aid stations in World War II and in Korea.
GSACEP: Are you beginning to feel attached to emergency medicine, at this point? I guess I’m interested in where the shift occurs. When does the military begin to slowly accept the need for emergency department training and what’s the turning point?
WOLCOTT: That’s an excellent question, and the reason it’s an excellent question is because the military had, in 1978, no real need for emergency physicians, Military and civilian emergency rooms were still staffed by rostered physicians. So, the military could continue to offer care that was the equivalent of the civilian community by rostering its staff to work in the ER nights and weekends. By 1985, hospitals across the country in the civilian sector were beginning to contract with people who were specializing in emergency medicine. They clearly weren’t all people that had residencies in emergency medicine, but they were people that had experience. People who were working to sit for the boards. The military had to decide how was it going to do that? Primarily, it was going to staff emergency departments by contracting with civilian groups the same way most civilian hospitals were doing to provide the emergency department with physicians who met whatever the standard was at that particular point. That continues to be the model in most of the military hospitals. Currently, contracted physicians, contracted either individually or with groups, staff most emergency departments. Today, most of them are board certified, because that is the standard in the community.
At the time, the issue really was: What are you going to do with people who you’ve spent an
incredible amount of money training for three years in emergency medicine? What are you going to do with them in the military?
The kind of people that thought the military was a lot of fun, and the people that did military stuff, were fun people to hang around. And so we made it something that, going from an emergency medicine residency to being a division surgeon, to being a surgeon in a combat unit, to being a surgeon in Special Forces, to being a surgeon with the SEALS, was a neat thing to go do. And that really was where the military saw the value of these people, and it took quite a while. It wasn’t really until the second Gulf war that they began to see the impact of having these emergency medicine trained people around.
The first Gulf war, the medics showed up late and heavy, to quote General Schwarzkopf. It took forever for the military to assemble the resources in the Gulf that they said they would need to care for the projected level of casualties. General Schwarzkopf’s attack was delayed because the medical support couldn’t get there.
Fortunately, by the time the second Gulf war came around, enough of these emergency medicine trained doctors had come into the positions as majors, lieutenant colonels, and junior colonels in the military who had a background, if you will, in this idea of emergency medicine being something that reached all the way forward to the level of the corpsman and all the way back to the level of evacuation. They had begun to experiment with different ways of configuring packages of care providers that you could move far forward. You could combine them or you could take them apart. You could provide them with small amounts of supplies to accomplish an awful lot of work. And you could link them up with air medical evacuation of really sick patients. Because in the civilian community and in military emergency medicine we were now moving sicker and sicker and sicker patients by ambulance from community hospitals to larger community hospitals to large teaching hospitals. They learned to do that same thing in their military emergency medicine residency. Note that when I was teaching that first class of medical students, the Air Force’s rules were you couldn’t put somebody in an Air Force evacuation plane that wasn’t stable enough to fly all the way from where you picked them up to where you landed them with no intervention, because there wasn’t any intervention possible. That was the standard. Today, you’ve seen what they put on the airplane in Afghanistan to fly to Germany with equipment mounted all over them and everything else.
What I tell people is the contribution of military emergency medicine was the second Gulf war went off on time, because the medics were no longer the anchor that was keeping things from happening.
They had worked out a way to use these principles to clear the wounded from the battlefield, and to move them out of theater, without requiring huge amounts of in-theater hospitals.
GSACEP: One last thing: What do you think makes for a good emergency medical physician?
WOLCOTT: I think they have to be able to multitask and solve multiple problems all at the same time. That’s the attraction of it, and that’s the curse of it.