The Air Force put Todd Rasmussen through medical school, and he planned to serve a while and then go into private practice at the renowned Mayo Clinic in Minnesota. He started his military career as a vascular surgeon in Northern Virginia, a few weeks before Sept. 11, 2001.

“You could sort of see smoke from the Pentagon. I thought, boy, my military career as a surgeon … it’s gonna be vastly different than what I expected,” he recalls.

Rasmussen switched to trauma surgery as casualty numbers soared to the highest rates since Vietnam. At first, the way patients arrived within days from the war zone thousands of miles away amazed him. That wore off though, when he realized patients weren’t getting care soon enough. By the time they reached the U.S., their wounds were contaminated and sometimes too late to treat without amputation.

“It’s hard to admit we let we let somebody down and that somebody was a U.S. service member,” he says. “And so, you know, it’s hard to admit we could have done better. But I think maybe the only thing worse is not admitting it.”

Mounting casualties made it impossible to ignore, and the Pentagon did change. As with previous wars, saving lives on the battlefield inspired medical innovations in Iraq and Afghanistan. By moving medical care closer to the front, and treating combat wounds within the so-called “golden hour,” or even the first 30 minutes after injury, casualty rates dropped.

Now Rasmussen and other veteran medical officers warn that
U.S. military health care again needs a course correction. After a decade of downsizing, Defense Department officials also admit they need to rebuild the medical force and the general health of active duty troops. But restoring medical readiness to where it was during the last war, much less where is needs to be for the next one, is a by all accounts a herculean task.

War is the mother of invention

By 2005, about when he had planned to be going into private practice, Rasmussen instead deployed to Iraq. He saw the medical innovations in real time.

“I remember one U.S. service member who came to us … by helicopter from the front lines in Fallujah. And he had been operated on by a small group of surgeons near the front line. I think the assumption was that we would need to amputate this limb because of the extent of the soft tissue injury in the thigh,” he says.

In past wars, a wound like that would have denied the lower leg blood flow for too long, leaving no option but amputation. On closer inspection though, Rasmussen saw that the front-line doctors had used a temporary shunt in a new way. Essentially, they stuck a plastic straw into the thigh to keep blood flowing around the wound, saving the leg.

“We said, ‘Wait a minute! We can actually fix this… put the amputation saw away’,” he says.

A spiral in care

Rasmussen deployed six times between 2005 and 2012. On his first tour to Iraq, he worked in tents and saw medics improvising – using cargo straps as tourniquets. On his last tour, in Afghanistan, he operated in a fully equipped hospital with new concrete floors and access to MRI and CT scans. Then the wars wound down. And Rasmussen felt some of the progress slide back.

“There were efforts to outsource … beneficiary care from the military treatment facilities to civilian institutions, which emptied out and hollowed out storied military medical centers like Walter Reed,” he says.

Even before the wars ended the Pentagon activated a plan to tame massive healthcare costs by pushing military medical care into the private sector, especially for family members.

The result was a sort of spiral. Military hospitals lost the minimum numbers of patients they needed to keep doctors in practice. The quality of military care suffered, and many clinicians left. Even more resigned during the pandemic, and Pentagon planners realized that the private health care sector they had hoped to lean on actually needed help itself, from the military. But the cuts kept going, says Rasmussen.

Pentagon officials even floated an idea to close the Uniform Services University, the military’s medical school, which trains-up military doctors and preserves medical advances, like those made during the wars in Iraq and Afghanistan. “I mean, why do we need a military medical academy?” Rasmussen jokes.

“They achieved the highest rate of survival from battlefield wounds in the history of warfare. They were able to save people that would have died in any prior conflict,” says Dr. Art Kellerman, who served as dean of the Uniform Services University of the Health Sciences during the threats to shut it down.

Kellerman frames it as a national security priority. He says as much as a helmet or flak jacket, the success of U.S. military medicine gave troops confidence to rush into a firefight, knowing they would probably survive. U.S. allies joined the fight knowing a U.S. medevac would fly to the rescue within 30 minutes if they got blown up. What’s more, Kellerman says, those in the fight believed they’d not just survive, but live well.

“They dramatically improved their ability to rehabilitate wounded warriors after being injured. And many of them were able to return to duty and others were able to return home to be with their families and to function for the rest of their careers. Some of them today are members of Congress,” he says.

Kellerman says America needs that same ready medical force for any future conflict.

And the Pentagon now seems to agree.

A Defense Department internal memo obtained by NPR concluded that outsourcing didn’t actually save money but did hurt readiness. The so-called “stabilization memo” directs the Pentagon to reverse course, to bring more medical care back to its hospitals on base and increase medical staff, both to keep America’s standing army fit for duty and to make sure enough military doctors and nurses are trained up for a possible future war.

A different kind of war

Military strategists caution that generals often try to refight their last war, but America’s next war may be different. In Iraq and Afghanistan, the golden hour was possible because the U.S. had air superiority; the enemy had no planes or helicopters.

“Sooner or later, somewhere, we’re not going to have air superiority. And I don’t care if we think we are, we should plan for not having it,” says Dr. Sean Murphy, who served 44 years and retired in 2021 as Air Force deputy surgeon general.

Murphy points to Ukraine, where two conventional armies suffer massive casualties being evacuated by ground.

Or even more extreme: a possible conflict with China around Taiwan.

“What we’ve realized when we start looking at a theater like the Pacific, and the distances and a peer-to-peer fight, there is no way we’re going to get to the golden hour. So if we’re not going to be able to get a surgeon or somebody to the golden hour, then what we have to do is … to make everybody a medic,” he says.

To do that he says, the Pentagon needs, urgently, to build back its ready medical force.

“The most important fighting system we have is the human system. It’s not a plane or a ship or a tank,” says Rasmussen. He says he saw that again and again when he served.

“And that human system is only optimized and cared for if there is a robust and expert military health system,” he says. “I think degrading that risks our national security.”