Tactical medicine – one buzzword, many applications. Civilians are increasingly taking courses in life-saving measures in bloody special situations, the Austrian Alpine Association teaches “Tactical Alpine Medicine” and images from Ukraine remind us daily of the need for good medical training, even for “ordinary” soldiers. What role does “tactical medicine” play in the Austrian Armed Forces? Militär Aktuell asked practitioners at the Eastern and Southern Medical Centers and at the Hunting Command.
“Put simply, tactical medicine is about the application of medical measures that also work under extreme stress outside of the comfort zone,” explains Vice Lieutenant Michael Pauppill. Here, at the medical school in the East Medical Center in Vienna’s 21st district, Pauppill is the chief instructor for troop medical training. He is attended by qualified paramedics and emergency paramedics who learn about the military part of paramedic training in the Austrian Armed Forces. In the course of this, everyone is taught extended self-help and comrade help (erwSKH), the implementation of which in the curricula was significantly advanced by Vice Lieutenant Pauppill.
Since 2011, training in the erwSKH has been part of the training for all soldiers who are deployed abroad. They are one of the four groups of people in the armed forces who receive training in tactical medicine. The aim of the one-week training course is to teach rapid and efficient life-saving measures.
The bitter lessons learned from the UN mission in Mali (MINUSMA) meant that all soldiers and civilian staff in the UN Corps also had to complete erwSKH training. This was the “second bloodiest mission for the UN” since the United Nations was founded, as Pauppill notes. In ten years, 310 UN personnel died during the peacekeeping mission.
Not only the foreign contingents, but generally all cadre presence units benefit from the high level of medical knowledge in the Armed Forces, as they and the medical NCOs also have the erwSKH anchored in their training. They represent the third group of personnel.
The fourth pillar of personnel comes from the special forces. As we will find out later, the Hunting Command trains its soldiers in a SHA adapted to its requirements. “We have nothing to hide in international comparison. We deliver quality,” says Pauppill confidently.
Militia soldiers also receive at least some of this tactical medical training, depending on organizational resources. “Basic conscripts receive eight hours of training or refresher training in the basics of emergency medical care,” adds Chief Constable Phillip Pruntsch. The knowledge is then deepened depending on the situation. Pruntsch is deployed at the South Medical Center in Graz as a teaching sergeant for paramedics. He is responsible for the training and further training of paramedics serving in the Austrian Armed Forces, as well as for the coordination and training management of the erwSKH.
“Through constant training, you can try to minimize shock paralysis and automate the processes.”
Vizeleutnant Michael Pauppill
“You can do a lot with a handful of tools and a week’s training,” says Chief Constable Pruntsch, who knows what the purpose of tactical medicine is: “It is intended to train a certain stress resistance and be a simple system that always proves itself and is automatically called up in an emergency – starting with the sequence of the initial assessment of the patient through to the individual application of the measures.”
In addition to knowledge, the right equipment can make the difference between life and death. An IFAK is now carried abroad and in some cases also at home. The individual first aid kit is primarily used for personal care in an emergency. “Not all armies have this luxury,” emphasizes Pauppill.
Roots
How did it come about that Austria has such a high level of training? “We had a sad incident,” says Pauppill. Two Austrian soldiers were injured when a convoy that was being redeployed was shot at. Medical personnel cannot always be on site. This resulted in the decision to adapt the tactical medical training.
A serious incident, the so-called Good Friday battle in Afghanistan in 2010, also led to a rethink at several levels in the German Armed Forces. Something similar happened with the Austrian Federal Police, which decided to improve training for all officers in tactical emergency medicine after 2013, when a wanted poacher in Annaberg shot an officer from the Cobra task force, two police officers and a paramedic while on the run. As Vice-Lieutenant Pauppill knows, the Vienna Professional Rescue Service now also equips its vehicles with trauma and Mascal sets. The latter allow many injured people to be treated quickly in major emergencies. The Red Cross is now also providing training for tactical emergencies.
In emergency medicine, the civilian world is closely linked to that of the armed forces. Pauppill explains: “Soldiers can and may maintain their skills in a civilian environment.” The theory is taught in the armed forces, the practice in the civilian world. However, it is difficult to reconcile the legal situation of the two worlds in terms of authority to act.
At international symposia and workshops, medical personnel from the Austrian Armed Forces exchange ideas with other emergency services. Sometimes very realistic exercises with non-professional actors and lots of artificial blood are used to authentically convey training content to the audience under high stress. “Through constant training, you can try to minimize the shock paralysis and automate the processes,” says Pauppill. The courses mentioned at the beginning in the civilian world, from urban environments to mountains, are therefore fully justified, as all of our interviewees believe.
New challenges
The suffering in Ukraine (-> current news from the war in Ukraine) is a daily reminder of what war really means. The extent of it surprised Vice Lieutenant Pauppill and many of his colleagues. “But you can also see how quickly you can react. Ukraine has trained everyone across the board in hemostatic measures.”
Large-area splinter and blast injuries, burns and injuries caused by pressure waves are the most common types of damage. Treating them in the field is very difficult. Solutions have to be worked out in detail and ultimately taught so that they are effective in the event of an incident. “What needs to be done is to ensure that the initial measures are one hundred percent in place,” emphasizes Vice Lieutenant Pauppill. “In addition, much more attention needs to be paid to the application of the lanyard.”
The tourniquet, which is used to stop life-threatening bleeding, must be able to be applied under stress, but at the same time it must not be applied for too long – as is often the case in Ukraine – in order to avoid long-term damage.
According to Pauppill, further lessons can also be learned in areas such as the administration of medication. Solutions are currently being discussed, such as how antibiotics can be used to reduce the risk of infection for people who cannot be evacuated from the danger zone.
In many respects, time is playing against Ukraine: Pauppill says that 34 percent of medical personnel are reported to be absent. These gaps cannot be filled so quickly. The high density of reconnaissance and combat drones also makes it difficult or impossible to transport the injured out of the danger zone. “Autonomous systems – i.e. robots – will also find their way into the field of casualty transport,” says Pauppill, outlining the future. Unfortunately, this is also a time and financial challenge.
However, the reality of war is even shaking the foundations of tactical medical training. Chief Constable Pruntsch: “In training, efforts have so far been made to convey the importance of the ‘Golden Hour’.” According to this doctrine, wounded people with life-threatening injuries should be medically stabilized within an hour so that they can survive. “However, we can now see from the setting in Ukraine that this is difficult or even impossible to achieve. It involves a huge logistical and coordination effort that is not feasible on a large scale.”
What was already known to experts was sadly brought home to everyone with this conflict.
“In Ukraine, you can see that compliance with the ‘Golden Hour’
is difficult or even impossible
to implement.”Oberwachtmeister Phillip Pruntsch
Command thing
However, the difficulty of dealing with a medical emergency cannot be reduced to the care of the wounded and the work of the medic alone. The troops and the commander are faced with special tasks, reports Captain K. He is the commander of the medical platoon of the fighter command and, as a general practitioner, is responsible for the ambulance. Militär Aktuell visited him at the Maximilian barracks in Wiener Neustadt. “The commander has to decide a number of things, including whether the mission can still be carried out and how to set up all-round security. Do we have to remain stationary or is an evacuation possible?”
These and similar questions are therefore added to purely medical care. “The lessons learned so far have been based on the assumption of superior firepower and the possibility of rapid evacuation or at least the taking of safe cover. In Ukraine, however, the situation is different. Evacuation times are around 45 to 60 minutes, because only 0.9 percent of evacuations in the Ukraine take place by air,” says Captain K., describing the real conditions of war. However, wounded care in the field is only effective if evacuation and further care is available in the hinterland.
The protocols in “Western armies” therefore provide for the “prolonged fieldcare” phase as a secondary option. However, the associated holding of the patient for up to 48 hours by an emergency paramedic already places the highest demands on personnel, structures and materials in peacetime.
Speaking of material: copies of the mass-produced tourniquets have had and continue to have fatal consequences. A tourniquet must fit tightly and hold the pressure evenly. However, the material of the cheap products gives way by the dozen, gags even break off, resulting in high mortality rates due to blood loss.
The hunting command reacts: Prolonged field care, for example, plays a major role in hunting combat training. Technical developments in telemedicine are also attracting attention, bringing the doctor virtually “into the danger zone” via radio. Relatively small devices with imaging processes now support the analysis. Captain K. gives a glimpse into the future: “The development will have to go in the direction of more medical equipment being carried per person and the medic himself being light and fast on the move.”
All beginnings are …
Each team in the platoon has a medic. However, this medic is only ever secondarily responsible for medical cases in the Jagdkommando – first and foremost he is also an operator, i.e. a gunner. They are trained in the erwSKH in several stages. In the first week of training, they learn how to apply a tourniquet, how to treat chest injuries and what to do if someone is unconscious, among other things. This is followed by a three-week course to learn, for example, how to administer medication and how to establish a venous route. This enables operators to support the medic, but also – should he fail – to replace him at least partially.
Afterwards, those who wish to undergo specialized medical training and are capable of doing so undergo practical civilian training as paramedics and emergency medical technicians with emergency competence. This is followed by a three-week training course in which the prospective medics are instructed in minor surgical procedures, among other things. Operators have to refresh their knowledge every two years and prove it in exercises. Medics, in turn, are constantly on duty. “Ultimately, everyone has to know what their job is,” says Captain K., explaining the reason for the comprehensive training and testing.
Even after the training, which NATO-standard, Jagdkommando medics also go on missions in civilian rescue vehicles. In this way, they learn to lose their fear of touching and talking to patients. Captain K. himself is deployed as an emergency doctor. His colleague, who is responsible for diving medicine, is deployed annually as a doctor in a pressure chamber and another colleague, a trauma surgeon, is not only involved in teaching, but also regularly works in the outpatient department of a hospital – all by his own decision and conviction, mind you. According to K., the Armed Forces could be more present in regions with a weak infrastructure or, conversely, in large cities where there are many deployments. The knowledge would be in-house.
Diverse workplace
In addition to knowledge and equipment, mental strength is also one of the requirements of a paramedic. Captain K. speaks from experience: “You see a huge injury. The only thing that helps is to take a deep breath and be aware: If I don’t help, no one else will. The worst thing is to do nothing.”
Captain K. is convinced that the job has a lot to offer: “I’m supposed to do a lot of sport on duty, I get to go shooting on duty, I travel all over Austria and beyond: I’ve been to Africa, Bosnia and all over Europe, a month each in the jungle with the Foreign Legion and the SAS – that’s experience that you can’t get anywhere else, and in a short space of time.” For Captain K., one thing is clear: “The armed forces are an attractive employer for doctors.”
Medical graduates can also register with the hunting command and complete further training. “This gives us a large pool of experts that we can draw on.”
Wherever you look: A variety of conflicts will continue to force medical personnel and soldiers, and not least the military leadership, to advance and ensure the quality and quantity of training, material procurement and technical development. Tactical medicine is more relevant than it has been for a long time.
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