History repeats itself, first as tragedy, second as farce

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Editor-in-Chief, Chester ‘Trip’ Buckenmaier III, MD, COL, MC, USA

“History repeats itself, first as tragedy, second as farce.” – Karl Marx (1818-1883)

Arguably, war and man’s increasing sophistication when it comes to harming one another are the least attractive attributes of the species. The next war, like death and taxes, seems an inevitable part of the human condition as we close 2012 experiencing the longest conflict in American history. Although war represents humanity at its most wasteful and ruinous, it also can highlight some of the best qualities of man in terms of courage, altruism, resourcefulness and compassion. One of the dichotomies of war is the catalyst for positive changes that human conflict brings to the profession of medicine.

Certainly the present wars have not violated this historic truism, with the tremendous strides forward in battlefield critical care, patient transport, blood and fluid management, imaging, trauma surgery and pain management, to note only a few. Management of the wounded at home also has greatly improved, with enhanced understanding and management of the less-visible wounds of post-traumatic stress injury and traumatic brain injury. The advances in prosthetic development have been no less amazing, as warrior amputees with their prosthetics return to the battlefield in previously unheard of numbers.

In short, the federal system of medicine has created the finest multi-trauma care organization ever seen. While all federal medicine providers and support personnel have played their roles, and all should be justifiably pleased with their part in this epic effort, it is the medical response for the next war that I am concerned about.Throughout our military history, periods of conflict have been followed by a rapid drawdown of forces. For many conflicts in our history, these force reductions made complete sense, as the country demobilized from large international conflicts, and drafted citizens returned to civilian life. With the war in Iraq ended and the war in Afghanistan winding down, we again are undergoing a process of demobilization, with the Army reducing its size by 80,000 soldiers.

There are some noteworthy differences concerning this drawdown from those in the past, however. Unlike many historic conflicts, we now fight our wars using an all-volunteer force (sometimes called the “other 1%”). We also fight these wars with a significantly smaller standing Army. For perspective, when the Berlin Wall fell in November 1989, the Army had 770,000 soldiers on active duty, about 200,000 more than were on active duty when the last troops left Iraq last year. (“Earlier drawdowns give idea of what’s to come,” Army Times, Feb. 19, 2012). Certainly, smaller armies are now possible, as the nature of modern conflict, technology and improved soldier sophistication make massive standing armies unnecessary. This point was famously driven home by President Obama’s “horses and bayonets” comment in the recent presidential debates.

As an active duty officer, I have a vested interest in the size of our military, although as a taxpayer I understand the fiscal need to have only as many soldiers as are essential for the nation’s defense. The “right” number of troops required for our defense is a question well beyond my scope of understanding, and not a topic I necessarily feel compelled to debate.

My concern, rooted in the reality of the present drawdown, is the loss or degradation of all the knowledge federal medicine has amassed regarding managing combat casualties during the last 11 years of conflict. As terrible and wasteful as war is, it would be an even greater unforgivable waste to allow the medical lessons on this longest American conflict to be lost to posterity. In my own area of pain management, despite all the advances we have made in managing pain on the battlefield and at home, we still have difficulty in fielding these advances uniformly throughout federal medicine. An unwarranted variability in pain management practice continues to plague the system. How will we position ourselves to be even better, medically, in the next war when faced with the apathy and loss of expertise that accompanies the contraction of any organization? I believe the answer is through education and training. My challenge to all federal medicine providers of the past two decades is to seek opportunities to preserve the tremendous depth and breadth of military medical knowledge that has been forged in 11 years of continuous conflict. Work to ensure that the best practices you have developed are codified in the military medical doctrine for the next conflict. Write the textbooks, produce the research papers, speak at the national meetings and lecture to your students. So many lives have been saved by the efforts of this latest, greatest generation of federal medicine providers.

Federal medicine was forced to create this laudable trauma system out of the heartbreak of 9/11 and the necessities of modern conflict. So many more lives will be positively impacted in the next war, if we invest ourselves in the hard work of internalizing the lessons we have learned into the new standards of practice for the next conflict. Failure to accomplish this last, and perhaps most important, task of the current wars, would truly be both a tragedy and a farce.

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