The U.S. military has allowed the world's biggest wartime trauma network to unravel, against the advice of prominent uniformed and civilian trauma experts who urged the Pentagon to sustain it for future conflicts.

The U.S. military's Central Command commissioned a group of experts to carry out a detailed review of the health system. They traveled into harm's way during the wars in Iraq and Afghanistan to assess the readiness of the military health system. And their recommendations, obtained by U.S. News & World Report, have never been publicly released.

They examined hard-earned gains in combat casualty care – hard-earned because the new evidence reveals that the military health system was totally unprepared for the bloodiest conflicts since the war in Vietnam.

They offered dozens of recommendations, including establishing the Joint Trauma System as the lead agency to enforce "standards of excellence in the care of the injured."

In 2003, when U.S. President George W. Bush appeared on television to announce the start of the Iraq war, "an organized trauma system did not exist nor had it even been conceived," assert the authors of the 2010 Military Trauma System Review report. In Iraq alone, over the next six and a half years, the military recorded more than 3,400 combat deaths, 800 deaths unrelated to hostile action and 31,000 combatants wounded in action.

Those estimates do not include those of the U.S. Special Forces who had been fighting and dying in Afghanistan since Sept. 11, 2001.

It would take the Pentagon until 2007 to establish a functioning trauma center overseas and build a detailed registry to catalogue combatants' traumatic injuries.

In 2007 alone, the first year detailed trauma records were kept, the hub of the network, Landstuhl Regional Medical Center in Germany, treated approximately 2,200 coalition patients, more than half with major trauma. Over the next few years, that number would grow to more than 12,000 trauma patients, 4,000 with significant and potentially life-threatening injuries.

Patients were airlifted to Landstuhl from major base hospitals in Baghdad and Balad, Iraq, and from dozens of mobile field hospitals and forward surgical teams throughout the combat theater.

"We were getting patients seven days a week, 50 patients on each plane," says Kathleen Martin, Landstuhl's trauma nursing director from 2006 to 2014. "The walking wounded sat in jump-seats on one side of the plane. Stretcher patients were stacked three high."

Once stabilized at Landstuhl, patients were airlifted to Walter Reed National Military Medical Center, in Bethesda, Maryland; Brooke Army Medical Center in San Antonio, and other hospitals in the United States for follow-up treatment.

In the beginning, Martin says, the military couldn't even keep track of patients as they moved from one location to another. "Commanders were calling and saying, 'How's my guy?'" Martin says. "I have no idea," she would have to answer. "All I know is he's not here right now."

Preparing a Hospital for War

Crew members from a U.S. Army medevac team wait for a mission at Forward Operating Base Pasab in Afghanistan's Kandahar Province in 2011. (JOHANNES EISELE/AFP/Getty Images)

Martin was one of many who worked to transform Landstuhl, then a vast, but sleepy hospital for service members and their families stationed in Europe, Africa and the Middle East, into a sophisticated level I trauma center and evacuation station for coalition forces.

"It took us at least three years during the middle of the war with huge trauma volumes, 2,000 patients a year – 60 [intensive-care] patients per day – to get up to the standards of civilian trauma centers credentialed in the U.S.," says Dr. Warren Dorlac, a retired Air Force colonel who was Landstuhl's trauma medical director from 2004 to 2007. "We were able to do it, but it took us years of hard work."

Dorlac and other experts say that wounded warriors paid the price for delay with their limbs and their lives. "I can guarantee you that during the first two and a half years of the war, we weren't doing what needed to be done to assure optimal care of trauma patients," Dorlac says. "We were doing our best, but it wasn't up to standards of civilian trauma centers."

"The learning curve is expensive – blood and suffering and death," says a military trauma expert who spoke on condition of anonymity and who has patched up troops in multiple conflicts.

The military's vision is lofty – "That every soldier, marine, sailor, or airman injured on ANY battlefield or in ANY theater of operations has the optimal chance for survival and maximum potential for functional recovery" – but the reports and interviews with dozens of surgeons suggest the Pentagon has other priorities.

Today, eight years after Landstuhl achieved certification as the only American College of Surgeons Level I trauma center outside the United States, the military has allowed Landstuhl's trauma program to lapse from Level I, providing the highest standard of care, to Level III, the lowest. To be recognized as a Level I trauma center, Landstuhl had to satisfy 241 ACS requirements.

The staffing and infrastructure required to achieve Level I status is gone, Dorlac says. "There's very little of it left anymore. It cannot do the same things it did in the past. It's supposed to, and the Army surgeon general will tell you it does, but it doesn't."

Army Surgeon General Nadja West resigned in July. She could not be reached for comment.

Landstuhl must reapply in May 2020 to retain its Level III status. Army Colonel Michael Weber, a vascular surgeon and the hospital's commander, says the Pentagon is considering what level of trauma certification, if any, to pursue. "That is part of an assessment strategic leaders will make over the next year," Weber says.

Active duty surgeons are frustrated with the level of care they can provide. "I would like our soldiers to get the same kind of care that a drug dealer would get if shot on the streets of Chicago," says one surgeon, currently based in the U.S., who asked to remain anonymous to avoid retribution from superiors. "They don't."

Backsliding Between Wars

Historically, the military's trauma capability waxes in war and wanes in peace. The goal of the two reviews of the military's trauma network – one carried out entirely by objective, non-DOD trauma experts and the other by a mix of military and non-military experts – was to propose ways to sustain the network in peacetime. This proved especially difficult in the era of the all-volunteer military.

The end of the Vietnam-era draft meant that the Pentagon had to build its own combat casualty-care capabilities. The military bureaucracy could no longer simply draft busy surgeons when war broke out. But it is challenging to sustain that level of care in peacetime. Although Landstuhl uses eight of its 11 operating rooms, the hospital now caters mostly to outpatients, about 46,000 of them every year.

"Landstuhl is mainly an outpatient surgery center when there isn't a war going on," says Dr. Matthew Martin, a trauma and critical-care surgeon at Scripps Mercy Hospital in San Diego, who retired from the military in October 2018. From 2007 to 2018, Martin served as trauma medical director and chief of surgical critical care at Madigan Army Medical Center, near Tacoma, Washington.

Surgeons, nurses and technicians working in Landstuhl's operating rooms perform more routine procedures than trauma surgery. If war breaks out, surgeons say, the military medical command will have to start over.

"It was entirely obvious that this was going to happen," says Martin, of Scripps. "You can't keep surgeons there when they're not operating. That's not great when it comes to readiness; you're going to need spin up time to get up to speed."

Measuring Outcomes

Starting over costs lives, the evidence clearly indicates, and this is true for the entire continuum of combat casualty care from the point of injury to the recovery room.

A study published in 2012 by more than a dozen top military surgeons found that, with better care, approximately one of four – 1,000 of 4,500 – American combatants who died in battle during wars in Iraq and Afghanistan might have survived.

The study , "Death on the Battlefield (2001-2011): Implications for the Future of Combat Casualty Care," wasn't just an accounting exercise. The authors signaled their intent in the study's title: to sound the alarm so that the military would be better prepared to save lives the next time.

Many lives could be saved by better pre-hospital care, the study found.

"I would like our soldiers to get the same kind of care that a drug dealer would get if shot on the streets of Chicago. They don't."

"Most battlefield casualties died of their injuries before ever reaching a surgeon," the study's lead author, Dr. Brian Eastridge, a retired Army colonel who served as trauma consultant to the U.S. Army surgeon general, and his colleagues wrote.

Two other studies lend weight to the notion that many combatants died who might have been saved.

A study of all U.S. casualties in Iraq and Afghanistan from October 2001 through December 2017 – nearly 57,000 – found that survival increased 3-fold during the course of the conflicts. Over time, improvements in care cut the case-fatality rate roughly in half, from 20% to 10% in Afghanistan and from 20% to 8.6% in Iraq.

Another study by 17 leading combat casualty experts examined the proportion of combatants who "died of wounds" in Iraq. This measure refers only to those who died after they reached military treatment facilities; it is regarded as a more reliable measure of surgical outcomes than "killed in action," which applies to combatants who died before reaching the hospital, and the case-fatality rate, a broad measure of mortality that encompasses both groups.

This study found that overall survival was 3% higher in Iraq than in Vietnam, 90% compared with 87%. However, the percentage of those who died of their wounds in Iraq was markedly higher: 5% compared with 3% in Vietnam. Critics of the study note that many factors may account for the difference, from the time spent in transport to the hospital to the nature of the patient's wounds, which in Iraq were often inflicted by improvised explosives.

Statistics are one way to gauge the scope of human suffering from injury or disease. Another is the trauma experienced by survivors and by those who try to help them. Martin's eight years at Landstuhl have indelibly linked the numbers to names and faces. They haunt her dreams.

"I can still see them lying in their beds," she says. "Our amputees."

Revolving Door Leadership

The Landstuhl Regional Medical Center in Germany (Washington Post/Getty Images)

Landstuhl's commander, Col. Michael Weber, says he is optimistic that the hospital can care for the surge of patients should war break out.

The hospital's intensive care unit, which on a day in July had just four patients, could expand from six to 12 beds, he says. The hospital staffs just 57 of its 1,000 adult inpatient beds, but can staff more if needed.

"We're postured very well to be able to surge to respond to additional casualty flows," Weber says. "We're not alone in this. We have medical planners on staff, we have close coordination with the regional medical command in Europe and we have an excellent relationship with the Air Force medical service and the 30th medical brigade, assigned to the European theater."

Technology can help, he says, citing software programs that guide planners who are trying to predict the number of casualties associated with military operations.

If war should break out, however, Weber – a vascular surgeon who arrived at the hospital from Africa Command just two months ago – will have to learn on the job.

That is something he has in common with most Landstuhl commanders, who pass through Landstuhl at a brisk pace, Martin says, barely staying long enough to get to know the place. "In eight years, I had six commanders," Martin says. "They leave. They get promoted early. You lose corporate memory. You see pieces of it slipping away."

In an effort to stem the leakage, several longtime Landstuhl staffers gathered their insights into a book, "A Legacy of Lessons Learned: Landstuhl Regional Medical Center during Wartime 2001-2014," authored by Karen Hennessy and published by the Borden Institute under the auspices of the U.S. Army Surgeon General .

When asked, Weber was unaware of the book, his press aide, Gino Mattorano, director of public affairs for the Regional Health Command Europe, said in an email. "We are going to get him a copy (we have several...), because now he wants to read it!"

Martin vividly remembers the moment that she learned that her efforts to preserve Landstuhl's trauma capability had failed. She and her husband were attending a Christmas Party at the home of Landstuhl's commander.

At the time, Martin was working feverishly on a management plan to sustain Landstuhl as a Level I trauma center, even though the flow of trauma patients had tapered to a relative trickle. As part of her plan, she started visiting battalions, clinics and bases throughout Germany to encourage them to route their patients through Landstuhl to increase the hospital's volume.

The commander encouraged her. "I felt he really understood," Martin says. "He knew this was my mission. I wanted it to be my legacy too."

But the Army had begun to consider cutbacks, and, at the party, the commander delivered the bad news. "He looked me in the eye and said, 'Kathy, we can't do it. We can't sustain it,'"

The memory of that conversation still weighs on her. "I never talk about whether I have PTSD or not but I'm sitting here almost in tears," Martin says. "I said, "We have to sustain it. if there's just one life that we save because we're ready…"