MILITARY MEDICINE, 166, 5:394, 2001

The Ranger Medic

Guarantor: MAJ Chris George Pappas, MC USA
Contributor: MAJ Chris George Pappas, Me USA

The Ranger :medic (military occupational specialty 91B) pro- cle.' We adopted many of their recommendations. Their con-
vides advanced trauma management across the operational cepts of care under fire, tactical field care, and casualty
spectrum in which the 75th Ranger Regiment is employed. evacuation are sound.These concepts formed the basis for the
Ranger medic duties, both in combat environments and in discussion ''Tactical Management ofUrbanWarfare Casualties"
training, medical training, professional progression, and med- conducted at the Casualty CareResearch Center forum preced-
ical assets in the Ranger battalion are detailed. Ranger medic
training man.agement tools and techniques are discussed and ing the 1998 Special Operations Medical Association confer-
illustrated. The role of the combat lifesaver, force moderniza- ence. The Casualty CareResearch Center panel used the Task
tion, and interoperability issues facing the medical team are Force Ranger raid in Somalia to generate medical scenarios for
discussed. The Ranger medic is a capable special operations analysis and discussion.
tactical medi.c.
75th Ranger Regiment Mission
Introduction
The 75th Ranger Regiment is an airborne task force capable
he Rangf.~r medic (military occupational specialty [MOS]
T 91B) is the tactical medical provider for the 75th Ranger
Regiment, the u.s. Army's elite lightinfantry. Through training,
of force projection worldwide. The regiment can perform the
entire spectrum of light infantry tasks and numerous special
operations tasks, but its most likely employment includes the
leadership, and experience, he becomes oneofthe mosteffective following:
combat medics in the U.S. Army. He is capable of performing
across the operational spectrum of 75th Ranger Regiment em- - crisis action planning followed by rapid strategic deploy-
ployment, providing advanced trauma management in the worst ment and the conduct of an airborne assault to seize an
ofconditions. Thisarticle is based on a presentation to the U.S. airfield, establisha lodgment for follow-on forces, or evac-
Army Special Operations Command (USASOC) Surgeon's Con- uate designated noncombatants;
ference in December 1998. - deliberate planning as part of a joint special operations
Within Special Operations Forces (SOF) , the Special Forces task force followed by air assault or an airborne assault
Medical Sergeant MOS 18D is the epitome ofthe SOFmedic. The operation to conductcoordinated seizure or destruction of
force structure, selection, training, retention, and employment key facilities, support other special operations forces, or
issues are well developed for the 18D medic, becausethe nearly other operations, as directed by the national command
700 18Ds form the bulk ofSOF medics. The other SOF medics, authority.
which include the 91B Ranger medic, the 91B flight medics of The 75th Ranger Regiment is composed of three battalions
the Task Force 160th Special Operations Aviation Regiment, and a regimental headquarters. The regimental headquarters
U.S. Air Force flight medics, and Navy Sea, Air, Land indepen- and the 3d Battalion are located at Fort Benning, Georgia. The
dent duty corpsmen, do not have the same refined program. 1st Battalion is located at HunterArmy Air Field in Savannah,
There are approximately 56 91Bs within the Ranger regiment, Georgia. The 2d Battalion is located at FortLewis, Washington.
who representa smallfraction ofSOF medics. This smallnum- This geographic separation makes consolidated medical train-
ber of Ranger medics provided an opportunity for the develop- ing difficult.
ment ofa Ranger medic training and careerprogression plan. Ranger battalions have approximately 600 men each, com-
The 3d Ranger Battalion's trauma management team devel- posed of three rifle companies and a headquarters and head-
oped the medical training program described in this article. quarters company. Eachrifle company is composed ofthreerifle
Many substantive changes to our techniques, tactics, and pro- platoons and oneweapons platoon. Employment ofRanger com-
cedures were made because of lessons learned by members of panies and platoons will involve intense combat operations of
3d Battalion in the streets of Mogadishu, Somalia, in 1993. limited duration with limited combat support and combat ser-
Additionally, we owe a tremendous debt to Drs. Butler, Hag- vice support. This will result in extended evacuation times to
mann, and Butlerfor their thoughts detailed in a previous arti- higherlevels ofmedical care and place an increased burden on
the Ranger medical team to provide patient resuscitation and
Department ofFamily Practice, Madigan Army Medical Center, Tacoma, WA 98431. stabilization.
Formerly Battalion Surgeon, 3d Battalion, 75thRanger Regiment, FortBenning, GA
31905.
Presented at the U.S. Army Special Operations Command Surgeon's Conference, Medical Team Mission
Tampa, FL, December 4-5, 1998.
The conclusions and opinions expressed are those ofthe authorand donot nec- Each Ranger battalionis a modified tableoforganization and
essarily reflect theposition orpolicy ofthe U.S. Government, the U.S. Department of equipment or "go-to-war" unit with the following medical per-
Defense, the U.S. Department oftheArmy, or the U.S. Army Medical Command.
This manuscript was received for review in December 1999. The revised manu- sonnel: one 62B general medical officer, one 65D physician
script wasaccepted for publication in August 2000. assistant, and 1491B medics (Fig. 1). Ourmedical teammission
Reprint & Copyright © byAssociation ofMilitary Surgeons ofU.S., 2001. is as follows:

Military Medicine, Vol. 166, May 2001 394

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 The Ranger Medic
Platoon Medic
SPC, 9181V
LEGEND: Platoon Medic
SPC, 9181V
CPT Captain
SFC Sergeant First Class Platoon Medic
SSG Staff Sergeant Pvt-SPC, 9181P
SGT Sergeant
SPC Specialist
PVT Private
Co Company
Fig. 1. Ranger battalion medical modified table of organization and equipment.
- Provide tactical advanced trauma management from the
pointofinjuryto higherlevels ofcareand evacuation. Our
current staffing allocates one Ranger medic per 40-man
platoon (assaultforce).
- Provide quality garrison health care and rehabilitation to
injuredRangers. Thisincludes the day-to-day operation of
the battalionaid station (BAS).
- Assist in maintaining unit readiness by monitoring and
maintaining soldier readiness program status. This in-
cludesproviding and tracking more than 10immunization
series.
Additionally, our medics provide medical coverage for all
Ranger trainingevents requiring medical coverage above that of
a combat life saver (C18). The memorandum of understanding
between the USASOC and the U.S. Army Medical Command
delineates the unit and supporting medical activity or medical
centerresponsibilities. 2 Thisdocument is noteworthy becauseit
requires the supporting medical activity/medical center to pro-
vide garrison health care to our unit. Unfortunately, forvarious
reasons, this garrison responsibility falls on the Ranger medical
team, thus adding another trainingdistraction from our go-to-
war mission.
Medics screen sick call in the company aid stations and
provide the level of care approved by the battalion surgeon at
that level. Rangers requiring a higher level of care go the BAS,
where medics perform assessmentand treatmentunder a med-
icalofficer's supervision. Ranger medics are not trainedfor gar-
risonhealth care delivery, so theyreceive on-the-job training in
the BAS.
Aphysical therapist from the local community hospital con-
ducts physical therapysick callin our BAS. The physical ther-
apisthelpsreturn Rangers tofull function sooner while teaching
our medics basicphysical therapyprinciples. Thegreatestben-
efitofhaving a physical therapist in our BAS is the elimination
ofthe stigma ofsick call. Rangers know that theywill return to
full function sooner and are less likely to overtrain until the
injuryprogresses to a more significant injury. The regiment is
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395
Platoon Medic Platoon Medic
SPC, 9181V SPC, 9181V
Platoon Medic Platoon Medic
Pvt-SPC, 9181P Pvt-SPC, 9181P
Platoon Medic Platoon Medic
Pvt-SPC, 91 81P Pvt-SPC, 9181 P
currently studying the effects ofa comprehensive physical ther-
apy program on return-to-duty rates.
Ranger medics maintainthe same physical standards as the
line infantrymen. They must run 5 miles in less than 40 min-
utes, road march 2 hours weekly, road march 20 miles with
combat equipment quarterly, and conducta 30-mile roadmarch
with assault pack semiannually. These rigorous physical re-
qulrements are necessary becauseour operational environment
calls for violent assaults with the ability to endure hardships
and extended operations.
Ranger-Specific Training
Our mission profile requires expertise in various infiltration
techniques. We use mass tactical airborne operations to per-
form our primary mission of airfield seizure. If the ME1T-T
(mission, enemy, terrain, troops, and time available] analysis
permits, weair-land on the airfield, facilitating the rapidassem-
bly of forces on the ground. We have an ongoing relationship
with U.S. Army rotary wing assets, because many of our mis-
sions are conducted using helicopter insertion techniques.
These include both air assault methods and the fast ropeinser-
tion/extraction system. Using this system, Rangers can rapidly
insert into objectives that do not have enough space for the
aircrafttoland.Rangers can alsoinfiltrate usingsmalland large
boats and other clandestine methods.
TheRanger medic is assigned to the platoon or company that
he supports. This ensures that he is fully trained in the same
skills and tasks ofhis unit and gainsthe trust and confidence of
the Rangers within that unit.TheRanger mission does not allow
time for integration of attachments after alert. Additionally,
Ranger medics donot become a liability becauseofignorance of
tactical procedures or lack of proficiency in necessary Ranger
skills. Thebest medical training in the world does no good ifthe
medic becomes a casualty, causes casualties, or is in the wrong
place because he is unfamiliar with the supported unit's tech-
Military Medicine, Vol. 166, May 2001
 396 The Ranger Medic

niques, tactics, or procedures. For these reasons, there is a
growing recognition in the civilian sectorofthe utilityoftactical
medicine as a specialty."
Professional Progression
The Ranger medic is most frequently a recent graduate ofthe
U.S. Army Medical Department Center and School and is E-I
(private) through E-3 (private first class). Hemayor may not be
an emergency medical technician-basic (EMT-B). We developed
a pyramid of progression (Fig. 2) to illustrate our vision of
Ranger medic training. We developed this tool for several rea-
sons. First, it provides a visual plan for educatingthe chain of
command. Thts is critical because the command will support
our training plan onlywhen it is understood, appropriate, and
has a defined end point.Second, it allows us to integrateincom-
ing medics at the appropriate level and plan the schooling re-
quired. Finally, it is an excellent tool for counseling incoming
medics. It eliminates uncertainty and allows the medic to track
his own professional progression. This program helped us to
attain the level of 10 nationally registered emergency medical
technician-paramedics. The time in battalion is listed on the
left, with the rank and duty position structure on the right. Our
training progression and increasing level of medic sophistica-
tion addresses manyofthe concernsexpressed previously byDe
Lorenzo."
DutyPosition Requirements
The duty position requirement matrix (Fig. 3) reorganizes the
information found in the pyramid of progression. The left col-
umn lists the schools and sustainment trainingeventsrequired
foreach duty position listedat the top.Again, this is an excellent
tool for briefmg the chain of command as well as for medic
counseling.
Training Template
The Ranger regiment participates in the Joint Operational
Readiness Training System cycle of training management. A
cycle lasts approximately 90 days, with three recurring cycles
allowing onebattalionto be the Ranger Ready Force 1 (RRF-1) at
anyone time. ThisrecurringRRF-1 cycle allows onebattalionto
be on the IS-hour sequence to respondto any crisis or mission.
Four ofthese cycles make up one calendaryear. RRF-3 focuses
onblockleave and individual training. RRF-2 focuses on rotary-
wing and flxed-wing bilateraltrainingeventsandjoint readiness
exercises that prepare the battalion to assume RRF-1. Rotary-
wing bilateral training events allow complete integration of ro-
tary-wing assets for infiltration and extraction. Fixed-wing bi-
lateral trainingeventsperform the same function withAir Force
assets.
Recurring Ranger regiment training cycles allow us opportu-
nities to plan keymedical trainingeventsforboth the team and
individuals. We developed a training template representing five
Joint Operational Readiness Training System cycles to plan
medical events(Fig. 4). We use this forboth long-range planning
and counseling of individual medics. The bars represent the
time window in which the medic would attend the designated
training event. We use a similar matrix to allocate personnel,
allowing us to maximize the number ofmedics in schools, after
staffing key training events.

84 Months ANCOC SFC

8 wks Battalion Senior Medic
60-84 Months BNCOC SSG
18 wks BN Medic

16-60 Months SGT-SSG

CO-BN Medic
20-60 Months SPC-SGT
PLT-CO Medic

18-24 Months PFC-SPC

/ ---L \ PLT Medic

8-18 Months EMT-B/SOCM PHTLS BIO Chern EFMB PV2-PFC

4 wks/6 mos 1 wk 1 wk 3 wks PLT Medic
Basic Training AIT ABN RIP
0-8 Months PVT
8 wks 10 wks 3 wks 4 wks
Trainee

LEGEND:
ABN Airborne School JM Jumpmaster
AFMIC Armed Forces Medical Intelligence Course OEMS Operational and Emergency Medical Skills
AIT Advanced Individual Training PHTLS PreHospital Trauma Life Support
ANCOC Advanced Non-Commissioned Officer's Course PLDC Primary Leadership Development Course
BNCOC Basic Non-Commissioned Officer's Course RIP Ranger Indoctrination Program
EFMB Expert Field Medic Badge SOCM Special Operations Combat Medic
EMT-P Emergency Medical Technician-Paramedic

Fig. 2. Pyramid of progression.

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 The Ranger Medic 397

School Platoon Platoon Company the chain of command is the key to our success, because it is
Battalion Senior
Medic Medic Senior
(E-1-E-3) (E-4 - E-5) Medic
based on the adage that the men will do best what the com-
Medic or Main Effort
Company Augmentee
(E-5-E-6) mander checks.
EMT-B / I X
EMT-P (ACLS) X X X
Training within our battalionis divided intotrainingpriority 1
BLS X X X X (P-1) and support priority 2 (P-2). Company training forms the
PHTLS X X X X bulk of training within the battalion, with the P-2 company
EFMB X X X X
Ranger X X X supporting the three other P-1 companies. The P-2medics run
Chem/Bio
Casualty
X X X the daily sick call, as described above. P-2 medics go to the
BLS Instructor X X X Martin Army Community Hospital Emergency Department to
PHTLS Instructor
OEMS
X X
X
X gainmore experience on the last work dayofthe week. We have
X
AFMIC X an excellent working relationship with the Emergency Depart-
ment, and the medics are very positive about their experiences
*EMS Rotation there. The P-1 companies' medics conduct medical training at
(Annual) X X X least one-half day per week. The company commanders brief
*EMT Refresher
(Every two years) X X X X this "low-density" (noninfantry) training on the company-level
* Not yet Implemented trainingmatrixto the battalion commander and staffweekly.
Fig. 3. Duty position requirements. See Figure 2 for abbreviations. We provide quarterly medical training eventsfor our medics
and the infantrymen (MOS lIB) EMT-Bs (to be detailed below).
We plan these trauma refresher trainingevents3 to 4 monthsin
Internal Training advance during long-range training meetings. We schedule
Regimental Training Circular 350-1 details our training re- them during maintenance stand-down weeks when there is no
quirements. All major training events have integrated medical need for medical coverage. Every year, one of our trauma re-
training and tasks. Our platoon- and company-level live fire freshers is a Pre-Hospital Trauma Life Support (PHTLS) course.
rangeshaveobservers/ controllers for allkeyevents and subunit Our unit is a PHTLS site, and this aids in medic credentials
elements. A medical observer/controller monitors casualty sustainment.
treatment and evacuation from the point ofinjury to the casu- We recognize the importance ofnationalregistry certification
alty collection points. Commanders emphasize areas needing for our medics for several reasons. It signifies a greaterlevel of
sustainment and improvement at the after-action review. This medical training. This is a confidence builder and provides ac-
allows the widest dissemination to the team leadersand above. cess to more training opportunities. Additionally, it serves us
The after-action review process allows the integration of casu- well during operations other than war, when we anticipate a
altyevacuation intothe scheme ofmaneuver. Thissupportfrom broader spectrum of patients (e.g., children, women, and geri-

JORTS CYCLE: 1 2 3 4 5

JSOMTC

'---- EFMB 1

RANGER

OEMS

I EMT REF I I EMT REF

I MEDEX ~ I MEDEX ~ MEDEX ~ I MEDEX ~ MEDEX ~

* Prior to entry into Battalion

LEGEND:
EFMB Expert Field Medic Badge
Basic Training
EMT REF Emergency Medical Technician Refresher Training
Advanced Individual Training (AIT) +/ - EMT-B JORTS Joint Operational Readiness Training System
Airborne JRX Joint Readiness Exercise
Ranger Indoctrination Program JSOMTC Joint Special Operations Medical Training Center
MEDEX Medical Exercise
OEMS Operational and Emergency Medical Skills
Fig. 4. Ranger medic training template, major training/schools.

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 398
atric patients). Duringmedical training, we emphasize and bal-
ance the subtle differences between civilian standard of care
and tactical medicine.
Annually, 'we take all of our medics off post for a I-week
medical exercise. We perform the most resource-intensive train-
ing during this week. We take this opportunity to learn from
other medical units and compare equipment and techniques
used. Again, we plan this at the long-range training meeting to
coincide with battalion maintenance stand-downweeks.
We provide medical training to selected Rangers within the
battalion: CiS, PHTLS, and Basic Life Support. All incoming
Rangers attend the Ranger Indoctrination Program before as-
signment to a battalion. The Ranger Indoctrination Program
includes 40 hours ofCLS training, and Rangers earn their CLS
certificates. Once assigned, Rangers receive approximately 40
hours of medical training annually.
Ranger Rifle Platoon Medical Assets
Each Ranger platoon has an extensive medical capability in
both personnel and assets. The Ranger regiment has several
policies, both old and new, that provide this depth. Each rifle
squad contains one lIB who is a nationallyregistered EMT-B.
The 4-week course leading to this certification is given by the
local emergency medical system and runs during our RRF-1
status when we are stable at home station. Our battalion usu-
allysends between25 and 30 Rangers annually. We commonly
refer to this Ranger as the squad EMT-B. We currently have 36
nationallyregistered lIB EMT-Bs in our battalion.
The most significant change occurred when our regimental
commander mandated that every Ranger within the regiment
must be CLS certified and participatein approximately 40 hours
of annual medical training. This is a significant commitment.
Our mission, force structure, and combatexperience tellus that
a medic is usually not the first responder to an injured soldier.
This was a major lesson learned from the Somalia after-action
report and officer professional development. 5 We must be ableto
competently perform self-aid and buddy aid. The proximity to
medical aid is important-it is well documented that the lack of
hemorrhage control is a significant cause of mortality in com-
bat." The days of getting hit and crying "Medic!" (and not per-
forming any aid until the medic arrived) are over.
Each Ranger rifle platoon carries a significant amount of
medical supplies (classVIII). Each Ranger carries an Army tour-
niquet to assist in extremity hemorrhage control, alongwith the
standard field dressing. Key leaders (teamleaders, squad lead-
ers, platoon sergeants, platoon leaders) carry leader battle
packs consisting of intravenous fluids, Kerlix, and Ace wraps.
Each squad :EMT-B carries a modified CLS bag. Our battalion
commanderfurther required that each fire team of four to five
Rangers had a designatedCLS provider whoalso carried a mod-
ified CLS bag. This way, every fire team, the smallest combat
unit, had a squad EMT-B or designated CLS provider. This is
critical in the conduct of urban operations, in which troop dis-
persal is the norm.
We initially used the CLS programbut then modified it to fit
our needs. W'e restructured our CLS training programto reflect
an increased emphasis on trauma and the types of wounds
expected on the modem battlefield. Additionally, our program
has more trauma-related skills and hands-on training modules
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The Ranger Medic
than the original. We modified the CLS packinglist and renamed
our modified CLS training programthe Ranger First Responder
Course.
Force Modernization
The 75th Ranger Regiment has a stated mission of testing,
evaluating, and adopting new techniques, tactics, procedures,
and equipmentfor the Army. The regiment allocates significant
resourcesto its force modernization program. TheArmy adopted
several regiment-initiated programs: the M240 machine gun,
the machine gun spare barrel bag, the 200-round ammunition
bag for the M240, the Aimpoint 5000 electro-optical gunsight,
the modularlightweight loadcarrying equipmentrucksack, and
the Rangerassault carry kit.
We conducted a mission analysis to determine the medical
capabilities and equipment needed for our operational spec-
trum. This "bottom-up" review identified solutions from past
combat and training experiences. Examples ofour medical ini-
tiativesinclude the following:
1. The portable intensive care unit. This unit monitors a
patient's vital signs and provides defibrillation, allowing
medics to focus on patient stabilization and performing
necessary procedures. We have a prototype rack system
that attaches the portable intensive care unit, mini-vent,
suction, and oxygen bottles to a stretcher either on the
ground or on the medical special operations vehicle (a
modified Land Rover).
2. Sternal intraosseous infusionset. We adopted the FAST 1
intraosseous device for the following reasons: (a) intrave-
nous access can be difficult to attain in a trauma patient,
and doing so frequently exceeds the time needed to trans-
port the patient to definitive care": (b) venouscutdownsare
time intensive and difficult to perform in our operational
environment; (c) the Ranger body armor (ballistic vest)
maximizes the chance of having an intact sternum; (d) the
device chosen is more effective than other similar prod-
ucts; and (e) the device is approved by the Food and Drug
Administration.
3. Hetastarch. We are using hetastarch for fluid resuscita-
tion because of its positive effect in the hypotensive
trauma patient.v" It is well tolerated, does not need refrig-
eration, and is reasonablyaffordable. We have a protocol
for its use, and we recognize that normal saline is still the
best solutionfor dehydration and heat casualties.
4. Combitube. We wrestled with the situation of blind intu-
bations in an environment not conducive to either the
rapid sequenceinductionforintubation or the use oflights
(lighted laryngoscope). We use the Combitube as an ad-
junct in situations of limited visibility to provide assis-
tance for ventilatory support.
5. Communication system with boom microphone and at-
tached low-light source.Theregiment uses Motorola Saber
radios with a hand microphone. We improved it with the
TEA TASC II headset attachment. With the headset, we
can monitorour medical frequency despite a noisyopera-
tional environment and do so with minimal hand move-
ments. Thissystemhas a push-to-talkbutton wornon our
load-carrying equipment. Additionally, we attach a lip
 The Ranger Medic
lightto the boom microphone, giving us a point source of
green lightforpatientillumination. Thisis critical because
medical procedures cannot be performed effectively with
our issued PVS-7Ds and PVS-14s night vision devices. A
short focal length is the major problem with these night
vision devices. They are very sensitive to maintaining a
fixed distance from the patient and quickly become a hin-
drance duringpatient assessment and care.
6. Ranger Rescue Wrap. Keeping injuredRangers warmdur-
ing cold weather operations is a challenge. This is more
than a concern for patient comfort because of the addi-
tional stresses imposed on a hypotensive patient. This
insulatedbagallows 360 accessto the patient,has pock-
0 to allow us to work on patientswithout the constant refocusing
ets forwarming packetsand intravenous fluids, and has a
fluid-resistant disposable liner. We are using the Norwe-
gianpersonal heaterin conjunction withthe Rescue Wrap.
Our initial uses duringtraining havebeen quite positive.
7. Assault vest. We are testing the new Natick assault vest
that puts our gearon our chestand not on our waist. With
this vest, the medic can carryenough medical equipment
and class VIII supplies to openan airway, perform needle
decompressions, and stop bleeding for several patients.
New Directions
We are in the midst of an evolutionary path in the develop-
mentofthe Ranger medic. Hewasoriginally "home grown," with
training at the SOF paramedic courseat FortSamHouston, but
he is now receiving his trainingat the Joint Special Operations
Medical Training Center (JSOMTC) withthe designation ofspe-
cialoperations combat medic. This new pathway is ensuringa
higher level oftraining and recognition ofhis unique skills and
abilities. Some Ranger medics previously trained at Fort Sam
Houston will be grandfathered and receive the additional skill
identifier ofW-1.
Otherinitiatives include modifying how we care for patients.
We havea force structure that was devised 40 to 50 years ago.
We question why a platoon should have only one medic. There
are manyadvantages ofworking in two-man trauma teams. The
trauma team approach allows us to rapidly assess, stabilize,
and prepare a patient for evacuation. A glance into any trauma
room in an emergency department across the country will show
a team of physicians, nurses, technicians, and others working
on one injured person. Why should we limit ourselves to one
medic per 40 menwitha highprobability ofmultiple casualties
and mass casualtysituations?We haveconducted training op-
erations using two-man trauma teams at the platoon and com-
pany level with positive results.
Additionally, our current rank structure does not supportthe
time it takes to train Ranger medics. ARanger medic is a senior
E-4 (specialist) or a newly promoted E-5 (sergeant) by the time
he is fully trained. Atthis time, he must move up to a company
senior medic position or leave the unit. We requested a rank
upgrade ofour platoon medics to E-5as part ofour Ranger 2010
proposals to keepthis level ofexpertise at the platoon level. We
are working throughthe force design update process to upgrade
12 E-4 combat medics per battalionto E-5.
Ground casualtyevacuation alsoneedsimprovement. We are
looking at the four-wheeled all-terrain vehicles used by the Air
Force and the 82nd Airborne Division for patient transport.
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399
These vehicles are light, fast, fitwithin mostairframes, and can
rapidly move stable patients around the airfield.
Issues
There are unresolved equipment and trainingissues that are
beyond our ability to address at the unit level. Theregiment has
a stated goal of working at night completely in the infrared
spectrum. Currently, the medical teamis the only section inca-
pableofmeeting this goal becauseofequipment limitations. We
need a set ofnightvision goggles with an extended focal length
required by the current nightvision devices.
Medic sustainmenttrainingat the JSOMTC is anotherissue.
High operational tempos, limited access to training opportuni-
ties, and increasing restrictions on resources made medic sus-
tainment difficult for many units. TheJSOMTC addressed this
issue at the USASOC Surgeon's Conference by unveiling the
SOF Medical Skills Sustainment Program. It requires all SOF
medics to return to the JSOMTC every 2 years fortraining. The
initial draftwasexcellent and shouldrectify a problem facing all
SOF units.
Casualty evacuation is the last major issue involving our
medical community and special operations command. This is-
sue has implications at both the "ground level," between the end
users, and the highercommands. SOF does not have dedicated
casualtyevacuation assets and must use mission aircraft when
designated during the operational planning sequence." We
solved this issue for our battalion by tasking our supporting
fixed-wing and rotary-wing units to provide flight medics and
surgeons/physician assistants forour bilateral training events.
Thisworks extraordinarily well; wehavea solid "chain ofcare"
from point of injury by the individual Ranger (self-aid, buddy
aid, CLS provider) to the Ranger medic, the flight medic, and
then to higher echelons of care. Unfortunately, there are no
established standard operating procedures for this between our
higher commands. More globally, allinterested commands must
address interoperability issues to establish a standard operat-
ing procedure for all future operations. Important issues include
the level ofcare provided to stabilize the patientbefore evacua-
tion' the level of care provided while in flight, and training
opportunities to exercise this "handoff." Some ofthe more mun-
dane issues include litter configuration and type (Sked-Co vs.
Israeli), patient procedure cards, and patient rosters for the
transfer ofpatients at the helicopter landing zone.
Summary
The Ranger medic is a select and well-trained soldier whose
mission is to provide the best trauma care in the worstofcon-
ditions. His selection, training, and equipment set himapart as
a capable member of the casualty care system for the 75th
Ranger Regiment. His training program, professional progres-
sion, and trainingmanagement tools were discussed in the hope
that this will provide a paradigm forother units seeking proven
solutions. Additionally, issues and concerns were highlighted to
stimulate discussion, decision, and action.
Rangers lead the way!
Military Medicine, Vol. 166, May 2001
 400
Acknowledgments
The author thanks SFC Robert M. Miller, NREMf-P, MAJ Bret T. Acker-
mann, MC USA, MAJ Richard W. Kemp, IN USA, MAJ Gary J. Volesky, IN
USA, and CPT Dan S. Mosely, MC USA, for their thoughtful reviews. Addi-
tionally, the mentorship provided by COL Craig H. Llewellyn, MC USA (Ret.),
and LTC John Hagmann, MC USA, is greatly appreciated.
References
1. Butler FK, Hagmann J, Butler EG: Tactical combat casualty care in special
operations. Milit Med 1996; 161(suppl): 3.
2. Memorandum of understanding between U.S. Army Special Operations Com-
mand and U.S. Army Medical Command, 1998.
Commentary
"The muffleddrum's sadrollhasbeat, thesoldier's last tattoo; no
more on life'sparade shall meetthatbrave andfallen few. On Fame's
eternal camping ground, theirsilenttentsarespread; andglory
guards, 'with solemn round, thebivouac of thedead. "
Theodore O'Hara
"The Bivouac of the Dead" (1847)
From the greens of Lexington, over the bloody fields of
Gettysburg, upon the deadly rolling hills of Antietam. Through
the death-filled jungles of Vietnam, and across the vast desolate
deserts of Iraq. In Spartan places like Dunkers' Church and the
field aid stations at the Wilderness, in Cold Harbor and the
airfield of Tocumen, doctors, nurses, and medics on the
battlefields of America have found ways to save lives. The
challenge has been to get these trained personnel to the right
place at the right time with the requisite skills, both current and
practiced, so that they were capable of doing that which combat
medics must do.
All too often, our TO&E medics are relegated to duties in a
motor pool, as clerks and administrative personnel, and to
myriad additional duties which keep them from practicing their
medical skills, and certainly from honing them. Even specific
programs such as the Medical Proficiency Training (MPf)
Program are subscribed to at a level often less than 20%, and
then remain inconsistent in their ability to train medics. Medical
personnel from TO&E units working temporarily in IDA
positions to sustain and enhance their medical skills are
frequently pulled indiscriminately from their training programs
back to their units for duties other than medical. In part, this is
a fault of our own medical system, as too many MPT programs
are 1/change the linen/empty the bedpans/clean the
rooms/fake out the trash" exercises with little enhancing
medical training.
The Army Surgeon General, General James Peake,
conceived and initiated a program entitled 1/91 Whiskey"
(91W), the sole purpose of which is to raise the competence of
the combat medic so that soldiers are exceedingly proficient at
those medical skills combat medics need to save lives on the
battlefield. It is a bold and aggressive change in our training
paradigm that will put truly effective combat medics in our line
units. It is not without difficulties, however, as resourcing such
a program is difficult for both the Army Medical Department
and the brigades and divisions which we serve. It is also
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The Ranger Medic
3. Smith BD: Tactical medics: front-line medicine evolves as a specialty. J Emerg
Med Serv 1999; 24: 50-64.
4. De Lorenzo RA: Improving combat casualty care and field medicine: focus on the
military medic. Milit Med 1997; 162: 268-72.
5. Somalia: lessons learned. Officer professional development comments, 3d Bat-
talion' 75th Ranger Regiment, Fort Benning, GA, 1997.
6. Bellamy RF: The causes of death in conventional land warfare: implications for
combat casualty care research. Milit Med 1984; 149: 55-62.
7. Smith JP, Bodai BI, HillAS, Frey CF: Prehospital stabilization of critically injured
patients: a failed concept. J Trauma 1985; 25: 65-70.
8. Puri VK, Howard M, Paidipaty BB, Singh S: Resuscitation in hypovolemia and
shock: a prospective study of hydroxyethyl starch and albumin. Crit Care Med
1983; 11: 518-23.
9. Falk JL, O'Brien JF, Kerr R: Fluid resuscitation in traumatic hemorrhagic shock.
Crit Care Clin 1992; 8: 323-40.
difficult to get past the emotional turmoil, hard work, and
change in the way we train necessary to bring about this
manner of enhanced combat medic training.
The following two [preceding and next] articles are superb
in describing medical training programs that produce top-
notch, quality medics capable of functioning professionally and
competently as medical care providers, not only in the
peacetime environment, but more importantly, in conflict. The
training programs are exceptional for the combat medic they
produce. They are also unique in that they are largely unit-
based and unit-resourced; both belong to units in the Special
Operations arena under the US Army Special Operations
Command, specifically the Ranger Regiment and its battalions,
and the 160th Special Operations Aviation Regiment with its
subordinate units.
The two authors know well of what they speak, for they
have been unit. surgeons in these Special Operations
organizations, and have had a large hand in the training those
combat and flight medics receive (and sustain) in the premier
units they serve. It is no accident that the Ranger medics and
the 160 th SOAR flight medics are competent, professional,
highly trained, and exceedingly proficient. It is also no accident
that those flight medics and Ranger medics have truly saved
lives on battlefields from Grenada to Panama to Iraq to Somalia.
The articles written by Drs. Pappas and Mosely point to
medical training and sustainment well beyond that which the
basic combat medic receives today. As these young authors
ably describe, and as General Peake directed in implementing
his "1/91 Whiskey" Program, we can either learn from our
mistakes in training combat medics- - and suffer the loss of
great soldiers as we have from Antietam to Vietnam to Iraq-or
we can truly train and empower our medics to save lives and
preserve the fighting strength of today's Army.
To be the best is not an accident of time or circumstance
but rather a deliberate, rehearsed, and executed exercise. The
medical expertise and competence our combat medics must
have on the battlefield to save lives is the heart of that to which
these authors speak.
Darrel R. Porr
Brigadier General, US Army
Commanding General
Southeast Regional Medical Command/Dwight
David Eisenhower Army Medical Center
Fort Gordon, GA 30905-5650