Complete Story
10/27/2025
History of Military Emergency Medicine: Interview with Retired Lt Gen (Dr.) Paul K. Carlton, Jr. - PART 1
Lt Col (ret) Torree McGowan, MD, FACEP
GSACEP commissioned this interview with Lt. Gen (Dr.) Paul K. Carlton, Jr. as part of its History of Military Emergency Medicine project. At 69, Dr. Carlton continues to work at Texas A & M University in Bryan, TX. During his distinguished career in the United States Air Force, Dr. Carlton, Jr. served as the 17th Surgeon General of the Air Force (1999-2002). Prior to that assignment, he was the Commander and Director of the Air Force Medical Operations Agency (1999-2002) at Bolling AFB, Washington, D.C. His story and contributions to military emergency medicine starts in 1972 when, at 25, he co-authored a legislative bill and completed his senior project to establish an emergency medical services system while attending medical school at the University of Colorado.
GSACEP: When do we start to begin to implement EMEDs? Is that after Desert Storm?
CARLTON: Well, it's before Desert Storm, because at Scott I was also the Air Force Special Operations Command Surgeon. That was when we had three medical centers in the military airlift command, and I was assigned to the 23rd Air Force guy who was the Special Ops guy. So I had an opportunity to see systems thinking, or lack therein, and thought, boy, this is a place that I need to put my emergency physicians, because we don’t have full resources. You have to think quick. You have to figure out what to do with what you have. So the seeds were sown in those two years as we tried to address the issues of how do we provide long-distance care when there is no sophisticated medical facility available.
But the seeds were sown there. And then integrating those actually didn’t occur until I got to the next duty assignment, which was San Antonio.
We actually were designing custom-made teams well prior to EMEDs. EMEDs is a '99 discussion. EMEDs was 10 years in evolution before it became known as EMEDs.
GSACEP: What was the first name, and what were the members and sort of the missions of those first mobile local teams?
CARLTON: Well, that was the so-called FAST team, the Flying Ambulance Surgical Trauma team. That was out of the 1983 Beirut bomb experience, where we said if there's any mass casualty event anywhere in our area of responsibility, we have three positioned teams, the Airevac is ready to go, and we are ready to respond. That came about when a new Command SG came to town, Bill Greendyke. He received a brief on how to make this rapid response happen, authorized the FAST teams, and moved the whole effort forward a great deal.
It was a 20-member team that involved a surgical team, the equipment there in the triage team. We did not have emergency physicians, so they were not included in that group. Orthopedic surgeons and general surgeons were involved. Anesthesia, and then the associated people to take care of them. The idea being that you could fill a gap for 12 to 24 hours until more help could come.
Part of the 20-member team was a five-member Airevac team that, once they had stabilized the casualties, would get on the Airevac platform and take them wherever they were going. The Airevac team would then get off the incoming airplane, come plug into our team so that we could foster communications from one spot to another.
This is where the Mobile Field Surgical Team, the public health team, the critical care, all of those are modular building blocks that then, when you put them all together, are the EMEDs discussions. Now, Wilford Hall is the flagship, and again, my San Antonio experience was broken into two phases. One was the education and training command surgeon, the other was the commander at Wilford Hall. But I ended up with nine years in San Antonio working on education and training, and pulling call at Wilford Hall. Now that's when I really got exposed to the emergency physicians and plugged them into some of these smaller teams, specifically in the Mobile Field Surgical Team. I was also the pararescue surgeon, because they fell under the education and training command. So our Air Force first responder, if you will, EMT in the field, was called a pararescue man. We started bringing them into Wilford Hall to rotate with us. We also brought in the 18Ds and the Navy SEALS so that they became the junior members on our surgical team, again focusing on the education and the training part that I thought was a deficit going forward.
GSACEP: Is this still an experimental phase where you're just basically getting teams onto the ground in case of a crisis situation, and then having Airevac guys move them back in echelon?
CARLTON: That was—okay, there's a white world and there's a black world. The black world is a Special Ops world we don’t talk to you about. So the FAST team came about, the Gulf War one came about where we used the FAST team equipment set to actually go on some black missions. But then the defining event for Airevac and for critical care in the air was the Mogadishu issue. You've read Black Hawk Down. What you don’t read is that there had been a soldier bitten by a shark that took off his buttock, and Airevac required the senior surgeon to go with him too, so when Black Hawk Down occurred, the Army was functioning one surgeon less than normal. So instead of three, they had two. And it was because Airevac said, “We won't accept this patient, he might get sick. You have to send a senior surgeon.” So as you might imagine, the Army wasn’t very happy with that. Nor should they be. And that drove the whole Special Ops critical care in the air, and we actually configured some airplanes so that we could do critical care in the air. And again, you have to go back again, Special Ops '88 to '90, when I'm at Scott, is when we were laying the requirements for the C-17. I had the privilege to serve on that group and convince them that we didn’t want to use a dedicated Airevac platform. That we wanted, on a C-17, to have the ability inherent in the airplane to take care of up to 10 casualties without reconfiguration. But everything was then carried on the airplane.
Those were dedicated airplanes for the Airevac mission. We used the C-54, modified DC-6. In the Korean conflict, we used the 707 and the C-141 in the Vietnam conflict. We used the C-141 in the Desert Shield/Desert Storm conflict. Now, those were dedicated platforms, so they would routinely fly a mission twice a week. My dad was the commander of the Military Airlift Command, and he complained to me that using dedicated airplanes instead of the airlift flow made no sense to him. So I listened to that. The Airevac flow, then two dedicated missions, means that's the only time you used Airevac. If we had an airplane configured every day into a base, then you'd haul equipment in, and you could haul patients out. So it's a world different, and again that was with some trepidation. But we got the commander of the Military Airlift Command at that time was a gentleman named H.T. Johnson. He signed off on it, so the C-17, from its inception, was designed to be a retrograde holder of people without a major equipment change. It had the equipment on board. So we got rid of our dedicated airplane, and then we could use airplanes of opportunity, and that meant that we could do twice a day, three times a day, whatever the mission was. We just had to provide the medical crew for them.
That was when we had large hospitals forward, and we didn’t want to do that. We wanted to get people home with their families. So we wanted a very small footprint forward and the ability to use retrograde airlift. The airlift then had brought something else in, and then very quickly reconfigured the airplane and took patients out. That gave us much more flexibility. So the C-17, then, was really a transformational airplane for us in terms of the ability to move.
GSACEP: What specifically did your dad tell you about the flaws of the system he had seen?
CARLTON: Well, what he told me was it was absolutely stupid to dedicate an airplane and not rely on flow. Made no sense because then you had an airplane sitting around, and it would have to then go to wherever it was needed. Where you would most likely need it was someplace that we already had an airflow going into. You just needed to be able to reconfigure the airplane and have the medical crew to go with it.
Now back to—in the current war, we have critical care and Airevac teams on site in Bagram so that when a C-17 comes in, offloads its cargo, they reconfigure the airplane, and home they go to—now that then means we have to be a bit more forward. But we can be much more flexible in terms of our capabilities.
GSACEP: How does your experience in Desert Storm play into this whole scenario we're describing that comes later? Take me through what happens with Desert Storm, the overall medical philosophy of what the Air Force was going to do, how it was going to do it, and then what went right and what went wrong.
CARLTON: The Desert Storm experience taught me that we hadn’t changed at all, despite all the efforts, and the things that I've been involved with in the black world. When it came to a regular conflict, that Airevac hadn’t changed, we still said, “The Army's got a problem, it's not our problem.” The Navy, taking care of Marines, still had a problem. It wasn't systems thinking. And it had to change. Now, that didn’t get any traction. But the Mogadishu issue did, because we, the Air Force, demanded the senior Army surgeon leave so that they fought that fight—the medical fight—one hand tied behind their back. And then they did a superb job. That's not the issue. That put us over the top, so that the homework that we had been doing on certifying equipment, things of that sort, we then got the line to understand, “yes, we have to do that.” So the Haiti op in '94 was the first time we showed all of our hands in terms of the mobile building blocks, if you will, that became, five years later, EMEDs.
GSACEP: Let's talk about Haiti. When you say you showed the first hand, how did it work in concert? What were the flaws and strengths of Haiti in '94?
CARLTON: Haiti in '94 was still a black ops. The teams that we had that we deployed from Wilford Hall were still classified. But we had the best medical work plan I've ever seen. We could guarantee surgery within 20 minutes. We could do critical care in the air. And I mean, it was the best plan I've ever seen. And then Haiti folded; no casualties were generated, we never used the plan to prove its worth! If you'll recall, Haiti folded and we never used force that we admitted to, in that Haiti operation. Then we moved people in there; we had a presence in Haiti, but we did not have to defeat an enemy force. That was the basis for what we did in Iraq.
GSACEP: In terms of Desert Storm, the idea was to get everybody back to the central Naval Hospital. Was that the overall plan?
CARLTON: The master plan was Army and Navy were on their own. They would bring their casualties to several casualty collection points. And at some point, when the casualty was entirely well, we could Airevac them back to the United States or to Germany, or we could do a tactical Airevac from one of the forward units to one of those big hospitals. But the plan was exactly what we'd done in Vietnam, and that is to have large hospitals set up to receive the casualties and not worry about getting them home.
Look out for Part 2 in the Winter 2025 EPIC Newsletter!
