“… be bold and challenge the status quo because it can lead to profound change…”

What would you consider to be the highlights of your military medical career so far?

I think the highlights are where I have responded to significant challenge or where I found ways to simplify complexity. And I’d say in some extreme cases, it’s where I’ve experienced post traumatic growth. If I give you some examples. A sentinel event for me, and the impact of which has endured throughout my career, was when I was at the receiving end of a terrorist bomb. In November 1991, the Irish Republican Army targeted the military hospital where I was working in Northern Ireland. I acted as the Medical Commander for that incident. I thought there was a lot that we did well, but that we could have done better if there was a system—and at the time there was no international system, for how to approach a multiple casualty incident, irrespective of the cause. That led to the development of the MIMMS program, Major Incident Medical Management and Support. We started teaching it from 1993, initially in Manchester in the UK, but it very quickly spread nationally and within a year it had become international. The course endures and it’s still relevant today. We developed a military version of that course in 1998, and it became a NATO standard training program from 2004. Just over the last number of months, we’ve been revising the content to make MIMMS as relevant as possible for contemporary warfighting at scale. So, we continue to learn, and pressure test the concepts within MIMMS. From MIMMS, we developed Battlefield Casualty Drills in 1998. I thought that every soldier needed to know the principles that we were teaching the professionals at the scene of a major incident, but these principles needed to be much simpler. So, we contracted the seven principles of MIMMS (C – Command, S – Safety, C – Communication, A – Assessment, T – Triage, T – Treatment, T – Transport) down into Control, then ACT (Assess, Communicate, Triage) and a series of treatment drills. It has been successful for the last 20 years, and we continue to use that framework to teach every soldier. Of course, we’ve updated it over the years with a new concept going from ABC (Airway, Breathing, Circulation) to ABC (, catastrophic bleeding) in treatment, and refining exactly what the soldier can do to treat themselves or their buddy with the addition of the tourniquet, the pressure bandage, and topical haemostatics. But the overarching principles are still there. Most recently, taking the same principles that we’ve been teaching soldiers, we have made them relevant to civilians when they are presented with multiple casualties, the driver there being terrorism. In 2016, we introduced a new charity in the UK called citizenAID which has got international visibility, where we provide the knowledge of how to keep yourself and your friends and family alive until the emergency services can get to the scene to help you. In terms of other highlights, in 1999 I deployed to Kosovo as a part of the first ever emergency medicine team in a field hospital. At that time, we were a Cinderella specialty, but the Emergency Department very rapidly became a core capability of a field hospital because we were able to demonstrate the particular role that emergency medicine as a team could have in the field. In parallel, this was my first experience of capacity building on operations. I was asked by our Department for International Development (now part of the Foreign, Commonwealth and Development Office) to support the civilian Non-Government Organisations to design, build and equip an emergency department in the 2400 bedded Pristina hospital to UK best practice standards within a six-week period. This was a pretty tough ask because it required changes to the infrastructure, finding the equipment, and, more importantly, training for the staff. We also needed to liaise with the Dean of their medical school to bring in emergency medicine as a new specialty so as to ensure that this specialty could endure. Proudly I can say that the emergency centre that we built in 1999 is still there and it is still functioning today some 25 years later. There are two more highlights, the first was to establish and lead our process of major trauma audit and governance, including the creation of our Joint Theatre Trauma Registry. I did this from 1997 through to 2010, and I believe that it underpinned our national revolution in combat casualty care because it provided both the evidence for continuing change and the proof of continuing improvement. Data is absolutely the ‘king’ when you’re trying to drive serial change. All my deployments have been a highlight, including 4 tours of Iraq and 3 tours of Afghanistan, but the one that was the pinnacle was in 2009 when I was the medical director of a multinational field hospital with British, Danish, American, and Estonian personnel all working together. That absolutely cemented in my mind the value and the power of multinationality in the deployed space. I would also say that I continue to take great pleasure and intrinsic reward from the current senior leadership appointments that I hold and the privilege that they afford to work alongside other clinical leaders at the national and international level. 

Major General Timothy Hodgetts, Chairman of the Committee of the Chiefs of Military Medical Services in NATO (COMEDS), Surgeon General United Kingdom (source: Defence Medical Services)

Could you summarise your involvement with NATO and the COMEDS structures prior to taking up the role as chairman of COMEDS in 2021?

My first contact with NATO was Kosovo. As I’ve already mentioned, in 1999 that was a NATO mission and we were the first British field hospital to set up just outside the capital, Pristina. On that tour I wrote the disaster plan for Kosovo. I engaged with the NATO headquarters in Pristina, we exercised this as a multinational response plan, and we used the MIMMS principles. This was an opportunity to introduce MIMMS within the NATO operational environment and it set the conditions for MIMMS to become the standard and what was taught in the NATO School from 2004. I continued to frequently attend that course as an instructor. Since then, it has been taken over by the Military Medicine Centre of Excellence in Budapest, Hungary. My mission to Afghanistan in 2009 with the multinational field hospital was also under a NATO umbrella as part of ISAF and was genuinely a multinational operating environment. The strong demonstration of multinational cooperation was clear with absolute reliance between facilities. That really emphasized for me both interoperability and interchangeability. Interoperability is the ability for one nation’s casualty to pass through a multinational chain and then ultimately end up within their own Home Nation. Interchangeability is the ability to drop in one nation’s clinicians, either as individuals or as a team, into another nation’s facility where they can function effectively and be part of the overall team. I think we did both of those well on recent operations. In 2011, I became the medical Director for Headquarters Allied Rapid Direction Corps and that placed me in a full time NATO environment as a Corps level headquarters that was configured to command the deployable NATO Response Force. These were my NATO engagements prior to taking up the COMEDS Chair role. 

From your position now as Chairman, how would you assess the value of COMEDS, particularly over the course of the COVID crisis and the Russian invasion of Ukraine?

I think the visibility of COMEDS and the understanding of the value that it can add as an instrument of strategic medical advice to the NATO senior leadership has been greatly enhanced during COVID. This is largely due to the efforts of my predecessor, Brigadier General Bubenik. Since I started my tenure in December 2021, we are more into the recovery period and learning the lessons from COVID, which the Military Medical Centre of Excellence is leading on. But we’re also in a period of an exhausted workforce and we must understand how we re-energize that workforce for the future. My focus has been on the Russian war in Ukraine, understanding and translating the lessons to enhance NATO medical preparedness, which involves reviewing our collective capabilities for military medical support. We have observed the behaviours of the aggressor to flout the Laws of Armed Conflict in targeting medical treatment facilities and transport, and we understand what that means for how we may operate in the future. Although there is no NATO operation specifically to assist Ukraine, the extant support is the consequence of bilateral or multilateral arrangements across the nations. We have used our sophisticated and mature medical networks through the Chiefs of Medical Services, to make arrangements for casualty redistribution across Europe; to share visibility and enhance coherence of bilateral medical donations; and to provide direct advice to clinicians in Ukraine on specifics of casualty treatment and rehabilitation.

What do you think are the issues for NATO’s military medical services looking into the next five years?

Principally, we will continue to strengthen the cohesion and coherence of the NATO Alliance from a medical perspective. We have already got an extraordinary level of dialogue, sharing of information, and mutual support between the Allies. I think the Alliance, from a medical perspective, has really been energized by the current conflict. We will also continue to innovate across the spectrum of military medicine and particularly where technology and digitization can enable our people or spare our people. In the future, we will have to accept that we have returned to an era of preparedness for Large Scale Combat Operations, where medical is a key enabler to support both the moral and physical components of fighting power, and we need to recognize that future solutions to today’s challenges will increasingly involve civilmilitary cooperation. This is at the heart of our new NATO Medical Support Capstone Concept. We have seen that civilian healthcare systems have relied on the military healthcare system during COVID for both strategic capacity and niche capabilities. In war, we can anticipate that the military would similarly rely to some degree on civilian healthcare services for definitive care and rehabilitation capacity. How much reliance will be dependent on the different national structures. In a natural disaster, we can see today that there’s much that we can achieve by working together and as an example, the UK has put out a combined military and NGO medical capability in support of the international response to the earthquake in Turkey.

What advice would you give to your younger self at the start of your medical career from your experiences?

Just pulling out a few short aphorisms, I would say: be bold and challenge the status quo because it can lead to profound change; be determined against resistance, particularly when you know that what you’re doing is right, and determination will often win through; and perhaps most importantly, enjoy the ride because it is a one-way journey and there are no refunds!

In closing, is there anything else that you particularly want to add?

I would reemphasize the importance of battlefield medicine in contemporary conflict and war, because we know that the first cry on the battlefield is “Follow me!” and the second cry is “Medic!” We need to be there, and we need to be ready. Let me finish by paraphrasing General Rupert Smith: “War will produce casualties. If your plan is good, it’s the enemy’s casualties. If your plan is bad, it’s your own. But whatever, you’ve got to plan for casualties!” 

Major General, thank you for the interview!

Date: 10/12/2023

Source: EMMS - European Military Medical Services 2023