Mountain Medicine Course

Phase One: Pre-environmental Training

Today began the Mountain Medicine Course hosted at the Marine Corps Mountain Warfare Training Center (MCMWTC) near Bridgeport, CA. Yesterday, the class flew into Reno-Tahoe Airport where a few instructors and staff waited with buses and a box truck to transport us and our gear the two hours south through the mountains to the remote schoolhouse. After arriving late in the evening, we were given a short brief and shown to our spartan living quarters. The “squad bays” – what we would call home for the next eighteen days – were open bay barracks with bunk beds and lockers and open showers. There were a few electrical outlets, spotty cell signal, and dysfunctional WiFi – a perfect place to learn the mountain medicine craft away from the outside world.

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We were a diverse class of 24 composed of medical doctors, corpsmen attached to Marine units, a Marine infantryman and a demolitions expert, two Navy SEAL medics, and three German medical officers. All were males except for one student, a Reserve Lieutenant Commander Family Medicine doctor who was assigned as class leader due to her seniority. The class gelled quickly and each offered a unique perspective and skillset that proved valuable to the entire class throughout the remainder of the course.

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After breakfast, we met in a classroom in our uniforms for the typical DOD course introductory briefs and paperwork. The command leadership introduced themselves and gave an environmental lecture detailing the forested mountains surrounding the schoolhouse. While the 650 acre schoolhouse complex is owned by the Marine Corps, the land surrounding the base where the various classes train is the Humboldt-Toiyabe National Forest – federal land managed by the national Forest Service. The classes are held to the same standards as any other hiker or camper adhering to the mantra of “leave no trace.” No fires without a permit, no digging, no cutting branches or trees, no leaving trash, no harassing or killing animals, etc. We became intimately familiar with this concept later during our field exercises when we were required to pack out our trash and use “wag bags” for collecting our waste.

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The MWTC currently offers multiple formal courses including the Mountain Medicine Course, a Cold Weather Medicine Course, a Summer and Winter Mountain Leaders Course, an Animal Packers Course, a High-Angle Sniper’s Course, and also hosts many Marine Corps unit exercises throughout the year. Interestingly, due to the similar latitude, mountainous environment, weather, and compartmentalized terrain, the MWTC was originally created in the 1950s Korean War Era as a training site preparing troops for the cold weather and mountain warfare prevalent on the Korean peninsula. Recently, with evolving world events, there has been a resurgence of interest and focus on mountainous and cold weather training at the MCMWTC.

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Following the morning briefs, we donned our PT gear and performed a Navy Physical Readiness Test. After max pushups and situps, we marched in columns down to State Route 108 where we ran 1.5 miles for time. The rigors of the course require that as a baseline level of fitness you must be able to do at least fifty pushups and fifty situps and run 1.5 miles in fourteen minutes. This sounds pretty easy, but the MWTC is at 6500 feet, and we were living at sea level the day before. Most were already feeling the effects of the elevation change: increased urination, increased respiratory rate and heart rate, etc. The run sucked, most lost thirty to sixty seconds on their run times, but only one of the 24 in the class failed the run, and one crushed the run at 9:07.

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That afternoon we returned to the classroom and learned about nutrition in extreme environments, specifically at high altitude and in the cold. Interestingly, your caloric requirement nearly doubles in extreme environments due to the metabolic demands. After a lecture on mountain safety and leadership, we headed outside to the “rope corral,” a small area behind the squad bays cordoned off by rope and metal poles with a center area for the instructors and the perimeter for the students. We were each issued a Petzl rock climbing helmet, two locking carabiners, a length of climbing rope, two lengths of cordage, and two lengths of water tape. We then learned about “rope corral attire” – remove watches and rings to prevent “degloving,” tuck blouses and roll sleeves to prevent snagging, and unblouse trousers. Once we learned the requirements of the rope corral, we were taught five climbing knots required for advancement in the course – the square knot with two locking overhands, double fisherman’s knot, roundturn and two half-hitches, roundturn and a bowline, water tape knot, and a six finger prusic. The rest of the afternoon we practiced tying these knots with the guidance of the instructors.

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On day two, we were issued all of our mountaineering gear: main packs (“rucks”), assault packs, sleeping systems, tarps and sleeping mats, clothing base layers and warming layers, Goretex, dry bags, Nalgenes and CamelBak bladders. We then returned to the rope corral where we learned the remaining required knots: midline figure eight, alpine butterfly, clovehitch, munter hitch, munter mule, slip figure eight, retrace figure eight, end of the line prusic with a bowline, around the body bowline with a figure eight just out of reach, and the Swiss seat – now referred to as the “military rappel harness.” To pass the course, each student must tie these knots within a specific time with specific standards for each knot. Thankfully, the test was still a week away, so we had time to practice. That afternoon we returned to the classroom for more lectures on initial stabilization and evacuation of casualties in mountainous environments, heat illness and hydration, and wilderness wound management.

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We were also introduced to the SKED, a flexible lightweight litter system that would be implemented throughout the remainder of the course. The instructors demonstrated how to properly secure a patient in the SKED and rig it up ready for transport. Passing the “SKED exam” was a also requirement to continue the course, and we quickly learned that this would be a difficult task requiring hours of study and practice over the next weeks to become proficient. There were dozens of failure points, and the nitpicking of the instructors was purposeful, since any failure of the system could mean death for the patient.

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Day three started with a 5K road ruck with all of our gear – approximately fifty pounds. The instructor cadre were beta-testing the ruck as an alternate fitness test in place of the Navy PRT since moving a heavy load at altitude over distance within a set time would better represent the course fitness requirements than the standard navy pushups, situps and run. The drop dead time was 45 minutes, which we all made, with some of the heroes crushing the time in under thirty minutes.

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We then returned to the classroom for more lectures. This became the pattern for the first week with a few variations. Lectures in the morning followed by the rope corral and SKED in the afternoon. The pre-environmental training phase was designed to acclimatize our bodies to the altitude and environment and to cram as much mountain medicine into our brains as possible for the following practical exercises.

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After the first week, we were given a day off to recuperate and prepare for the next phase. Most of us spent our time doing laundry, practicing knot tying, working the SKED, packing our gear, working out, and then going out on the town for dinner. “Out on the town” at Mountain Medicine meant going to a sports bar and grill in Bridgeport thirty minutes away. The schoolhouse is pretty far removed from most of civilization, with the closest “big” town and Walmart over an hour away. But getting away temporarily after the intensity of the previous week was just the mental break we needed before getting back to work.

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Phase Two: LTA/Field

Phase two began early the next morning with refueling at the cafeteria with a last warm meal before heading back to the squad bays. Breakfast in the cafeteria had become a daily tradition, and the food there was surprisingly delicious with fresh fruit, tolerable coffee and eggs to order. While the food was great, the coolest attribute of the cafeteria was the large wall of windows that offered a panoramic view of the mountainscape surrounding the schoolhouse. The scenery was incredible during the course, and many times I found myself just breathing in the fresh mountain air and mentally absorbing the the beauty.

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Outside the squad bays, we lined our packs and to our dismay were instructed to remove everything from the packs for inspection. We spent much of the night before carefully stuffing and arranging each piece of gear in our packs to optimize the weight distribution and knew that it would take a while to rearrange the gear. Shortly after inspection and hastily shoving everything back into our main packs, we assembled in columns and marched off toward the edge of the base.

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At the fenceline, the class was unleashed on a five kilometer ruck “at our own pace” toward the Leavitt Training Area where we would spend the next four days mountaineering. The fitness heroes charged off on a blistering pace with the rest of us trailing behind just surviving. At this point, our main packs contained all of our issued gear, our mountaineering gear, food for four days, two Nalgenes and a CamelBak filled with water, and our assault packs lashed on top with the remainder of our necessary gear – all weighing in at about eighty pounds.

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Level ground with that load was difficult enough, but the elevation change at altitude was crushing. We started at 6500 feet and climbed to the trail’s high point at 7300 feet where we stopped for a break and instruction and “scree surfing.” After catching our breath, emerging from our pain cave, and admiring the surrounding beauty, our instructors were quick to remind us that we were not even carrying a combat load which would easily add another thirty pounds.

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The ruck then devolved into a downhill race until we emerged at training area and finished with a maximum pull-ups competition – it seemed that everything eventually turned into a competition. After stowing our packs, we grabbed our mountaineering gear and assembled at a new rope corral to practice knot tying for the upcoming exam. Following lunch, our first training module at the LTA covered “fixed lanes.” Fixed lanes utilize ropes anchored strategically by an expert lead climber allowing other climbers to ascend a slope or cliff-face safely. After the instructors discussed the utility of fixed lanes in combat and demonstrated appropriate utilization, we spent the rest of the afternoon practicing traversing a up and down a small cliff-face.

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Later that night, we assembled at the cliff-faces again in the dark exercising light and sound discipline, then one by one ascended a ravine following a fixed lane established by the instructors earlier that afternoon. It was a harrowing experience traversing the cliff-faces in the nearly pitch black and having no idea what was above or below. But by implementing the skills learned earlier that day, clipping in with both carabiners and establishing a good footing and handhold with each movement, we all climbed the cliff safely. At the top we grouped into small teams and rigged up a SKED with no light and minimal noise simulating combat conditions.

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The next morning started at a mountain stream where we learned about “swift water rescue.” Rescuing each other from the frigid waters cemented the training, or at least gave us a healthy respect for the danger of freezing mountain streams. Over the next few days, we learned to rappel and belay, then rappelled the LTA cliffs and alternated belaying each other. Then we climbed the cliffs of varying difficulties with ratings based off the Yosemite Decimal Rating System (YDRS). Next, the instructors provided rubberized M4s and taught the basics of patrolling and reacting to contact before ambushing our formation and expecting us to respond accordingly.

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In order to complete the Mountain Medicine Course, there were four separate required milestones to be completed satisfactorily. Initially, upon arrival at the course, each candidate passed the fitness test except for one student who failed, and was sent home. The next two failure points were the knot test and the SKED test at the LTA. Only two students completely “cleaned” both tests initially without any failures. Most of us failed a few knots and passed on the retest the next day. The SKED was all or nothing – if any detail was unsatisfactory, the entire SKED was a failure. Thankfully, everyone passed on the retest except for a few who then remediated and passed on the final day at the LTA.

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On the last afternoon at the LTA, we were introduced to what initially seemed like an incredibly complex “raise and lower system” comprised of climbing rope, water tape anchors, cordage, a pulley system, and carabiners. We would utilize this system during the next week to raise and lower casualties in our SKEDs on slopes that would be impassable without the system. While seemingly complex initially, we spent the rest of the evening troubleshooting the system as a class until the mangled mess of rope and carabiners began to make sense. The next morning, a few unlucky souls were deemed casualties, whom we then secured in the SKEDs and lifted up the mountain with accompanying litter teams. Once up top, we assembled the lowering systems and retraced our steps. Little did we know, but we would do this ad nauseam during the field exercise the following week.

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On our final day, after repacking our gear, we assembled in tactical files and broke into separate squads for the hike back to the schoolhouse. Before the formation even made it to the trailhead, the instructors ambushed the class and began inflicting casualties. After reacting to contact, returning fire and suppressing the threat, the closest students administered medical care while the rest of us set up a defensive perimeter. Two of our classmates were “injured” significantly. We quickly wrapped them in SKEDs and began our evacuation. After making radio contact with higher (the instructors), we were informed that no MEDEVAC platforms were available at that time. They also informed us that a large enemy force was headed in our immediate direction and would overrun our position soon. And so began the most painful experience of mountain medicine. We morphed from three squads to two squads, with one patient and litter team per squad. The first kilometer was somewhat disorganized, but we soon fell into a rhythm of switching litter teams every 50-100 yards depending on the terrain. We also crossloaded the patients’ gear to distribute the extra weight.

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One of my most comical course memories occurred moments after the ambush at the LTA trailhead. I was near the front of the formation providing security, when I briefly turned and saw our squad leader, one of the SEAL medics, running full steam up the trail toward me. As he approached, I realized that he was carrying two rifles, his ruck, and one of the casualty’s rucks balanced on top of his ruck pushing his chin down into his chest. He dumped the extra ruck at my feet and asked me to take a turn. At that moment, I couldn’t decide whether to laugh or cry, but in retrospect, I laugh every time. After strapping the ruck to my chest, and rolling onto my knees, I waddled down the trail with the rest of the squad smiling through the sweat.

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The remainder of each squad provided security, spent a few moments recovering, and then readied to switch out with the litter team. One casualty weighed 220 pounds, and the other weighed 160 pounds, which made for an interesting dynamic. So we began switching the patients between the squads as the heavier squad began to lag. While this experience was physically draining, it was mentally enlightening. Just four days previous, we made this same hike with only our personal gear and thought it was difficult. Now we were carrying significantly heavier and more awkward loads that required teamwork and coordination. It was amazing to see what teamwork could accomplish. Also, by the end of the 5K mountain CASEVAC, our system had morphed into a well oiled machine with each squad transitioning quickly, taking short breaks, and moving relatively swiftly. The entire movement lasted four hours, and most of us were wiped at the end. But more mental barriers were eliminated, which was vital for success in the upcoming Field Exercise. Showers, a mattress, and a warm non-MRE meal that night back at the schoolhouse never felt better.

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The next few days we discussed altitude medicine and participated in a training evolution with a local Search and Rescue team. We learned the basics of helo operations and how to safely perform a MEDEVAC with a patient in the SKED. Afterward, a lucky student also was hoisted into the air with a SAR team member and briefly flew over the surrounding mountain ridges. We finally earned another day of liberty, but spent most of it preparing our gear for the final Field Exercise that started the next day.

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Phase Three: FEX

Earlier that week the instructors gave a WARNO (Warning Order) brief detailing the scenario for our final practical exam – the Field Exercise (FEX). Our mission as a combined medical support team was to assist the “South Toiyabe Army” and the associated 24th MEU with any medical requirements and MEDEVACs. Our enemy – the “North Toiyabe Army” (read North Koreans) – were infiltrating small units across the border who were engaging in irregular warfare, attempting assassinations, and disrupting any vulnerable infrastructure. We spent the rest of that evening studying topographical maps and satellite imaging, planning our movements, packing our gear, establishing our callsigns, ensuring our communications were functioning, and mentally preparing for the next few days. For the FEX,  we added more team gear to our load: radios, SKEDs, Medbags, squad rope gear, and all of our climbing gear.

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Early the next morning, we loaded onto two large transport trucks which then drove up the mountainside and deep into the Toiyabe National forest where they inserted us at a pre-established Command Post (CP). After another short brief, we formed into tactical files and began our trek across the mountains to our next CP. Due to forest fires in the vicinity, we established a defensive perimeter at an alternate CP near a lake, collected water for the group via our filter systems, and then built ad hoc shelters for the night utilizing survival training from earlier in the course.

After establishing our camp, we were tasked with a CASEVAC mission and given the ten digit grid of the injured servicemember. Utilizing our topo maps, land navigation, and a GPS backup, we located the individual about 700 meters away up a steep mountain ridge. After stabilizing medically, we began the extrication process with a SKED and our lowering system. The height of the ridge required constructing the lower system multiple times and slowly relaying the injured man down the slope in phases. But after a few iterations, we established a routine and became much more efficient. After a debrief back at our camp, we settled into our shelters for the evening and established our night security with roving patrols.

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The next morning we were awakened by the sharp bark of radio traffic, another large enemy force was detected by an ISR (Intelligence, Surveillance, Reconnaissance) platform and appeared to be heading in our direction. At this point, we realized that whenever the instructors thought we were moving too slowly or needed us to move in a different direction, they would create an imaginary enemy force that was about to descend upon us and wreak havoc. So, we quickly packed our gear, dismantled our shelters, and again marched off in tactical files hurriedly up and over a neighboring ridge line.

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The surrounding scenery was breathtaking, each moment we paused, the mountain wind and eery silence and austere beauty enveloped us. We spent the first half of the day climbing up and down the mountain slopes dodging the enemy force behind us, but we were eventually ambushed and sustained casualties. Thankfully, the casualties were ambulatory, so we cross-loaded their gear and walked them down the mountain to an open field where they were “MEDEVACd,” and then put back into play. We were getting good at our movements, navigation, communication, and medical care so the instructors began inflicting casualties on our leadership disrupting our groove and forcing others to assume leadership roles.

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After a brief break in that valley, we were assigned another CASEVAC mission. A friendly unit had taken casualties nearby and needed medical assistance. Their location was only a few hundred meters away, but nearly straight up a massive ridge on the opposite side of the small valley. So again we began our trek. At ten thousand feet in elevation, loaded down with gear, and with the steep grade, we slowly meandered up the ridge taking one or two steps before pausing momentarily to catch our breath. It took more than an hour to reach the ridge line and find the casualties, but we again began the CASEVAC process. We tended to medical needs, wrapped the injured snugly in the SKEDs, found sturdy trees for anchors, assembled our lower systems, and began to carry the casualties back down the mountain. The height of the ridge forced us to relay the casualties down the slope, build another lower system, and begin lowering again. We repeated this process half a dozen times before reaching a grade that allowed us to just carry the litters. After crossing a large boulder field and a small stream, we arrived at the MEDEVAC landing zone (LZ), but the instructors informed us that we were too late and the LZ had changed locations to another 1500 meters down the road.

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At this point it did not matter. We were exhausted, caked in dirt and sweat, but quickly assembled our squads and raced down the road with our two casualties in order to make the LZ in time. At least we were on level ground, the easiest litter carry ever. We again made rapid transitions, pushed hard for about 100 meters, then switched the litter teams. Each squad was flying, we had refined our process to an art, and were at the pinnacle of functioning for that course. We could see two large transport trucks in the distance, and methodically and rapidly moved in their direction. After arriving at the LZ, the instructors informed us that the transport trucks were there for us and the FEX was terminating a day early due to the approaching forest fires. They had pushed us extra hard that day since we were stopping early. After a short debrief, we loaded onto the trucks and headed back out of the mountains to our squad bays and the schoolhouse. That last drive down the mountains was beautiful, absolutely beautiful.

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The last two days were admin days that allowed for graduation, turning in all of our gear, cleaning the squad bays, and preparing for our return home. The surrounding forest fires prevented most travel, but some were able to escape to Yosemite and other surrounding unique tourist sites. On the last day, we were given course certificates and then separated heading in all different directions. What a cool 18 days.

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Lessons Learned

CASEVAC: Evacuation of a casualty at altitude, with elevation changes, over mountainous terrain and significant distances absolutely sucks. This was probably the biggest learning point of the course. If there is a way to safely evacuate by air or by ground vehicle, then that is much preferred to carrying the casualty out. We realized though, that in a worst case scenario anything is possible. But depending on the size of the group performing the CASEVAC, that group will likely rapidly become exhausted and combat ineffective. A study of the Battle of Takur Ghar vividly portrays the difficulties, nuances, considerations, and the absolute suck of mountain CASEVAC while under fire.(Takur Ghar Washington Post)(Robert’s Ridge Amazon.com)

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Mountaineering: This course was a fantastic introduction to many mountaineering skills including rappelling/belaying, rucking, knot tying, basic survival, load bearing and strategic packing which are all essential skills for thriving in a mountainous environment. But without further skill development and maintenance, these skills are perishable. The MCMWTC hosts a six week intensive Summer and Winter Mountain Leaders Course for those individuals who care to further develop and hone their mountaineering skills and then serve as subject matter experts to their units. Likely future conflicts in countries covered in rugged mountainous terrain mandate that we as a military be intimately familiar with thriving, not just surviving in these environments.

Academics: Unfortunately, the academics were not as intensive as some were expecting, but per the instructors it was a “combat medic” course and not necessarily designed for the medical officers. With such a diverse class including non-medical personnel, it was probably for the better. The myriad of practical skills learned though were fantastic, and the breadth of skills covered during that short eighteen days could only be rivaled in the civilian world by multiple courses and thousands of dollars. So ultimately the course was well worth the time and effort and cost as a student.

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Fitness: Performance at altitude over significant distances and elevation changes absolutely requires an excellent base of fitness. The course was physically exhausting, and combat in mountainous environments is physically brutal. Adequate preparation and acclimatization is mandatory.

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-Brad Kinney MD

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