COL Donald J. Kosiak, MD, has spent almost thirty years in the Army National Guard, and he has spent most of that time doing arithmetic that the rest of military medicine has been slow to do. An emergency physician by training, South Dakota's State Surgeon, and Chief Medical Officer at Leidos, he joined WarDocs at the Defense Strategies Institute Operational Medicine Symposium in San Antonio to make an argument that is easy to state and hard to absorb: the conversations military medicine is comfortable having are conversations about individual patients, and the next fight will not be fought one patient at a time.
The through-line is scale. He describes panels that still frame the problem as a cold weather injury, a bad burn, a patient who needs ECMO — the eaches, as he calls them — and then asks the question that reframes everything. What is a physician supposed to do with six thousand burn patients, one tube of ointment, and seven sterile dressings? How does triage doctrine survive casualty estimates in the thousands per day? He extends the same logic to casualty notification, and to a civilian system that has never been asked to absorb the shock: when the Guard and Reserve mobilize, roughly seventy percent of the Army's medical assets leave hospitals that already run at ninety-six percent capacity by design, and the VA loses staff at the same moment.
The episode is not abstract. He deployed to northern Iraq in 2004 with the 25th Infantry Division, backfilling a Massachusetts National Guard unit, at the same time his father — also a physician, also in uniform — served at a nearby combat support hospital. They had one Thanksgiving dinner together. Then he went into atrial fibrillation on a treadmill, was evacuated to Germany, and, sharing a name with a senior colonel in the same theater, watched the notification chain deliver the wrong news to the wrong family members. He came home through the evacuation system he had been feeding, and he has been thinking about what it felt like ever since.
He is equally concrete about solutions: continuous readiness evaluation instead of a once-a-year questionnaire, band-aid sensors and geolocation so a handful of clinicians can hold fifteen hundred casualties in prolonged field care, ambient listening that returns time to clinicians, and a pharmaceutical supply chain treated as a national security problem. What he wants people to leave with is a little bit of fear — enough urgency to write something down and plan.
Chapters
(00:36-07:39) From North Dakota to Mosul: A Guard Physician's Path to War
(07:40-12:08) Becoming the Patient: Evacuation, Confusion, and What It Taught Him
(12:09-17:14) Leidos, Systems Integration, and the Founding of OP MED
(17:15-26:29) LSCO Math: Six Thousand Burn Patients and Days to Anarchy
(26:30-38:00) AI, Readiness, and the Case for the Guard and Reserve
Chapter Summaries
(00:36-07:39) From North Dakota to Mosul: A Guard Physician's Path to War
A father in the Air Force and then public health, a rural North Dakota practice, and a National Guard scholarship that looked like a way to pay for medical school. Nine-eleven arrives two months into residency and redirects a career. He describes landing in Iraq and mistaking incoming fire for fireworks, and the credentialing problem that assigned specialists as general medical officers.
(07:40-12:08) Becoming the Patient: Evacuation, Confusion, and What It Taught Him
Atrial fibrillation on a treadmill in theater turns an emergency physician into a patient in his own evacuation chain. A senior colonel in the same area of operations shares his exact name, and the notification calls reach the wrong family members with the wrong story. He rides the system all the way back to Germany and catalogs what it does to the people inside it.
(12:09-17:14) Leidos, Systems Integration, and the Founding of OP MED
The move from clinical leadership to industry, and what a systems integrator actually does for the federal customer: take a startup's capability, translate it into military requirements, and sew the pieces into something the military can buy. He also recounts how the Operational Medicine Symposium began — about fifty people in a room eight years ago, now nearly fifteen hundred registrants.
(17:15-26:29) LSCO Math: Six Thousand Burn Patients and Days to Anarchy
The core argument. Casualty estimates in the thousands per day break triage doctrine built around individual patients, and they break casualty notification with it. He walks through civilian hospital capacity, VA staffing, thirty-day stockpiles, the pharmaceutical supply chain as a national security question, and the power industry's measure of how long a population holds together without electricity.
(26:30-38:00) AI, Readiness, and the Case for the Guard and Reserve
Continuous readiness evaluation modeled on how security clearances changed, remote monitoring that lets a few clinicians hold fifteen hundred casualties, and ambient listening that gives time back to clinicians in garrison. He closes on Arctic and tropical medicine, the lessons sitting unread in a World War II museum, and why the Guard and Reserve deserve a serious look from anyone entering the profession.
Take Home Messages
Scale Breaks Doctrine Built for Individuals: Military medicine is comfortable discussing the single complex patient — the burn, the cold weather injury, the ECMO candidate. Casualty estimates in the thousands per day make that framing a trap, because the decisions that matter shift from treatment to triage, allocation, and movement. Training and conference agendas have to follow the math.
The Civilian System Is Part of the Force Structure: Roughly seventy percent of the Army's medical assets live in the Guard and Reserve, and those clinicians are pulled from hospitals already operating near ninety-seven percent capacity. Mobilization empties civilian emergency departments and the VA at the same moment the nation needs surge capacity. Planning that stops at the installation gate is not planning.
Supply Chains Are a Clinical Problem: Thirty days of stock is not nine months of war, and pharmaceuticals whose raw materials are manufactured overseas are a national security exposure, not a procurement footnote. The same constraint governs malaria prophylaxis in the Pacific and warming capability in the Arctic. A capability that cannot be resupplied is a capability you do not have.
Readiness Should Be Continuous, Not Annual: A periodic health assessment is accurate for exactly one day, and only if the answers were honest. Claims data, prescription records, profile status, and fitness results already exist in digital form and can flag who genuinely needs a visit. Security clearances moved to continuous evaluation years ago; readiness screening can follow the same path.
A Little Fear Is a Planning Tool: The goal of an operational medicine conference is not reassurance. Leaving with the sense that preparation is incomplete and time is short is what produces written plans, honest requirements, and the next year's answers. Comfort is what keeps lessons sitting unread in a museum.
Episode Keywords
military medicine, large-scale combat operations, LSCO, near-peer conflict, mass casualty triage, burn care, combat casualty care, Army National Guard, Guard and Reserve, state surgeon, operational medicine, OP MED Symposium, Defense Strategies Institute, Leidos, military health system, casualty evacuation, prolonged field care, remote patient monitoring, medical readiness, pharmaceutical supply chain, Arctic medicine, emergency medicine, combat support hospital, WarDocs podcast
Hashtags
#MilitaryMedicine, #LSCO, #OperationalMedicine, #CombatCasualtyCare, #ArmyNationalGuard, #MedicalReadiness, #WarDocs, #OpMedTV
More from the Operational Medicine Symposium
This episode is part of the WarDocs and OpMed TV interview series recorded at the Defense Strategies Institute Operational Medicine Symposium in San Antonio, March 2026. Watch the full set of DSI OP MED videos here: https://hubs.li/Q04jRhjP0
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