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Combat Performance

Threat Stress

Paul Garcia

25 February 2010
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Combat Performance

Abstract

This paper will discuss the effect that fear has on the performance of medical personnel

in the combat setting. The fight or flight response can cause physiological changes in the medic

that can impact the medic in a negative way. These changes affect multiple systems in the body.

Usually the medic can handle some of these changes but when their life is threatened the

flooding of hormones overwhelms the medic’s ability to see, think, hear, and react. These

changes can put the medic, patient, and mission in danger. Recognition of the fight or flight

response is imperative in austere environments to maximize situational awareness and optimal

performance.

One factor that can gage the level of threat stress is the heart rate. Hormonal induced

tachycardia is a condition that needs to be recognized by the operator and worked through. This

type of tachycardia cannot be reproduced with exercise alone. Fear is a important part of

hormonal induced tachycardia. The ability to recognize this condition must begin in training and

training needs to be realistic to recreate situations that the medic will find themselves in. The

more dynamic the training the higher the heart rate rises the more likely the medic’s performance

will be hampered. If the medic can recognize what he is experiencing is normal he can work

through the event with simple steps to lower the heart rate and perform to the best of his abilities.

There are several factors that are part of combat performance. This paper will mention some of

them, but training will be the focus because it will be the introduction to skills and the

inoculation to stress will begin at this point.

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Threat Stress

Combat Medicine is the care given in the most austere environments in the world.

Military medics have been providing care in these environments since medical treatment was

integrated in to the battlefield. To operate successfully in these environment medics need to be to

be able perform in combat; the medic must combine the ability to critically solve problems,

utilize technology, implement fine and gross motor skills while getting shot at. Combat

performance depends on all of these systems working together to provide a clear thinking,

deliberate health care provider. On the battle field fear is one thing that will cause a medic to be

unsuccessful at his mission and that mission is to save lives. Fear stimulates the sympathetic

nervous system and this system responsible for the fight or flight response. This response has

been reported throughout the history of war. Carl Von Clausewitz described this response to fear

in these words, “fog can prevent the enemy from being seen, a gun firing when it should, a report

from reaching a commander” (Mc Kay, 2008, p.1.). This response can cause medical personnel

lose the ability to perform simple tasks or gain the ability to lift heavy objects. The stimulation of

the sympathetic nervous system while the performer is under stress is called threat stress. Fear

can bring on threat stress which will cause a hormonal response that will degrade the

performance of the combat medic if the medic is not trained to control this response.

The response that is experienced by medics during life threatening situations is

commonly referred to as the fight or flight response. The fight or fight response occurs when

there is a stimulation of the nervous system. The nervous system is separated into two major

divisions the somatic and the autonomic nervous systems. The autonomic nervous system is

further divided into the parasympathetic and the sympathetic nervous system. The sympathetic

nervous system is the division that responsible the release of hormones that are responsible for
 Combat Performance 4

the fight or fight response. When there is stimulation the hormones that are released include

adrenalin and cortisol. When fear places the medic in extremis the hormones affect the medic

from head to toe. The brain is affected by a loss of critical thinking skills. The thought process

shifts from the area responsible for complex problem solving to the area that controls basic

survival activities. The warrior medic will also experience changes to the senses which include

peripheral narrowing (tunnel vision) and auditory exclusion. Dave Grossman (2008) interviewed

a champion shooter, Massad Ayoob, who stated:

These changes will tune out everything that the brain does not perceive to be important to

the accomplishment of the mission. Everything I’ve seen tells me that most of auditory

exclusion (like tunnel vision) is a matter of cortical perception. The ears still hear and the

eyes still see, but as it focuses on the mission, the cortex of the brain is screening out

awareness of what it deems insignificant to the goal (pg 57).

These sensory changes could cause the medic to miss threats that are present on a asymmetrical

battlefield. Another change that occurs with fear is the loss of fine motor skills and the increase

in gross motor skills. The life saver will be able to carry wounded with the increase in the gross

motor skills but the ability to perform surgical airways and the ability to introduce intravenous

catheters will diminish with the loss of fine motor skills. These are a few examples of changes

that occur when the medic is experiencing threat stress other changes include sweating, increased

heart rate, and increased respiratory rate. The changes in thinking, vision, hearing and motor

skills diminish the combat performance of medical personnel in life threatening situations.

The level of performance of medical personnel can be associated to the heart rate. The

heart rate is classified by Dave Grossman in a color designation of white, yellow, red, grey and

black. The normal heart rate range is 60-80 this is the classification of white. At this heart rate
 Combat Performance 5

thought processes are normal fine motor skills are intact and gross motor skills can perform daily

activities. When fear causes the release of adrenalin the heart rate begins to climb when it

reaches the next level the heart rate is 80-115 this is condition yellow. Condition yellow is

different from condition white because the level of vigilance increases. Condition yellow could

be compared to walking down a dark alley known for violence. If the heart rate continues to

increase the medic will reach condition red. Condition red is when the heart rate is between 115

and 145 and this considered to be the optimal performance level. Condition red has the benefit of

increased strength, reaction time, and speed but the medic will have a loss in fine motor skills.

The next condition is grey is a heart rate from 145-175 this condition is reserved for special

operations units who train to work at this level. There is no difference between red and gray

except for the operator training extensively to work in this condition. The last condition is when

the heart rate is above 175 and this condition is labeled as black. In condition black the irrational

behavior occurs such as freezing, loss of bowel control, loss of urine control and gross motor

skills are at the maximum level. Escaping from the threat is the only thing that the person is able

to do. The rate of the heart that is experienced with hormonal induced tachycardia is directly

related to the degradation combat performance when the medic is experiencing extreme stress.

Recognizing the effects of hormonal induced tachycardia is the first step in increasing

combat performance. The recognition of threat stress must occur in training so that the medic can

come up with strategies to work past the effects of adrenalin. Stress inoculation must occur prior

to the medic reaching the battle field. Stress inoculation is achieved by exposing the medic to

realistic training in similar environments, wearing full tactical gear, treating patients that model

actual battle field injuries. Realistic training creates confidence and confidence makes competent

life savers. The more exposure the medic has the more opportunities the medic has to try to stay
 Combat Performance 6

in condition red. Condition red can be maintained with breathing exercises to lower the heart

rate. This breathing exercise is called combat breathing by Bruce Siddle (2008), the technique

advocates for the medic must breathe in for three seconds; hold the breath for three seconds:

followed by a three second exhale. (p.106) Combat performance of the medic on the battle field

is directly related to the ability to control the heart rate. If the medic cannot control the heart rate

then performance will suffer.

In summary operating in austere environments while patients are in extremis can bring

about the effects of threat stress; which can debilitate a medic on the battle field. The combat

medic must work against the natural response to fear. The natural human response to fear can

cause the responder to not be able to see, hear, focus or perform life saving interventions.

Without these basic functions the medic is left vulnerable to the surrounding threats in combat

and both the medic and the injured could die. Recognizing that the fear response is setting in and

taking steps to counter those effects can mean the difference in life and death. At the point of

injury the ability to dial the heart rate down to achieve maximum performance is something that

is learned and repetition of realistic scenario training is how the medic will achieve control.

Without control the performance of the medic will be devastated by hormonal induced

tachycardia. Maximum combat performance is a few breaths away.

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References

Grossman, Dave, (2004). On Combat: The psychology and physiology of deadly conflict in war

and in peace. Millstadt. Warrior Science Group publications.

Mc Kay, Sean and Siddle, Bruce (n.d.)Rescue Human Factors .Retrieved February 11,2010,from

http://www.narescue.com/Rescue-Human-Factors-W84C226.aspx

Siddle, Bruce, (1995).Sharpening the warriors edge: the psychology of science and training.

Belleville. PPCT research publications.

Mc Kay, Sean and Siddle, Bruce (n.d.)Rescue Human Factors .Retrieved February 11,2010,from

http://www.narescue.com/Rescue-Human-Factors-W84C226.aspx

Stress and Combat Performance(September 2000).Retrieved from

www.hooah4health.com/toolbox/stress/sec01b_combat.doc