The American doctors weren't in the room, or even in the country, when they were informed that the man's crushed limb could be saved. The US service member had been deployed aboard a ship in the Middle East, but an equipment accident in March had left him with severe injuries that exceeded the ship's medical capabilities. He had to go ashore for care, but there wasn't a US-run medical facility available nearby. At a host-nation hospital in the region, local doctors monitored and treated him while reassuring their US counterparts from afar that he was in stable condition.

However, when he arrived at the American military hospital in Landstuhl, Germany, a week later, doctors saw a limb that had turned almost black and a life in danger. The incident, described publicly to an audience of military medical professionals by US Army Col. Jennifer Gurney during a panel on trauma case studies, speaks to a problem American forces have confronted amid the conflict with Iran. The system built for treating wounded troops during the post-9/11 Global War on Terror has struggled in this new fight.

Gurney, who recently rotated out after serving as director of the Pentagon's Joint Trauma System, shared details of the incident at an August conference that Business Insider attended. Her remarks were not an isolated warning. Other military leaders who spoke at the event, along with half a dozen military medical officials interviewed separately, described a casualty-care system grappling with a battlefield far different from Iraq and Afghanistan. Officials who spoke with Business Insider said that at the beginning of the Iran war, medical capabilities close to the fighting were constrained by persistent drone and missile threats.

They said that medical facilities on or near military centers have only recently received improved protection. Additionally, large, US-run hospitals in the region are absent, officials said, and reliance on host-nation hospitals, combined with limits on American oversight and fragmented records, has complicated efforts to track both patients and lessons from the war. A spokesperson for Central Command, which oversees US military operations in the Middle East, told Business Insider that the combatant command maintains "an extensive casualty care system" with liaison officers and "active embed teams" in the host-nation medical facilities. They added that the command surgeon's office "follows every case all the way back home."

CENTCOM said the system performed effectively overall and that 95% of wounded service members — most of whom had concussion-related injuries — were able to return to duty within hours or days.

A Pentagon Inspector General report to Congress released in mid-September documented some of the operational challenges surrounding casualty care during the conflict, echoing what officials told Business Insider. The independent investigation found a reliance on foreign medical centers due to the "resource and force protection challenges" of establishing large, fixed facilities. The report also said that US Army medical evacuation helicopters were forced to relocate in response to Iranian strikes, leaving US troops heavily dependent on ground vehicles and local ambulances in emergencies.

"We refined a trauma system for 20 years that we cannot lift and shift to this current environment," a senior medical official with combat experience told Business Insider. They recalled a deep sense of helplessness upon realizing that "we really didn't have a functional battlefield trauma system" when the war began.

The US military spent two decades building an unmatched medical system for saving the lives of wounded service members.

During the Global War on Terror, it operated a tightly connected chain designed to move severely wounded troops rapidly from the battlefield to advanced levels of care. During the conflicts in Iraq and Afghanistan, US and coalition forces maintained "Role 3" hospitals near major combat hot spots in those countries that provided advanced surgical care options beyond damage control — such as orthopedic, neurosurgical, and facial surgery — and postoperative care.

When the war with Iran began, that infrastructure was no longer in place. With the US withdrawal from Afghanistan and a vastly diminished footprint in Iraq, Role 3 hospitals were gone.

"Our service members should not pay the price because we can't organize and implement our battlefield trauma system," Gurney said at the August conference. A Defense Health Agency spokesperson told Business Insider that the discussion by Gurney and other military medical leaders "should not be interpreted as a characterization of current medical posture, partnerships, or personnel presence across the region." "The panel's purpose was to identify lessons that can inform the continued development of the globally integrated Combatant Command Trauma System, rather than to assess or characterize current operations," the spokesperson said.

Three medical officials told Business Insider that when the US launched Operation Epic Fury against Iran at the end of February, US medical teams near enough to the fighting to treat American troops wounded by drones and missiles lacked adequately protected facilities, limiting them. And the military's nearest major hospital was in Germany, thousands of miles away. Those gaps became evident one day into the war. On March 1, an Iranian drone struck US forces at Port Shuaiba in Kuwait, killing six US service members.

Some injured troops drove themselves to a hospital, and later waited in safe houses for evacuation, survivors told The Washington Post.

"There was absolutely no evacuation plan," an Army colonel wounded in the blast told The War Horse, an online publication covering the military. One soldier who survived the attack told Business Insider that troops scrambled beforehand to find medical supplies. A rehearsal that should have had troops physically walk through each step of a mass-casualty event was glossed over, they said. Thousands of miles away, medical providers at Landstuhl were unprepared for the wounded troops being airlifted their way, unaware at first that anyone had even been injured, the Post first reported.

Part of the problem, the survivor told Business Insider, was that the flight to the facility was not officially designated as a medical evacuation flight. The Army defended its casualty care to the Post, telling reporters that all wounded troops received "continuous physical, behavioral and TBI care," referring to care for traumatic brain injuries. In May, a soldier who survived the attack told CBS he believed one of his teammates who died in the attack might have been saved had the military established a medical presence close by.

There was no doctor or fixed aid station, despite earlier requests for additional medical support, they said. In response, a spokesman for Central Command told CBS that "no plan is ever perfect, but accusations suggesting blatant disregard for the safety of our forces are unfounded and inaccurate." The War Horse reported that some wounded troops struggled with delays in testing and treatment even after leaving Kuwait, underscoring how problems in the casualty-care system can extend beyond the battlefield itself.

The reported breakdowns in the system have drawn congressional scrutiny, with lawmakers seeking answers from the Pentagon. Not only has the network that once saved lives in Iraq and Afghanistan shrunk, but the battlefield it was designed for has changed.

The Global War on Terror saw injuries from improvised explosive devices that littered roads and pathways and devastated the lower body. Now, Gurney said at the conference, drones are causing "more head and neck injuries, more face injuries, more eye injuries." According to the military's casualty tracker, at least 19 troops had been killed and another 861 wounded as of Monday. One death was unrelated to combat. "They'll do an attack, you'll go to the bunker, you'll get the all clear, and as soon as you come out, they launch a drone attack," one senior medical official said of attacks by Iranian forces, particularly earlier in the war.

The persistent attacks have raised concerns about the long-term effects of repetitive mild TBI. "We've often thought of mild TBI as something where we can return someone to duty," the official said, but war with Iran is challenging that assumption. "Lessons learned from Operation Epic Fury reveal critical gaps in our understanding and treatment of blast injuries," Keith Bass, the assistant secretary of war for health affairs, said at the conference.

The drones and missiles causing these wounds are also threatening the facilities and crews meant to treat them. "We're way late," one medical official said of efforts to harden the smaller medical facilities that treat troops close to battlefields, known as Role 2s. Those key facilities are beginning to receive better fortifications months into the war, they said. For decades, such sites have often consisted of tents or small buildings surrounded by concrete barriers to protect against ground-level threats like gunshots or bombs — perimeter protections that can't defend against new threats from above.

Evidence of drones' devastating impact on a trauma system can be found on the Ukrainian battlefield, where some field hospitals have moved underground for protection. There, casualty evacuation is slow, and troops may wait days, even weeks, for higher-level care.

The Iran war has also exposed long-standing staffing problems, including too few medical providers and too few opportunities for military clinicians to reliably hone skills in advanced trauma care in peacetime, concerns that have been highlighted in previous analyses and investigations. In March 2025, retired senior trauma leaders warned Congress that shrinking budgets, personnel shortages, and bureaucracy had left military medicine poorly positioned for a large-scale conflict.

Retired Air Force trauma surgeon Jeremy Cannon told lawmakers that "no one in DoD truly owns combat casualty care," and warned that without intervention, the system would "continue to slide into medical obsolescence." Those shortfalls have pushed some wounded American troops into foreign civilian and military hospitals in places like Oman, Bahrain, Kuwait, and Jordan. Three US officials told Business Insider that while host nations often provide high-quality care, expertise in treating complex combat injuries, such as severe trauma and traumatic brain injury, can vary widely.

"We've had a handful of severely injured patients, and we've had a handful of really serious quality problems," one senior medical official said. "Those are the patients we worry about." The US is deeply dependent on host-nation hospitals, officials said, emphasizing the importance of regional partners in caring for wounded US troops and their appreciation for that care. But they said American medical teams have limited ability to oversee care or intervene in another country's hospital operations, making it more difficult to monitor treatment and capture lessons and medical data from the battlefield.

A CENTCOM spokesperson challenged that characterization, maintaining that US personnel — liaison officers and "active embed teams" — oversee patient care at those foreign facilities and "physically see every single US service member" treated there.

CENTCOM declined to provide additional details about where those teams are located, how long they have been in those hospitals, and what medical roles they perform. Military medical officials who spoke with Business Insider said their experiences during the war left them concerned about the system's ability to consistently deliver the standard of care US troops expect. "We made the promise to our service members to take care of them," one senior medical official said. "We're failing on our promise to those that are going out there and potentially getting harmed. And that bothers most of us."