Six Thousand Burn Patients and the Brutal Math of Large-Scale War: COL Donald Kosiak, MD.
Military medicine has spent two decades getting very good at the individual patient. COL Donald J. Kosiak, MD, thinks that is exactly the problem. At the Defense Strategies Institute Operational Medicine Symposium in San Antonio, he put the question plainly: what does a physician do with six thousand burn patients?
The Eaches Versus the Thousands
COL Kosiak calls it the trap of the eaches. A panel will spend an hour on a cold weather injury, a complex burn, a patient who needs ECMO — all genuinely interesting, and all framed around one casualty at a time. That framing works in peacetime and it worked through two decades of counterinsurgency. It does not survive casualty estimates that run into the thousands per day. As an emergency physician, COL Kosiak is the first to say he loves learning burn care for the each. He is also the one asking which of nine thousand patients gets the seven sterile dressings.
Notification at Scale
The same arithmetic reaches past the point of injury. Today a casualty notification means uniformed officers at the door, a chaplain alongside, and months of contact afterward. Dr. Kosiak calls that one of the great services the Department of War provides. He also asks whether it survives thousands of casualties a day, and he is not willing to accept a return to telegrams. It is the kind of second-order problem that does not appear on a clinical agenda and will surface immediately in a real fight.
What Happens When the Guard Leaves
Roughly seventy percent of the Army's medical assets sit in the Guard and Reserve. Mobilize them and twenty to thirty percent of the clinical workforce walks out of American civilian hospitals, which by design run at ninety-six to ninety-seven percent capacity. The VA loses staff at the same moment. COL Kosiak points out that the buildings remain; the staff do not. Stockpiles that grew from two days to thirty after COVID still don't cover a nine-month campaign, and raw materials for much of the national pharmaceutical supply are manufactured elsewhere.
Days to Anarchy
He borrows a measure from the power industry, which tests outages against how long a population holds together without electricity. The answer is about seven days — and that is with everyone confident the power is coming back. In a near-peer conflict, with communications degraded and no clear explanation, that assumption disappears. He is careful to say he is not a doomsday planner. He is also clear that a few days of water and food is reasonable for any household to keep against a natural disaster or a man-made one.
What He Deployed Into, and What He Came Home In
COL Kosiak deployed to northern Iraq in 2004 with the 25th Infantry Division, receiving trauma from east of the Tigris at a forward aid station outside Mosul. His father, also a physician in uniform, was at the combat support hospital nearby; they managed one Thanksgiving dinner together. Then Dr. Kosiak (the younger) went into atrial fibrillation on a treadmill and became a patient in the evacuation chain he had been feeding. A senior colonel in the same theater carried the same name, and the notification calls landed on the wrong relatives with the wrong story. He flew the whole route to Germany and has been thinking about what that journey does to people ever since.
Where the Technology Actually Helps
COL Kosiak is not looking for a gadget. He wants continuous readiness evaluation in place of a once-a-year questionnaire, using claims, prescriptions, profiles and fitness data already sitting in digital form — the same shift security clearances made years ago. He wants sensors simple enough that three medics and a physician assistant can hold fifteen hundred casualties in prolonged field care, with vital signs and geolocation feeding a higher headquarters that can sequence movement. In garrison, he wants ambient listening to write the note, queue the orders, and give clinicians their time back.
A Little Bit of Fear
Asked what he wants people to carry out of the symposium, COL Kosiak does not say confidence. He wants a little fear, a little urgency, and the resolve to write something down — then to come back next year with an answer. Listen to the full conversation, and share it with someone who is still planning for the eaches.
HOW TO WATCH
Check out the full episode featuring COL Donald J. Kosiak, MD, on our YouTube channel:
GUEST BIO
COL Donald J. Kosiak, MD, is an emergency physician, South Dakota's State Surgeon, and Chief Medical Officer at Leidos. He has served nearly thirty years in the Army National Guard, deploying to northern Iraq in 2004 with the 25th Infantry Division, where he received casualties at a forward aid station outside Mosul. In his civilian career he has served as emergency department director, director of primary care, hospital chief of staff, and chief medical information officer, and he practices at a Level II trauma center. He has chaired the nationwide credentialing and privileging committee for the Army National Guard, and he was among the founders of the Defense Strategies Institute Operational Medicine Symposium, which has grown from roughly fifty attendees to nearly fifteen hundred registrants.
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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