Introduction

Major Rick Hanrahan:

This episode is the first part of a two-part interview with retired Lieutenant General Paul K. Carlton Jr., the former surgeon General of the U.S. Air Force and an 11,000-case surgeon with over 30 years of experience, on the topic “Leadership Through Disruptive Innovation”.

This interview includes some fascinating accounts of when his leadership was challenged in extremely high-stress situations and his innovative solutions, often in the face of putting his career on the line and potential courts martial. In this first part, we discuss his background, a relief effort in Haiti where he made life and death decisions, and an electrifying account of his personal experience at the Pentagon on 9/11, where he risked his life to save others. Here are a few highlights from part one of today’s show.

Show Excerpts, Lieutenant General Paul K. Carlton Jr.:

Proper preparation prevents poor performance. In this case, because we had been innovative in thinking of scenarios that could occur, we saved lives and a young tech sergeant came right behind him and said, “General, you want to see where the dying is, come with me.”

I said, “Okay, fight’s on boys. Let’s go.” So we followed them through the hole, through the debris path.

Announcer:

Welcome to The Air Force Judge Advocate General’s Reporter Podcast, where we interview leaders, innovators, and influencers on the law, leadership, and best practices of the day. And now to your host from The Air Force Judge Advocate General’s School.

Maj Hanrahan:

Welcome to another episode from The Air Force Judge Advocate General's School. I’m your host Major Rick Hanrahan. Remember, if you like the show, please consider subscribing on Apple Podcasts and leaving a review. This helps us to grow in outreach to the JAG Corps and beyond.

Well, we have an amazing interview in store for you today. We have the unique privilege to interview retired Lieutenant General Paul K. Carlton Jr., the former Surgeon General of the United States Air Force with a record of service spanning over 30 years in the U.S. Air Force from 1969 to 2002. And he’s here today to talk about a topic rarely discussed in an open forum like this. Leadership through quote unquote “disruptive innovation”.

Leadership and innovation are not always clean and simple in practice, rather innovation, true innovation, often requires a grit and determination to see through to the right thing in the face of significant adversity. And our guest today is no stranger to dealing in high stress, traumatic human endeavors as a leading surgeon. Sir, it is a pleasure to have you in studio today.

Lt Gen Carlton:

Maj Hanrahan:

Lieutenant General Carlton Jr. was born in Roswell, New Mexico and is the son of the late four-star General Paul K. Carlton Senior, a former military aircraft commander who retired with more than 12,000 flying hours in numerous aircraft, including as a World War II B-29 pilot who flew hundreds of hours of combat missions against the Japanese; was the aide-de-camp to Chief, General Curtis LeMay, among many other notable accomplishments. In other words, Lieutenant General Carlton Jr., in studio today with us, grew up around some of the most distinguished Air Force members of the 20th century. He earned his commission as a distinguished graduate from the U.S. Air Force Academy class of 1969. He next earned his Doctor of Medicine from the University of Colorado in 1973.

He has held numerous positions through his 30-year career to include assignments as a resident general surgeon in Wilford Hall at the USAF Medical Center in Lackland Air Force Base, Texas. He was a staff surgeon at the Royal Air Force base in Lakenheath England; Chief of General Surgery at Luke Air Force Base; Chairman, Department of Surgery, at Wiesbaden Air Base Germany; Commander of the USAF hospital at Torrejon Air Base, Spain; Commander, Medical Center, Scott Air Force Base, Illinois; Director of Medical Services and Training, at the Air Education and Training Command at Randolph Air Force Base in Texas; Commander of the 59th Medical Wing in Wilford Hall at Lackland Air Force Base; Commander, Director for the Air Force Medical Operations Agency Office of the Surgeon General, at Bolling Air Force Base; and from December of 1999, until October of 2002, he was the acting Surgeon General of the U.S. Air Force.

Lieutenant General Carlton has extensive in-theater experience as a leading surgeon in supportive operations and has been instrumental in medical innovation through his career. He conceptualized and implemented the first Air Force rapid response surgical team in Europe, called the Flying Ambulance Surgical Trauma Team during Operation DESERT STORM. He commanded the 1702nd Air Refueling Wing Contingency Hospital, completing 32 combat support missions and 140 combat flying hours in multiple aircraft.

He has published extensively in medical literature and he is an 11,000-case surgeon who continues to “wash his hands” whenever he can. His vision for medical care in the combat zone led directly to the best survival rate in the history of modern warfare.

Currently Lieutenant General Carlton is retired.

Well sir, did I at least provide a fair summary there?

Lt Gen Carlton:

Major Hanrahan, thank you very much. I was blessed to have a military career that enabled me to do what I love to do, enabled me to take care of the people that I love to take care of, our Air Force community, our military people in general, and enabled me to live my core values. So I had a little disappointment when I graduated from the Air Force Academy. I wasn’t allowed to go to pilot training because of eyesight problems. So I became a physician instead. Went to medical school. Went to a surgical residency and then came out of that residency into the system of the Air Force, and had the pleasure then to take care of our Air Force members, literally around the world.

When I was in England, I had the opportunity to operate in 16 different countries and we had three assignments overseas, again, England, Germany, and Spain. So I got to see medicine around the world. Understood it a little bit better than I had when I was strictly stateside and was able to implement some changes in our war plan that have resulted in the best survival in the history of war.

So I was blessed with a great team of innovators who were willing to do things differently than we had in World War II, in Vietnam, and even in the Gulf War. The net result of which is we have 11,000 service members extra, alive in this conflict than we would have had, had we simply followed the lead from Vietnam and the method of doing things in Vietnam. So I have been blessed Major, greatly. An opportunity to serve has been remarkable and my family and I have been blessed with that opportunity.

Interview - Part 1

Maj Hanrahan:

Thank you, sir. And we’re here today to talk about leadership, your leadership experiences and innovation, which you’ve literally lived your entire life. You had the opportunity to speak here around the University Circle and also to the JAG School yesterday, and just some incredible stories. So sir, perhaps you could talk about one or two of either the times when you faced potential court-martial or when you were fired or you faced being fired for different decisions that you had to make that were very challenging.

Lt Gen Carlton:

Well, obviously sharing those stories is fraught with hazards and lots of memories. Probably one of the more memorable was an episode that occurred in the mid-1990s.

I was a commander at Wilford Hall and I was called from a friend who was leading a Navy hospital in Haiti. He informed me that he had just received a badly injured person, had no ventilators in the entire country, and would I come pick up this patient with one of our brand new critical care in the air teams? He gave me all the information he had. I thought that was adequate. And so I requested a small airplane, a C-21, and a small critical care team to go pick this patient up.

When they arrived in Haiti from San Antonio, unfortunately there was a big surprise, and that was from this vehicle rollover. A GI vehicle had rolled over on a street in Haiti. There were three people inside. They were beaten with two by fours, stripped and left for dead.

And so they trickled in. First individual that came in was what I had been told about. But by the time my team arrived, there were two additional. The problem was since they had been beaten and stripped, they could not speak to us. They were head injured. We had no idea who they were. So we went to haircuts and said, okay, does the first guy have a GI haircut? The answer was, yes. Okay. I said, does the second guy have a GI haircut? The answer was no. I said, and the third person? They said it’s a female. I said, okay, go through their injuries with me. And my team chief recounted the injuries one by one. I said, all three of those people are survivable with intensive care methods. What do we have to do to get them evaluated and evacuated?

Well, he related that the State Department had very strict rules that included a name, a Social Security account number, a date of birth, the place of birth, and literally an entire family history, which was a system that I did not disagree with. Except I thought that these three individuals were related to the military because they were driving in a GI vehicle. I questioned the commander of the medical unit about how strict people were with moving on a GI vehicle. And he told me they were very, very strict. So I said, well, then the potential that these three injured people who will die on your hands is that they are related and therefore approved for military transport. He said, but we have no idea who they are. I said, well, pull out your pen and pencil and we will be creative. And so between the two of us, we came up with names, Social Security account numbers, dates of birth, places of birth for all three of these people off the top of our head.

Now you have to remember that this is a Secretary of Defense and Secretary of State-level evacuation. So we found a large airplane that was on an exercise in the Caribbean. They diverted into Haiti. We had our critical team on board. We had an AIRVAC team on board. So we loaded these three people up and moved them to San Antonio and into the Wilford Hall Hospital. They were very, very ill. We did not have to operate formally, although we had to put external fixators on these individuals, and they had a prolonged ventilator course. So about seven days into their ventilator course, the first one got well enough to come off a ventilator, the gentlemen with a proper GI haircut. In fact, he was a young staff sergeant. We quietly corrected his name, his Social Security account number, the other information that we had fabricated. And we’re very quiet about correcting that information.

The next person to come off of ventilator was the man that didn’t have a GI haircut. And that we had creatively came up with all of his information. And he said, first thing I gotta do is I gotta call my wife. I said, well, your wife is in the room next to you on a ventilator. And he said, that’s not my wife. So it became apparent that perhaps our creativity was a little more than we had expected.

So the third person then comes off of ventilator and she says, parlez vous Francais. So in fact, she was a French journalist, and we had kidnapped a French national from Haiti. That did not sit well with the Secretary of Defense, nor the Secretary of State that we had knowingly violated the rules of engagement. And they offered an opportunity for me to retire immediately and receive a formal UCMJ action. As a regular officer, I said, well, I don’t plan to retire. And I don’t plan to take a formal counsel from the UCMJ. I wish to be court-martialed. They came back and said, you’re being a jerk. I said, no, I’m being someone who values human life. And I was willing to take a chance that we could salvage these three people and did so. So I don’t think the French embassy nor the French public will be very interested in having me publicly court-martialed for saving a French national, do you?

Well, you might imagine my name was not very popular at that time, but they did decide to drop all charges and allow us to go ahead and finish taking care of these three individuals. So I don’t mean to be flippant with the rules nor regulations. I have to understand that rules and policies are made for good reason, but they are also made for good reason to have exceptions. In this exception, we saved three people’s lives who would otherwise certainly have died because we were creative with our names and Social Security account numbers, but it was certainly worthwhile to save these three persons’ lives. So all charges were eventually dropped and I returned to continue my role as the commander of the medical center in San Antonio.

Maj Hanrahan:

Sir, how do you know how to make those calculated risks or take those calculated risks in those types of situations?

Lt Gen Carlton:

Well, that’s a difficult question. Had I not been a surgeon and had some good idea that with proper medical care all three of these people could survive, I’m not sure that that same decision would have been made.

And so in every case, we don’t wish to flaunt the rules, the regulations, the policies, because I think they’re valid, but in every case, there are exceptions to that and it comes down to a matter, are lives worth betting your career on? And in my case, that was certainly worthwhile betting my caree, that because they were in a GI vehicle, they were eligible for care.

And in fact, this French journalist was an approved GI accompanier in the vehicle. So it was much ado about nothing. And people got all excited because we had been creative. Had I been court-martialed and retired, I would still make the same decision, because we’re in that difficult spot of what is my ethical obligation as a physician and what is my ethical obligation as a United States Air Force officer. And I value both of those greatly. I don’t feel that I can validate or I can blow those off. And so in that case, I thought it was worthwhile. The three people whose lives we saved would agree with that. Perhaps not everyone would.

Maj Hanrahan:

So I think that would be a fair characterization to say that in this situation, you didn’t let the process trump the result.

Lt Gen Carlton:

Yes. There’s a quote that I have found that I just love. It comes from one of the philosophers named Thomas Sowell. He says, “You never understand really, bureaucracies well, until you understand that a bureaucrat is so focused on process, that they deny product and the process is important, but the product is also important.”

So there are times in our military where we don’t follow the checklist. If you’re an aviator, because it hasn’t worked and you have to come up with a creative alternative. There are times in our medical community where you may agree with the process, but you don’t agree that the product would be three deaths. So this whole business of bureaucracies cannot ignore the human element that says do we have the opportunity to save a life or not? And do we have an opportunity to return somebody to a relatively normal life for a relatively small investment?

Maj Hanrahan:

Sir, if we can move to another example. You talked about your 9/11 experience. You talked about the actual experience leading up to 9/11, and then even 9/11 itself. Would you be willing to share that experience?

Lt Gen Carlton:

Yes, the 9/11 experience as all of you know, an airplane hit the Pentagon at 9:38 on the 11th of September of 2001. The important lesson to be learned is that we had done exercises in February.

So eight months before, I had been in the hallway with the clinic commander talking about how could we do a meaningful exercise? And an airplane went overhead. An airplane was overhead so low that we couldn’t hear each other.

So the clinic commander came back to me and said, why don’t we do an airplane hits the Pentagon?

I said, you know, that’s a very realistic exercise because in fact Air Florida had done exactly that same thing when they hit the 14th Street bridge in 1982.

So we played that exercise in May and we didn’t do a good job. We established that we had some get-well dates and our get-well dates were by the 1st of September.

So on the 28th of August, we had another airplane hit the Pentagon. At this time we had equipment, we had training. And the major thing we did was evacuate the building well, and I reported it on the 1st of September that we were ready to take an airplane strike. That got a big laugh from the Air Staff as you might imagine; but on 11 September, it didn’t laugh because the medics were then properly trained and ready to respond.

So again, proper preparation prevents poor performance. In this case, because we had been innovative in thinking of scenarios that could occur, we saved lives.

Maj Hanrahan:

And could you speak a little bit about that experience on 9/11, and you were there in the Pentagon when it was hit? I know you spoke to this with some of the folks here at Air University and I found it very fascinating. Is that something you could share with our audience?

Lt Gen Carlton:

Yes, it was interesting day, as you might imagine. We watched this, and this was the second day of the tenure of the new Chief of Staff and the second day of the tenure of the new Secretary of the Air Force. So as we’re in our staff meeting on that Tuesday morning, the Secretary of the Air Force was in his first discussion with our senior leadership, and the TV was turned on and it showed the first airplane hitting the World Towers. He wasn’t very happy about that, but then immediately the second airplane hit the World Towers, and it became apparent that we were under attack.

I ended up going to have my photo taken for an exercise the following day, and my seeing eye captain took me to that location, which was the impact zone. They were setting up their shop and they said, I got there about 9:35. And they said, well, we’ll focus our camera on you and get you out of here quickly. And so they did, and I left about two minutes later, and I went to the Vice Chief’s office. Again, the impact was at 9:38.

So in the Vice Chief’s office, we’re talking about New York City and what might we have to do to help New York City if they had a mass casualty situation when the building shook. The building shook and immediately we had smoke filling the room with the HVAC system air conditioning. And so it became very apparent to me that we had suffered an attack as well.

At that point, I reverted to my training mode. I went down to the clinic, I picked up a team and thought as I was heading there, where’s the worst place to be? And so I thought the worst place would be in the center courtyard, because you can’t get out. So I picked up a team. We headed to the center courtyard. I organized the team into the four different groups of minimal, immediate, delayed and expectant; and then turned to a fireman who was close by and said, "Where are my casualties, we’re ready to receive." He basically said, I have no idea. And a young tech sergeant came right behind him and said General, you want to see where the dying is, come with me.

So I grabbed the litter team, four other members of the group that was with me, a litter, and we headed down the 4 Corridor. We went through the, A, the B, the C, and in the D wing doors. We were turned back by smoke and fire. So we exited then the 4 Corridor into the AE alleyway, which was the only alleyway on the first floor. And it was used as a service organization to bring in things by truckload.

As we came out of the 4 Corridor, literally I couldn’t see for several seconds as the smoke was fairly thick, but the first thing I saw was a lady jump off the fifth floor. A very large man caught her in a typical fireman’s hands out and catches her. He broke her fall. He did a faceplant and the woman got up and ran away. Then as I’m looking in awe at that, another woman jumped out and this man, who was in the prone position face down, looked up, rose up like a football tackle and slammed his body into hers, which gave her a horizontal vector instead of a vertical vector and saved her life. She got up and ran away as well. He then obviously not very healthy after doing two faceplants, got up, saluted me. I was in uniform with my protective vest on and he said, "General, am I glad to see you". And it turns out, that’s a Navy SEAL. If any of you ever get in a tough spot, I would highly recommend you do it with a Navy SEAL.

He related that there was a hole in the wall of the AE Corridor where the landing gear has come down and that wall was the outer wall for the Navy Communications Center. The Navy Communications Center was a highly-classified, secure communications within the Navy communication system. A so-called SCIF. And so literally filling the AE Corridor were bright red folders that were marked "TOP SECRET SCI". And so, a very secure environment is normally required for those. And nobody quite knew what to do with those bright red folders. I said, ignore the folders, we’re focused on saving people’s lives.

The Navy SEAL then said, if we go through that hole, which had about six feet worth of debris on the bottom, and the flame that was shooting out was hitting the opposite wall about 20 feet away. So a very unpleasant place. He said, I think there’s still live people inside.

About that time, and I’m thinking, Hey Toto, we’re not in Kansas anymore. This is the real thing. Two Navy officers came from the opposite direction and burrowed through that six-foot-high wall of debris that was filling the hole. I said, “Okay, fight’s on boys. Let’s go”.

So we followed them through the hole, through the debris path. And the first thing that I did is I took a deep breath, my vision narrowed to my typical about to pass out from G loading vision, and I realized that I couldn’t survive in that environment, immediately came out.

There were several people in the alleyway by then, in addition to my four-man litter team. And I had them all strip and take their t-shirts off and soak the t-shirts in the water that was filling that AE Corridor so we could use as masks. I gathered those up—breathing through water enables you to breathe a bit more. It’s not as good as a respirator, but it’s certainly better than nothing. Went back into the building, passed those out to my other colleagues who were there. And then groped along the floor, looking for live people.

It was a very unpleasant situation as you might imagine, there were body parts that weren’t connected. So if I felt a hand, I pulled on the hand. If it wasn’t connected, I simply threw it away. I then pulled on one hand and a body followed, and I could tell that it was a woman, even though I couldn’t see very well. The bottom 12, 18 inches where you had some vision, everything else was very dark. And I felt, and she had a heartbeat. And so I thought, okay, this is a lady that’s alive. Let’s get her out of here. And so I did literally a mouth carry. I grabbed her uniform at her neck with my mouth so that I could be on all fours and still keep down low, to be able to breathe, and got her to the hole and passed her out.

Now, the funny part of that is we got back together about 10 days later, grabbed everybody that we could. And this lady came to that meeting in my office. And she said, I thought you were the devil incarnate when I woke up. You were one inch from my face and you had a black face. So I actually thought I’d gone to hell. I said, very fortunately, you had not.

So after I passed her out, I turned to my left and I saw a gentleman through that smoke and fire that was trying to lift something. But I couldn’t tell what he was trying to lift. He then got on his back. He pushed the fire and the water out of the way to get on his back, and he did a leg press. The leg press was of a table, which was encumbered with fire, with debris from the floor above, and through his body, between his head and his legs, I could see a face. He then said to me, get him out. I encouraged that gentleman in my most calm military voice to join me or he would die, and he didn’t move. So I hit him at about a five foot level with my wet t-shirt, which hit him right in the face. And he shook his head and it was obvious he was alive. So I went across the body of the man who had done the leg press, pulled this gentleman out, who happened to be a retired Navy Commander, pulled him out to me and passed him out.

The gentlemen then behind me, as I got under the table with my Navy colleague who had done the leg press, they begin passing me things. They passed me a respirator, they passed me a flashlight, they passed me a fire extinguisher. So all of a sudden I was literally the King of the Hill. I could breathe for the first time, I was armed with a fire extinguisher and I had a flashlight. So I could see a little bit.

The man in front of me, who was a Navy Lieutenant Commander, Dave Tarrantino, said “I heard screaming off to our right just two or three minutes ago. Let’s go right”.

About that time, the noise got much louder and I had trouble hearing him. And then I heard a very faint “Get Out”, and I thought, get out, man, I’m the King of the Hill. I can breathe. I can see, and I’m armed. Why would I want to get out? And then the voice got much higher pitched, “GET OUT”.

And I thought maybe he knows something I don’t know. So I grabbed the Navy Commander by the scruff of the neck. And about that time, the voice came through, in a very loud shrill voice this time, “GET OUT!”

So I grabbed the person in front of me, threw him to my left, followed him and said, “we gotta get out of here”. And I promptly ran into a set of legs who was the Navy SEAL. And he had come in to get us when the noise increased and he interpreted as the building falling down towards us. And so he had come in through the hole in his tank top and shorts into this fiery mess.

Maj Hanrahan:

That concludes part one of the interview with retired Lieutenant General Carlton Jr. In part two, we learn how his 9/11 experience concluded, explore another highly stressful leadership challenge, and his personal insights on leadership and innovation. Thank you and see you on the next episode.

Announcer:

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