AFJAGS Podcast, Episode 18

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Leadership Through Disruptive Innovation with
(Ret.) Lieutenant General (Dr.) Paul K. Carlton Jr. – Part 2

Host: Major Rick Hanrahan, USAF
Guest: Lieutenant General (Dr.) Paul K. Carlton Jr., USAF (Ret.)

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.”

Episode 18: Leadership Through Disruptive Innovation with (Ret.) Lieutenant General (Dr.) Paul K. Carlton Jr. – Part 2

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AUDIO | 23:10 | Air Force Judge Advocate Generals School Podcast - 18. Leadership Through Disruptive Innovation with (Ret.) Lt Gen Paul K. Carlton Jr - Part 2

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Major Rick Hanrahan:

This is part two of the 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. If you didn’t hear part one, please do. This part two picks up with Lieutenant General Carlton’s incredible account of 9/11 at the Pentagon in which we left off with a Navy SEAL there to assist in the midst of the inferno and chaos left in the wake of the plane crash. Here are a few highlights from part two of today’s show.

(Ret.) Lt Gen Paul K. Carlton Jr.:

We proceed to the hole and all of a sudden, we get blown through the hole as the building collapsed and the air wave blows us into the street of this AE Quarter. 

And so I never asked them to do anything that I didn’t do. I said, “Absolutely not, sir. I will choose to be court-martialed.”


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.

Interview - Part 2

Lt Gen Carlton Jr.:

And as soon as he got through the debris pile, he reached up and the Navy SCIF with a wire enclosure around the highly secret material, as he reached up to feel it. He could feel impact from the floor above collapsing it. So he struck a Big John pose and started screaming for us to GET OUT. I’m pushing the man ahead of me. I run into the Navy SEAL’s legs, and by this time, we see a little bit of a light above which is from the hole. We proceed to the hole and all of a sudden, we get blown through the hole as the building collapsed and the air wave, that is the building collapsed through whatever exit can occur, blows us into the street of this AE Quarter.

Now we all land in water and so none of us are burned. At that point, it was apparent that we had salvaged everybody that we could salvage from that area, and so I went back to my casualty collection point and did my medical thing with a young woman that was in extremis and got her to safety. If you will, literally I went out to the, I caught a golf cart with her on board. I thought I was gonna have to do a tracheostomy on her, and as I started to put the blade to her throat, she looked at me. 

When she looks at you, it implies that she’s awake and so I told her to squeeze my hand and she squeezed my hand and I said, “Okay lady, you keep squeezing my hand and you will not feel pressure on your neck. If you quit squeezing my hand, you will feel pressure and that is me establishing a surgical airway.” I got her out to the back of the Pentagon. We stopped a car on the highway. It happened to be a minivan. We put the lady in the back of the minivan, instructed the driver to take her to the nearest hospital. She bought a ventilator for about a week but survived without a surgical procedure, and ended up coming to our after action 10 days later. So it was a very eventful day.

Maj Hanrahan:

Incredible, sir. I’m speechless. I don’t even know what to say to that but I’m assuming your training and your experience or in-theater experience, literally it just kicked in almost like a switch it sounds like when this experience occurred at the Pentagon.

Lt Gen Carlton Jr.:

Well, the training and experience had kicked in. I think as a surgeon, I might have been more grossed out with the body parts. I wouldn’t have been so innovative if I hadn’t passed out before under G-loading in an F-16. I wouldn’t have thought, “how do I get us to breathe while we find out if there are live people in here?” And so certainly my training kicked in, certainly my thoughts as a surgeon and my background kicked in, but you become laser-focused on, okay, all I want is survivors and so my main contributions in that discussion were to remind people that bright red means nothing when we’re going after survivors and how to breathe for those several minutes that we were inside the building with the wet t-shirts. Those were really my contributions there.

Maj Hanrahan:

Thank you sir, for sharing that. Perhaps could we maybe get into one other experience where you had had a legal experience, a challenging experience where you had to make a decision and legal got involved and kind of how that experience played out and the decisions you made and why you made those decisions?

Lt Gen Carlton Jr.:

Well, you’re getting personal now, and the reality is I’ve discussed the events, the acute events of 9/11. The sidebar on that is that I had decided when I became the medical boss that if I were a terrorist, I would hit New York City and I would hit Washington D.C., and so I had been working with their hospital councils. I’d been to each of their hospital councils talking about how do we do mass casualties? What if one hospital is overwhelmed? 

So because we had practiced this scenario, as soon as I was relieved of my medical post inside the Pentagon in the inner circle, the JAG, a gentleman by the name of Joe Moreland gave me a ride back and on the ride, I tried to contact the Washington Hospital Center. I did so, and they told me that they did not need help, that they had handled our casualties well, and I could not get in touch with the New York hospital system.

So I went to my boss, at that time the Chief of Staff and said, “We may have a problem.” And I described the differential between a building collapse which generates five times as many dead as injured and a simple mass casualty situation which generates five times as many injured as dead. I said, “If they evacuated those World Trade Center Towers, then New York city could be overwhelmed. If they did not, then we have many more dead than we have injured.” 

He said, “When will you know?”

I said “72 to 96 hours.”

He said, “What do you propose?”

I said “Sir, I propose that we launch our medical fleet. We are the only response in the nation and we could provide 400 beds of medical and surgical capability within 24 hours to relieve New York City if necessary.”

He said, “That’s an interesting concept. Would you come back and brief the assembled Air Staff?”

So an hour later, I came back, I briefed the assembled Air Staff. We had a legal opinion at the time, the legal opinion instructed us that we had to make phone calls to the FEMA Director Joe Allbaugh very publicly for everybody to see and we had to make phone calls to the public health service very publicly so everybody could see to make sure that they didn’t think we were poaching. We all did so and the Chief of Staff turned to the Secretary and he said, “Mr. Secretary, I recommend that we launch the fleet.”

The Secretary said “Launch the fleet.”

And so we sent the word out. We literally launched everything we had, every expeditionary medical support activity that we had was launched and at McGuire Air Force Base 45 minutes outside New York City by the 22 hour mark, so the next morning. I then went to my political meeting where my political boss, a political appointee said “PK, what have you done?”

I said, “What do you mean?”

He said “You have defrauded Tricare of millions of dollars. You have launched the people that are the backbone of our medical system on a wild goose chase to New York City.”

I said “Well sir, I view that in a different light. I view that as responding to a national emergency with what we should do.”

He said “Well, I certainly see that differently and so does the Secretary of Defense.”

I said, “I’m sorry you don’t agree.”

He said, “So the Secretary of Defense has instructed me to have you come and personally apologize to him for not asking his permission or to start the UCMJ process and court-martial you.”

I said, “So I’m to apologize to a person who thinks the only person in the entire Department of Defense that can make a decision is the Secretary of Defense himself or I’m to be court-martialed for abiding by the rules of policy, the regulations, the chain of command and the humanitarian aspects of medical response?”

He said, “Yes, let’s go.”

I said, “Absolutely not sir. I will choose to be court-martialed.” And he was not quite prepared for that, but he set the motion, and so the entire group that was in the Air Staff meeting that was actually in my office, the Pentagon was closed, but our office was across the street or across the river at Bolling. Everybody there was interviewed and what exactly happened, and Article 32 is a fairly investigative—the civilian equivalent of a grand jury—and it was a tremendous intimidation to the Air Force senior staff that there’s only one person that can make a decision.

That went on for two years and finally the recommendation was that I receive a punitive letter of reprimand and be allowed to be continued to retire as a three-star, and I said, “No, I wish to be court-martialed. I wish the public to know that this is the environment that we’re living in” and all charges were dropped.

So it was a bit of legal-ese, it was a bit of brinksmanship. It was a bit of if you get innovative and do something outside the norm, and the normative process is about a 48-hour process to ask for help and so to launch on probability was brand new and was received differently. Now, my Air Force leadership chain was very pleased that I didn’t say, “Well, the Chief of Staff did it and the Secretary of the Air Force approved.” I simply said, “I wish to be court-martialed.” 

So it was a confusing time. I believe the Secretary of Defense, and in his book, he said “I had to get the Air Force under control by court-martialing a three-star.” Well, I was the three-star and he didn’t court-martial me, and he would have been embarrassed if he had tried. So there’s different perspectives on that event, now almost 20 years ago, but it was a painful process to wait through all of that Article 32 hearing.

Maj Hanrahan:

At its core, did you feel this as a direct attack on your own personal integrity, both as an officer and a surgeon?

Lt Gen Carlton Jr.:

Well whenever you have a complication in surgery, you look very longingly to say, “What in the world could I have done different?” I’ve been entrusted with the care of a person’s life and intensely personal when things don’t go correctly. So I was used to that environment of the soul searching. I was obviously very upset that I had to choose to go through a formal process for somebody simply having a different view of the reality. But it is a very personal thing and people are questioning your very integrity, your ability to make decisions and your ability to follow the rule of law. So I thought I was well covered on all of those items as well as on the humanitarian side for my actions.

Now as it turns out, we weren’t needed and so those 400 beds of medical and surgical capability that were just at McGuire Air Force Base were not needed. They went home within a couple of days. We had demonstrated to the Air Force leadership that we, the medical people with the expeditionary medical support packages, were ready to go to war—and simply three weeks later, all of those were deployed to support the war. 

So there were positives out of that. There were negatives out of that. Obviously an Article 32, the threat of a court-martial is never a positive thing, but you have to be convinced that I’ve done the right thing. I will suffer the consequence for it; and if the people of New York City would have needed us, then we would have been there to help them.

Maj Hanrahan:

So sir, we could spend days and days going through all kinds of other experiences you had and there’s many others, but perhaps you could just speak very briefly if we could kind of move to the summary here on your own personal leadership philosophy. What is leadership to you? What would you say to our young Airmen today about being a leader in the Air Force?

Lt Gen Carlton Jr.:

Major Hanrahan, that’s a very probing question. You have to, again, remember my background. My dad was a senior officer. I literally was, Curtis LeMay’s. I regarded him as a grandfather figure. I had grown up with Jimmy Doolittle’s son living next door and seeing Jim Doolittle on a regular basis. 

So I’d grown up with American heroes, and I realized that as I looked to the future, I couldn’t be a hero like them. I couldn’t be a pilot, I couldn’t be a Wing Commander, a Division Commander, but on the medical world, I could be a leader by example and by trying to make the systems better by valuing human life.

And so as I went through my surgical career—and I remember it took me nine years to be a surgeon—I then practiced as a surgeon exclusively for another seven years before I went off into command, and I was just about hitting my, okay, this is normal stride at about 3,000 cases at that point. And so I understood leadership, and I understood being able to look at a system critically with my background in the heavy airlift world— understanding airlift flow, understanding how the line of the Air Force works.

Then when I moved into, and I was a Wing Commander equivalent for eight years. Now some people would say, “You’re a slow learner.” Normally it’s a two year tour but they didn’t know what to do with a medic, and so I was a Wing Commander at Scott Air Force Base at the medical center there. I was a Wing Commander for five years at Wilford Hall. So I got to know the legal side of things very well, but I never became isolated as a leader and commander, and instead I continued my surgical career. I operated with the young residents. I taught them what I had learned to know. In fact, I challenged them when I thought I was getting too much “Yes sir, yes sir, three bags full.”  I would see something absolutely wrong, and if they didn’t correct me, then I would vigorously correct them. That as the Commander, I could tell ‘em to shine their shoes and they would do so or get a haircut and they would do so. But in the medical arena, I was simply a staff person that could help them or hurt them as we go through our career.

So I was part and parcel of what I did. And it doesn’t matter what I did in surgery, or what a weatherman does, or what a maintenance officer does, or what a pilot does, or what a nurse does. I was involved—and so I never asked them to do anything that I didn’t do. 

I had learned philosophically actually from talking to Curtis LeMay. Do you know where he ran his combat operations, when he led his missions over Germany? He flew the first mission from the left seat of his B-17, and realized he couldn’t command from there ‘cause he couldn’t see the other airplanes. And so from there on out, he would take off, he would get into the altitudes that were appropriate, and then when he got to the target zone he’d take the top turret position. He’d have another pilot sit in the left seat, and he would then be the top turret as a gunner and as a director for who to move into what position to maximize their defensive capability. So he was in it from the start.

So I’d seen my dad who never stopped flying and he ended up with 12,000 hours of flying time in it from the start. So I wasn’t about to get away from that and be a subject matter expert in something that I didn’t do every single day. And so my philosophy on that is whatever your area is, you have to stay rooted in your basics. You have to realize you’re part of this bigger Air Force team, and the whole is what makes the team. There’s nobody that’s more important than any other. It’s just we have different responsibilities. And so I didn’t believe in the isolation of leadership. 

Again, I think a leader needs to be part and parcel of everything that they’re involved with. Very visible, very vulnerable, and that’s how I lived. And so having seen that growing up, I thought that is something I should emulate, and I did. The price was high. I will tell you taking a level one trauma call as a 52 year-old left me pretty tired the next day. But it was worth it, because I then identified well with the youngsters that I had the privilege to lead.

Maj Hanrahan:

Sir, are there any final parting words you’d like to leave with our listeners on your perspective after over 30 years of experience, rising all the way to the level of the Surgeon General of the United States Air Force? Are there any final parting words you’d like to leave for our young Airmen and even for our non-military listeners on leadership and or innovation?

Lt Gen Carlton Jr.:

Well, I think the key lesson to be learned is that we’re parts of a bigger team. Every one of us has a contribution to make. Every one of us is an important part of the team, that the team can’t successfully accomplish their mission without that team effort. And every one of us should be looking every day for how can we do our job better? And so that’s the parting message I would have. 

This is the youngsters’ Air Force. It’s not my Air Force, it’s everybody who’s on active duty and in the retired group who remain affiliated, and looking to offer better solutions as they go along. So take part of it. Enjoy it. Pay attention to your family, but understand you’re part of a bigger thing that is called the United States Air Force, which is part of a bigger thing which is called the United States military.

Maj Hanrahan:

Sir, we greatly appreciate you taking your time today. I know you’re on a tight schedule and so much appreciation from here at the JAG School for coming in to speak with us, helping us to learn, spreading your wisdom. Thank you so much sir.

Lt Gen Carlton Jr.:

It’s my pleasure and it’s nice to have the old guys come periodically to share stories.


Maj Hanrahan:

Well, that concludes our interview with Lieutenant General Carlton Jr. My three key takeaways are one, innovation is not always pretty. Innovation, true innovation often takes a significant dose of guts, wherewithal and resounding self-assurance that you’re doing the quote-unquote right thing. The term disruptive within the innovation context does not mean recklessness, carelessness or inattention to detail. Rather it means the opposite, a deep understanding and appreciation for the rules, attention to detail and adherence to the rules, barring exceptional circumstances. Lieutenant General Carlton highlighted a few times in his career through this interview and told us a few others off air where he followed the rules as far as they would go, but ultimately made certain decisions that were not pre-approved or on any checklist. With that, he emphasized he never made one of those decisions flippantly or without very careful consideration of all the potential consequences.

That leads us to point two, if you’re going to make an unconventional decision, be sure you’re quote-unquote right. If your decision goes against the normal course of action or rules, you’d better be sure your decision constitutes a valid extenuating circumstance or exception. This might not necessarily mean that the sought outcome is achieved, but it does mean that your decision in light of all the surrounding circumstances was the quote-unquote right decision. This requires sound confidence in your decision and sound confidence almost invariably requires a plethora of preparation and experience to know exactly when and how an exception may apply. 

As Lieutenant General Carlton stated, proper preparation prevents poor performance. In other words, he said if he hadn’t been a trained surgeon coupled with his years of experience, thousands of cases and unique understanding of both the medical community and Air Force growing up with the likes of General Curtis LeMay and the Doolittles, he likely wouldn’t have made the same decisions. It’s safe to say his entire life had been shaped up to those decision points, and he made them with all his preparation and experiences in mind.

This leads us to the last point in number three, bold and innovative leadership requires personal courage. Even if you know you’re right and an exception applies, it still requires a bold personal courage and proportionally more as the stakes of failure rise. Lieutenant General Carlton took some significant risks with his career and even his life in the decisions and actions he made. With that, he understood that there are times when procedure is not everything, especially when lives are on the line. He quoted social theorist Thomas Sowell as once saying, “You will never understand bureaucracies until you understand that for bureaucrats, procedure is everything and outcomes are nothing.” Lieutenant General Carlton didn’t let bureaucratic process overcome the end result, which in his examples was to save lives. 

While many of us may not face such life-death situations, we can learn from his examples and insights. Ultimately, true innovation requires personal courage and conviction molded in significant preparation and experiences that on rare occasion may require you to face such difficult decisions. That’s also where supervisors, mentors, confidants and trusted peers can also be a lifeline, if and when applicable.

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Nothing from this show or any others should be construed as legal advice. Please consult an attorney for any legal issue. Nothing from this show is endorsed by the Federal Government, Air Force, or any of its components. All content and opinions are those of our guests and host. Thank you.