Evolving Mass Casualty Combat MEDEVAC

From Combat & Casualty Care, Q3 Summer 2019 Issue

As the U.S. Army grapples with the challenges of Large-Scale Combat Operations in the Future Operational Environment, so will the Army’s medical evacuation, or MEDEVAC, force.

By MG Patrick D. Sargent, Commander, Health Readiness Center of Excellence

It is almost a truism to say that we, as an Army, will be challenged in unique ways by armed conflict in the Future Operational Environment, or FOE. We are told that all domains—land, air, maritime, space, and cyber—will be contested and congested. Anti-access and area denial, or A2AD, strategies will deny us the land, air, and maritime superiority that we have come to expect. Large-scale combat operations, or LSCO, particularly against peer, near-peer adversaries, will present problem sets that we have not encountered in the contingency operations of the past two decades. Fundamentally, we expect LSCO to be more dangerous and difficult for the MEDEVAC force to operate–but it will not be impossible. We will not be able to evacuate in LSCO as we have in the contingency operations of the past two decades. To operate effectively, we must have a well-grounded understanding of the dynamics of LSCO, a sound grasp of the inherent risks, and take a clear-eyed approach to how to operate effectively on these future battlefields. To be successful, the MEDEVAC force must adapt itself to the new environment.

Perhaps the most critical adaptation required is one of mind-set. Over the last two decades—and for all the right reasons—we optimized the employment of the MEDEVAC force for the unique circumstances of the contingency operations to which the Army has been committed, particularly those in Iraq and Afghanistan. While the results have been superb in terms of lives saved, there have been unintended consequences. We have become habituated to a risk calculus that accepts relatively little risk in operations. We have become so reliant on our dominance of air and ground lines of communication that there are those who believe we cannot operate without it. We have become so accustomed to relying almost exclusively on our air ambulances that many have forgotten that Army MEDEVAC has both an air and a ground component. We have also become accustomed to relatively static operational environments to the point where many have forgotten how to plan, coordinate, and execute in dynamic environments where the situation is changing rapidly at the tactical, operational, and strategic levels. To be successful in the future, we must overcome the thinking we have cultivated over the last two decades and expand our mind-set to match the demands and dynamics of LSCO in the FOE.

Facing Greater Lethality of Conflict

It is not hard to accept that LSCO in the FOE, particularly against a peer, near-peer adversary, will present much more lethal environments than the contingencies of the past two decades. What we cannot accept is that this increased lethality will preclude our ability to conduct MEDEVAC. There are those who believe that, because the levels of risk to medical evacuation assets (air and ground) will be far greater than what we consider acceptable risk in our current contingency operations, we will cease to conduct medical evacuation operations. What they fail to understand is that these future battlefields will be more dangerous for the entire force, not just for the MEDEVAC force. Clearly, as articulated in the Multi-Domain Operations (MDO) and Echelons Above Brigade, or EAB, concepts, the rest of the force intends to operate on these more lethal battlefields. The MEDEVAC force cannot—and will not—stand aside as the rest of the force goes into harm’s way. We must understand that the threshold for what constitutes acceptable risk on the LSCO battlefield will be significantly different than what we use today.

As we look to potential LSCO conflicts in the FOE, there is a tendency by some to consider only the capabilities potential adversaries may bring to the fight. They assess the unopposed impact that these potential adversaries could have on the battlefield—and draw a number of flawed conclusions. They fail to acknowledge that the U.S. military—and our allies and partners—will bring significant opposition to these battlefields. An assessment of the opposed impact of potential adversary capabilities provides a much different picture. It acknowledges the challenges for U.S. forces—which will be considerable—but also highlights the opportunities. The MDO and EAB concepts, among others, provide the vision of how to create and leverage opportunities to penetrate and disintegrate adversary A2AD capabilities and exploit the resultant opportunities for movement and maneuver. In addition, the Army’s modernization strategy promises to establish and/or restore critical capabilities in the Force that will, at least, restore a degree of initial domain parity—enabling a degree of freedom of action from the outset of a contingency. So, while operations in LSCO in the FOE against a peer/near-peer adversary will be difficult, they will not be impossible.

Evolving Tactics of Combat Casualty Care

The scope, scale, and tempo of medical casualties during LSCO in the FOE will present distinct challenges to the MEDEVAC force—but will also make MEDEVAC an imperative. Failing to evacuate will put both the medical mission and the operational mission in jeopardy. Failing to evacuate will jeopardize the medical mission by risking culmination of forward medical treatment facilities through overwhelming the capacity of the medical providers and equipment or through consumption of medical supplies on hand faster than they can be replenished. Failing to evacuate will jeopardize the operational mission through the drain on combat power required to secure/protect the accumulating casualties and through the drag effect these accumulated casualties will have on movement and maneuver. In short, not evacuating in LSCO will not be an option. The scope, scale, and tempo of medical casualties in LSCO will require the full commitment of the MEDEVAC force—air and ground. Adversary lethality and reach will require MEDEVAC assets to be arrayed through the entire breadth and depth of a theater of operations in anticipation of casualties. The scheme of evacuation must carefully position air and ground ambulance assets for best effect—and dynamically reposition them throughout the course of an operation to anticipate casualty flows, weight critical efforts, and react to evacuation contingencies.

In general, air ambulances will focus on the evacuation of the most critically sick or wounded (where speed is of the essence and platform stability is essential); on rapid clearing of casualty backlogs on the battlefield and patient backlogs at treatment facilities when windows of opportunity enabling access are limited and evacuation velocity is key; and on providing commanders a capability to react rapidly to evacuation contingencies across the breadth and depth of a theater of operations. The speed and reach of our air ambulances make them highly flexible evacuation assets. It is anticipated that ground ambulances will move the bulk of the MEDEVAC workload, moving the lion’s share of priority and routine category patients and moving Urgent/Urgent-Surgical category patients when air ambulances cannot reasonably reach them. While the slower speed and shorter reach of ground ambulances make them less flexible assets than the air ambulance fleet, their greater proliferation through the force significantly offsets this lack of flexibility. Despite the evacuation capacity that MEDEVAC assets bring to the Force, there will likely be times when this capacity is exceeded—either in a specific locality or broadly across a theater of operations. Accordingly, operational commanders must plan to complement MEDEVAC assets with casualty evacuation, or CASEVAC, assets. This should include: dedicating assets to assist in evacuation when there is a high likelihood that MEDEVAC capacity will be exceeded; designating assets to be prepared to assist in evacuation to enable rapid transition to an evacuation contingency; and conditioning the Force to provide lift of opportunity when absolutely required with least the impact to their primary mission/task.

One of the primary challenges to the MEDEVAC force in LSCO will be battlefield access—the ability to get to casualties/patients in order to evacuate them. In LSCO, we must expect our adversaries to have the ability to interdict both air and ground lines of communication, or LOCs, thereby impeding the battlefield access of our MEDEVAC assets. However, an adversary’s ability to interdict our use of air and ground LOCs will not be uniform across the breadth and depth of a theater of operations, nor will it be uniform over time. An adversary’s ability to interdict air and ground LOCs will be greatest where he can mass effects. Simplistically, an adversary’s ability to mass effects will diminish with distance from the physical location of his assets. While the reality will be a bit more complex, in general, we can expect the greatest interdiction of LOCs in the vicinity of brigade combat teams in contact and to diminish, in terms of effects or duration of effects, through the depths of the division and corps support and consolidation areas and the theater’s joint security area. We can also expect an adversary’s ability to interdict LOCs in the operational area to be greatest at, or near, the outset of a campaign and to be diminished over time, assuming a degree of success by U.S. forces, as U.S. forces penetrate and disintegrate an adversary’s A2AD capabilities and then exploit the resultant windows of opportunity for movement and maneuver. The key throughout is that we constantly press to get our MEDEVAC assets as close as prudently possible to the casualty/patient needing evacuation. We cannot afford to cede any advantage to the enemy that he has not actually taken from us.

What this means is that the MEDEVAC force will have the battlefield access it requires to acquire and evacuate casualties/patients over much of a theater of operations. In these areas, achieving the 1-hour evacuation standard for urgent and urgent-surgical casualties should be well within the realm of the doable. Based on the reach and lethal capabilities of potential adversaries, we should expect significant numbers of wounded throughout the depth of the theater of operations. Even flying or driving ambulances to points of injury, or POI, will be possible in some cases; although nowhere near as prevalent as today. Where units are in contact with enemy formations, however, our ability to achieve the 1-hour evacuation standard will likely be challenged. Air ambulances will likely be precluded from regularly operating in these areas until U.S. operations to penetrate and disintegrate A2AD capabilities begin to have effect. It is unlikely that ground ambulances will be precluded from these areas but will find themselves slowed in the evacuation sequence. At the earliest prudent opportunity, the most critical patients will be transferred to air ambulances to speed them through the rest of the evacuation sequence. Wherever evacuation is delayed beyond the standards, our prolonged field care concepts and capabilities will be used to mitigate the risk to the sick and wounded—buying time until evacuation can be conducted.

Balancing Evacuation Force Deployment

The scope, scale, and tempo of medical casualties in LSCO will place a premium on effective and efficient employment of the MEDEVAC force. This will require establishing the right balance in the MEDEVAC force structure between assets assigned at tactical unit level—to serve the typical needs of those formations and those assigned at operational and theater-strategic command levels—to provide higher-level commanders the ability to weight critical efforts and react to contingencies. It will also require a mission command structure that can achieve unity of effort/purpose in highly dynamic situations from assets that are arrayed through the breadth and depth of a theater of operations and under both medical and non-medical command. This begins with the theater medical command-deployment support, or MEDCOM-DS, —and the evacuation planners in the Theater Patient Movement Cell (TPMC)—providing top-down guidance and direction—for the overarching scheme of MEDEVAC within the theater and reaches down through medical brigade support and multi-functional medical battalions and through corps, division, and brigade headquarters for bottom-up refinement. These elements must be able to dynamically plan, coordinate, and execute MEDEVAC operations that are integrated into and synchronized with schemes of maneuver and continually adapting to the demands of rapidly changing operational environments.

Not evacuating our sick and wounded in LSCO is not an option. Failing to evacuate may cause us to lose today’s battle—as the backlog of casualties/patients cause a cascade of medical and operational culmination on the battlefield. Failing to evacuate often enough—with its potential impact on Soldier morale and national will—may cause us to lose the next battle, the next campaign, the next contingency operation. While the evacuation of the sick and wounded will be difficult in LSCO in the FOE—it will not be impossible. To be successful in MEDEVAC in LSCO, we must adapt to the projected operational environment. While we must certainly adapt the MEDEVAC force structure and our mission command processes, the most critical adaptation is one of mindset. Without a mindset that grasps the dynamics of LSCO, that understands the challenges and sees the opportunities, and that refuses to cede any advantage to an adversary that the adversary has not actually taken away—we cannot be successful. Cultivating and inculcating such a mindset must be a high-priority effort throughout the medical force.