Medical Modernization: The Pivot Towards LSCO
Written by Major David M. Rodriguez
Every life cannot be saved during Large Scale Combat Operations (LSCO). Our MEDEVAC force does not possess enough air and ground assets to move thousands of patients simultaneously. In Iraq and Afghanistan, the U.S military enjoyed air supremacy in every campaign which permitted aeromedical evacuation (AE) at any hour in nearly every terrain. However, Chinese and Russian anti-access/area denial (A2AD) capabilities will vary the availability of AE and require a robust system of ground evacuation and patient hold capability to preserve life.
Our Army stands at a precipice as we prepare for a possible return to LSCO. As the Army emerges from the Global War on Terror (GWOT), we find ourselves ill-prepared for the conflict on the horizon. To maintain the Army’s competitive warfighting edge, cross-functional teams were established to close key capability gaps ahead of LSCO. The Combined Arms Support Command (CASCOM) commander, Major General (MG) Rodney D. Fogg, argues that sustainment capability must keep pace with new weapons systems to avoid support gaps.
MG Fogg points out that the weapons systems developed as part of the “Big 5” suffered from tremendous support issues because sustainment personnel were absent during the capability design. Determined to capitalize on those lessons learned, MG Fogg integrated CASCOM personnel across the cross-functional teams to avoid similar support problems which may arise during capability development.
Similarly, the Army Medical Department (AMEDD) integrated Capability Development Integration Directorate (CDID) personnel into the future vertical lift, next-generation fighting vehicle, network, and Soldier lethality initiatives to ensure medical variants meet the demands of the next conflict. Medical representation will be part of largest force modernization process since the end of the Vietnam conflict. Particularly close attention must be paid to the development of the next ground ambulance and Role 2 modernization.
One of the more insidious side-effects of the Global War on Terror is the deterioration of the ground medical evacuation (MEDEVAC) fleet. Modern ground MEDEVAC will be imperative to patient survival in LSCO. The commander of the US Army Medical Center of Excellence (MEDCoE), MG Patrick D. Sargent, writes:
We have become habituated to a risk calculus that accepts relatively little risk in operations. We have become so accustomed to relying almost exclusively on our air ambulances that many forget Army MEDEVAC has both air and a ground component.
Heavy reliance on AE imperils the force and reinforces the perpetuation of the “push button” paradigm regarding MEDEVAC. “Push button” refers to the genesis of the “golden hour” during the GWOT. The Army became accustomed to a one-hour point of injury (POI) to damage control surgery (DCS) evacuation standard. Simply put, by pressing the “talk” button on a radio hand microphone or typing on a computer, world-class AE arrived and transported the patient to DCS within an hour.
The presence of A2AD capabilities on the battlefield will restrict AE, and force the Army to rely on ground MEDEVAC for all categories of patients. For example, the Russian exclave located in Kaliningrad presents a significant problem set in the European theater. The A2AD bubble created by air defense capability will ground aviation for extended periods. Of utmost concern is transporting large numbers of wounded from the forward line of troops (FLOT) to the first DCS capability in the commander’s Health Support System.
In Iraq and Afghanistan, patient survival rates reached 90%  and created an insatiable appetite for on-demand AE. As a result, AE waxed as ground MEDEVAC waned. To prove effective in battle, the future ground MEDEVAC force requires significant updates across the doctrine, organization, training, and materiel elements of the DOTMLPF-P spectrum to modernize ground MEDEVAC, the Brigade Support Medical Company (BSMC), and the Medical Company (Ground Ambulance). Modernizing ground MEDEVAC before the Army faces a near-peer threat will expand the commander’s operational reach and allow him to maintain the initiative in offensive operations.
The US Army MEDCoE -newly realigned under Training and Doctrine Command (TRADOC)- must address doctrinal and capability gaps in ground MEDEVAC and BSMC composition before the outset of LSCO. Doctrine must emphasize a sense of methodical and coordinated support to maneuver forces as part of the larger sustainment plan.
Addressing Doctrinal Ambiguity in Ground MEDEVAC
Doctrinal ambiguity begins with the multitude of documents that pertain to MEDEVAC techniques and procedures. Army Techniques Publication (ATP) 4–02.2 Medical Evacuation is the U.S. Army’s chief medical evacuation document but, several field manuals (FMs), Army Training Publications (ATP), and Army Doctrinal Publications (ADPs) mention MEDEVAC techniques and procedures. The Army must first recognize ATP 4–02.2 as the sole source of MEDEVAC doctrine and consolidate into one seminal work.
Medical doctrine must remove phrases like, “far-forward and rapid response” and all inferences to the “Golden Hour”. Table 2–1 in the ATP mandates evacuation of Urgent and Urgent-Surgical category patients within one hour, this is commonly viewed as the expansion of the “Golden Hour” outside the CENTCOM AOR. The golden hour was only achievable in Afghanistan because of the relatively small size of the theater, the battlefield was non-contiguous, and troops were relatively static in concentrated areas, but the wide area LSCO will encompass and enemy A2AD capabilities will make the “Golden Hour” impossible.
Doctrine writers must change tables and phrases contained in ATP 4–02.2 to replace the false sense of urgency created by seemingly rigid timelines. The language must highlight careful, synchronized, and methodical planning which allows the commander to assume prudent risk and preserve scarce medical resources. First, remove timelines associated with medical evacuation. Timelines should be replaced with category and the phrase: “as soon as the tactical situation permits”. Second, remove the Urgent-Surgical category from our doctrine and adopt the NATO standard evacuation categories (Urgent, Priority, Routine) to simplify the evacuation request process. Lastly, change the primary tasks for MEDEVAC in table 1–1 in ATP 4–02.2 to read “carefully planned and synchronized response” instead of “rapid response”. Appendix A and B at the end of this article contain the current table and recommended changes to Table 2–1 and Table 1–1 in ATP 4–02.2.
These small changes reduce the doctrinal pressure to respond like civilian ambulance services. Instead, ground MEDEVAC assets perform patient acquisition as part of planned movements synchronized with other sustainment formations. For instance, ambulance crews operating as part of the BSMC accompany movements with the Brigade Support Battalion (BSB) from the Brigade Support Area (BSA) to the combat trains location to receive patients as part of the larger sustainment plan.
Too often ambulances move alone to remote locations to open Ambulance Exchange Points (AXPs) with lower roles of care without proper escort or security. In LSCO, this methodology recklessly gambles with the lives of patients and ambulance crews. Until the organization of the BSB and BSMC is changed to reflect the security requirements associated with perimeter defense in LSCO, sustainment units must band together to improve security while traveling.
Medical doctrine must provide a prescriptive measure for medical planners to emplace medical and surgical assets on the battlefield.
Addressing Doctrinal Emplacement of Medical Assets
Doctrine must help medical planners determine what “far-forward” truly means. The ambiguity of this term needlessly jeopardizes medical assets. Ask seven different medical service officers, “What is the doctrinal location for the Role 2?” and you will most likely receive seven different answers. Additionally, the phrase “far-forward” seems to justify commanders emplacing medical and surgical assets within range of medium artillery which is discouraged by FM 3–96. Medical doctrine must provide a prescriptive measure for medical planners to emplace medical and surgical assets on the battlefield. The loss of Role 2 or a Forward Resuscitative Surgical Team (FRST) cannot be easily overcome.
Doctrine should specify the Role 2 occupies the BSA, support, or consolidation area, and only under special circumstances, moves forward into the close area for a specified (brief) amount of time. The conditions on the battlefield must warrant direct support from the brigade’s only Role 2 asset near the FLOT. Further, the brigade commander must be the sole decision authority when emplacing the BSA or the BSMC within medium artillery range. Maneuver battalions do not possess the logistical capability to sustain the Role 2 and places an undue burden on the maneuver commander to secure, supply, and move the Role 2 while simultaneously engaged in close combat.
Organizational, Training, and Materiel Approaches to Closing the Ground MEDEVAC Gap
AE capability improved significantly during the GWOT while an aging fleet of Field Litter Ambulances (FLA) nears obsolesce. Ground evacuation took a back seat because improvised explosive devices (IEDs) virtually eliminated ground evacuation, particularly in Afghanistan where dangerous mountain roads were often mined with IEDs. These FLAs are still pressed into service at weapons ranges and public displays, but offer little real value on the battlefield.
Ambulance Medical Equipment Sets (MES) are not equipped to handle more than one urgent patient. FLA crews normally operate with limited resuscitative and vital signs-monitoring equipment, and with one medic providing en route care. This does not resemble the same care received at a Role 2 facility and represents what FM 4–02 describes as “decremented” care or a decrease in the continuum of care.
Ground ambulance crews are not organized to transport post-surgical patients en route to a Role 3 treatment facility. This gap negates the benefits of forward surgical assets when AE is impossible. To close this gap, the BSMC’s evacuation platoon must increase in size to include the assignment of a Certified Registered Nurse Anesthetist (CRNA) or anesthesiologist to monitor patient reactions during transportation to the Role 3. The CRNA or anesthesiologist will detect adverse reactions to medications and post-surgical complications arising from anesthesia. The British 16th Medical Regiment operates a similar capability from the Role 3, and its highly specialized ambulance crews are capable of transporting post-surgical patients from the Division Support Area (DSA) to the Role 3 located in the Corps Support Area (CSA). These tasks are simply out of the combat medic’s scope of practice.
The ground ambulance company must be reorganized to perform ground MEDEVAC of post-surgical patients acquired from FRSTs co-located with Role 2s. Further, this assignment must reside in doctrine as well. Similar to the way the newly published FM 4–0 is driving the creation of the division sustainment brigade, a medical doctrinal overhaul will drive the creation of new medical capability. This re-organization will mean the difference between life and death for post-surgical patients when air corridors are closed due to A2AD systems. See Appendix C for recommended doctrinal changes.
The BSMC’s patient hold section is not adequately staffed or equipped to provide prolonged field care.
Modernizing the BSMC’s Patient Hold for LSCO
The BSMC’s patient hold section is not adequately staffed or equipped to provide prolonged field care. According to doctrine, the BSMC should provide a miniscule 20-bed capacity to care for minimally wounded patients who will return to duty within 72 hours. The few vitals monitoring sets will quickly be exhausted, and manual methods of monitoring patient vitals will consume the entire BSMC staff’s time. Inevitably, the patient hold section will have to hold several patients who require round-the-clock monitoring. The section’s one nurse and four medics will prove too little to provide adequate care. Additionally, the section’s patient monitoring equipment sets will prove incapable of multiplying the efforts of its small staff. A thorough study of the myriad doctrinal publications regarding medical operations leaves one wanting for a document describing how the patient hold section must operate. In LSCO, this section will prove too small to maintain 24-hour care and monitoring for 20 patients awaiting transfer to higher levels of care.
For a planned response to patient transfer to occur, the Role 2 must be prepared to hold priority and urgent patients until Suppression of Enemy Air Defense (SEAD) opens brief air corridors. The patient hold section must undergo a design update to perform 24-hour care for all categories of patients, not just minimal. At a minimum, the patient hold section must employ 2 critical care nurses and 8 medics. This creates a much more manageable patient ratio of 1:2. The mission of the patient hold section therefore changes from holding minimally wounded for 72 hours, to caring for priority and urgent evacuation category patients for a minimum of 24 hours to allow time for SEAD to open air corridors.
Without the constraints of the “Golden Hour” the Role 2 and Role 3 should operate a schedule-based evacuation model synchronized with the sustainment battle rhythm. The increased patient hold capability will provide the time and space for an extended wait time for evacuation to the Role 3. The Role 2, BSB convoys, and Forward Support Company (FSC) will meet at Logistics Release Points (LRPs) or combat trains command posts (CTCPs) as part of a sustainment operation, instead of an emergency response for every casualty. Imagine the ring routes aviation units flew in Afghanistan to regularly deliver personnel and supplies to the many different combat outposts throughout the country; this concept is similar to that operation. At a minimum, the Role 2’s medical units plan for twice daily movement of routine and priority patients from the Role 1.
This schedule-based system allows time for the evacuation platoon leader to plan and synchronize movement with the BSB tactical operations center, improves security while ambulances travel with logistics convoys to pre-determined exchange points, simplifies ambulance crew rest cycles, and aligns medical resources with predictable patient arrival. Our current system of MEDEVAC delivers patients to the various roles of care in spurts. In a schedule-based environment, the Role 2 can reasonably predict when patients will arrive.
Role 2 ambulances with upgraded medical equipment sets will clear Role 1 facilities of patients. The Role 2’s improved patient hold section enables patients to remain in the Role 2 until the Role 3’s attached ground ambulances arrive according to the daily schedule. Air ambulances will remain the primary movement platform for urgent category patients. When the tactical situation permits, AE will retrieve patients from the Role 1 and deliver them to the Role 3. When A2AD prevents AE, ground MEDEVAC will fill the gap.
A LSCO conflict will demand more from the AMEDD than has been required since U.S. involvement in World War II. However, modernizing the BSMC patient hold, ground MEDEVAC, and doctrinal approaches to medical operations will save lives and preserve resources. The risk we face is the numerous lives and damaged morale we incur while current doctrine and capabilities are ill-suited for the task of LSCO. The operational concept presented will slow the evacuation process, and replace speed with sound tactical medicine. These concepts will not save every Soldier’s life and I fully recognize promulgating a strategy where we accept losses is not a popular opinion. However, if implemented properly, these changes may stem the tide of unnecessary death high intensity conflicts are expected to generate.
1. Fogg, Rodney. 2019. From the Big Five to Cross Functional Teams: Integrating Sustainment into Modernization. October 9.
2. The “Big 5” program was the U.S. Army initiative to fill capability gaps -post-Vietnam- to resume great power competition with the Soviet Army. The program brought the Apache attack helicopter, Abrams main battle tank, Bradley fighting vehicle, Patriot missile system, and the Black Hawk helicopter into the Army inventory.
3. Sargent, Patrick. 2019. “Evolving mass casualty combat MEDEVAC.” Combat & Casualty Care, October 16: 4–8.
4. Sternberg, Steve. 2019. “U.S. News.” A crack in the armor: surgeons see a military hospital as a shadow of its past, October 10.
MAJ David Rodriguez was commissioned through ROTC as an active duty Medical Service Corps Officer in 2009. He is currently a student at the Command and General Staff College.
The views expressed in this article are the authors’ alone and do not reflect the official position of the Medical Service Corps, the Department of Defense, or the US Government.