Closing the Gap for Integrated Casualty Evacuation

Logistical operations in a contested environment

Operational forces in future wars must be small, agile, and have a low signature to survive the Miniaturized Sensor and Precision Weapons Revolution in Military Affairs (RMA). This will have transformational effects on both peer and asymmetric conflicts.1 When combined with the scale and ferocity of peer conflicts, the RMA will generate casualty volumes not seen since World War II and Korea.2 This especially holds true in a maritime conflict between the United States and the People’s Republic of China, where the tyranny of distance and timeframes of protracted conflict impose significant challenges on health service support (HSS) operations. Successful casualty evacuation is a particular vulnerability because a crucial gap exists between ongoing innovation efforts at the tactical level and well-established treatment facilities at the strategic level.

For operations inside the first island chain of the South China Sea, and the INDOPACOM area of operations more broadly, our naval forces have developed a doctrinal architecture for a future fight against China. These concepts include Distributed Maritime Operations (DMO) by our fleets and Expeditionary Advanced Base Operations (EABO) by our FMF.3 The two concepts converge with Littoral Operations in a Contested Environment (LOCE), where Navy and FMF medical operations will have to be integrated and synchronized with theater-wide logistical operations to maximize the survivability of the critically wounded. 

The challenge of medically supporting the Marine Corps during contested EABO and LOCE is formidable. The Navy and Marine Corps are redesigning their medical force packages to increase their survivability within the enemy’s weapons engagement zone (WEZ).4 However, the medical concept of operations and requirements for the littorals are underdeveloped and present a particular friction point between the HSS capabilities supporting the naval force with DMO and those supporting the Marine Littoral Regiments executing EABO.5 

Medical forces will need to care for larger casualty volumes during sustained operations while minimizing the targeting risk that HSS operations pose to maneuvering forces. Bridging EABO and DMO requires new medical enablers within the contested littorals who can perform patient staging, and patient holding and coordinate numerous disparate evacuation elements spread over large distances.

EABO HSS Adaptations Lack Operational-Level Integration Component for LOCE
Navy Medicine is adapting to China’s steadily increasing ability to contest the sea domain by investing in smaller, faster next-generation afloat medical capabilities, and smaller ashore expeditionary medical capabilities to support the mass casualties likely to occur at sea and on land.6Within the FMF, it is now widely accepted that traditional Role 1 battalion aid stations lack the holding capability, and traditional Role 2 shock trauma platoons lack the agility and scalability to meet the needs of the modern battlefield such as EABO.7 Marine Corps Combat Development Command has identified these gaps and is developing prolonged casualty care (PCC), damage control resuscitation (DCR), damage control surgery (DCS), and en route care capabilities that can maneuver and support the ground elements during contested EABO.8

Littoral Operations in a Contested Environment describes the “integrated application of Navy and Marine Corps capabilities to overcome emerging threats within littoral areas that are rapidly expanding in operational depth, complexity, and lethality.” The new medical capabilities that will support the Marine Littoral Regiments during contested EABO and the new, smaller afloat surgical capabilities supporting the maritime force all share the same limitations: they cannot hold mass casualties, regulate patient movement, and exercise the medical command and control (C2) necessary to coordinate and stage patients for rapid evacuation through the Theater Aeromedical Evacuation System (TAES)—particularly at logistical nodes used as aerial ports of debarkation (APODs) and seaports of debarkation (SPODs).9

The LOCE medical force—blue naval, and green FMF medical personnel—must collaborate to resolve these limitations and create a unified survival chain that offloads casualties from the maneuvering elements, stabilizes them for transport, integrates them into the TAES, and moves them outside the WEZ and ultimately to military treatment facilities (MTFs). 

Optimal Casualty Care Requires Greater Control over Casualty Flows
Medical operations must be entwined with logistical operations for the contested environment in a future maritime fight, especially for EABO and LOCE. The Navy and Marine Corps have no dedicated fixed or rotary MEDEVAC capabilities and have previously relied upon Army, Air Force, and allied assets for short-range evacuation during an era when air supremacy and overflight clearance were assured.10 The Air Force also provides the long-distance aeromedical evacuation (AE) capabilities which will be necessary in a war in the East and South China Seas, given the time and distance challenges there. 

There is also no indication that the Navy and Marine Corps’ reliance on combined and joint theatre-level evacuation capabilities can be significantly reduced or that an abundance of organic short-range MEDEVAC options can be created in a reasonable timeframe. Military Sealift Command and flattop vessels do offer additional options beyond Air Force AE to evacuate casualties out of theatre; however, their mobility and survivability constraints are significant, and getting casualties aboard them still requires separate short-range MEDEVAC or CASEVAC assets. Therefore, the most likely outcome is the frequent re-tasking of platforms (particularly rotary ones) primarily designed for sustainment operations as lifts of opportunity.

The challenges to ad-hoc CASEVAC include the limited total number of airframes, vehicles, and small boats—all with competing tasking priorities—as well as evasion of an advanced enemy’s kill chain. Whenever CASEVAC can be tasked to patients, the next challenge will be to find a destination. Higher levels of care will likely be out of range, necessitating intermediate holding and staging locations. Intermediate medical units within the WEZ will also be distributed over larger areas and will have to become smaller to maintain mobility and survivability, in turn reducing their patient capacities and placing greater demand on casualty holding at other locations. 

In other words, casualty evacuation at the scale of future conflict will be an extraordinarily complex undertaking with many failure points. We risk thousands of preventable deaths due to casualties not being efficiently stabilized and evacuated outside the WEZ. If bogged down by these casualties, combat arms units will become combat-ineffective.

Historically, the failure to create robust medical C2 frameworks for casualty evacuation has been a consistent feature of post-Vietnam conventional conflicts.11 These failures significantly worsened medical outcomes in conflicts that were very one-sided in the United States’ favor.12 In a true peer conflict, poor medical C2 implementation could cause catastrophic levels of preventable deaths and widespread breakdown of combat effectiveness due to the inability to extract large volumes of casualties engaged in kinetic operations. This would ultimately lead to a cascade of failures from the tactical, to the operational and then strategic levels.13 Our concern must therefore not just be that inefficient casualty management will cause preventable deaths, but that it can cause us to lose the war. 

The silver lining is that there are low-cost, low-footprint opportunities for the Navy and Marine Corps to connect the dots and create a comprehensive operational medical system. These new medical C2 and staging capabilities will mitigate the current casualty evacuation constraints and gaps associated with a contested maritime environment.

A Crucial Air Force Template for Medical C2 and Logistical Integration
To complete the survival chain and decompress maneuvering forces engaged in DMO and EABO while maintaining tight accountability over injured personnel, the Navy and Marine Corps will greatly benefit from adapting Air Force aeromedical evacuation liaison teams (AELTs) to their own purposes.14

Aeromedical evacuation liaison teams are designed to provide on-the-ground AE coordination in the combined, joint environment to steer casualties into the TAES. An AELT is composed of a flight nurse, a Medical Service Corps officer, and a communications expert trained and equipped for critical decisions necessary to
coordinate patient movement requests and build requirements for lifts of opportunity. Operating for up to 30 days without resupply, AELTs do not provide direct patient care. Instead, they embed with tactical units, command centers, or logistical nodes to coordinate patient flows to move patients out of theater. The AELTs decide on the optimal allocation of evacuation assets, balancing clinical conditions versus lift requirements. 

One of their key liaison functions is to enter casualties into the Transportation Command Regulating Command and Control Evacuation System for accountability and tracking of personnel until arrival to military treatment facilities in the United States.15 This complex liaison function also necessitates equipping AELTs with redundant secure and unsecure communications systems through a standardized communications package.16

At present, no Navy or Marine Corps HSS elements possess the necessary structure, training, skillsets, and organic communications equipment of the AELTs. Without a counterpart to AELTs, the medical C2 aspect, initiating and coordinating patient movement on ad-hoc and dedicated medical lifts, will fall on tactical commanders. A Navy and Marine Corps version of AELTs would also need to coordinate afloat and long-range ground evacuation (e.g. via allied nation rolling stock).17 Such a complex regulation and evacuation function cannot be foisted upon combat leaders who are already cognitively saturated by the demands of kinetic operations. Navy and Marine Corps capability modeled on the Air Force AELTs is therefore not a nice-to-have but an absolute requirement to ensure patient accountability and prevent mission failure 

Air Force Model for Patient Holding and Staging Would Enable Rapid Integration with Logistical Operations
Another crucial gap capability for bridging EABO with DMO and medical with sustainment operations in the contested environment is a patient holding and staging system to hold patients behind the forward line of troops for rapid embarkation of wounded service members on lifts of opportunity. Traditional Role 2 enhanced and Role 3 units have the capacity to treat and hold many patients but are too large and static to survive inside the WEZ. The Air Force En Route Patient Staging System (ERPSS) is a model capability to fill this gap. 

The ERPSS can provide modular configurations for staging patients at SPODs and APODs. Teams have a holding capacity between 10 and 250 beds, and a holding time between 6 and 72 hours.18 Each ERPSS “provides patient reception, complex medical/surgical nursing, limited emergent intervention” and, crucially, ensures patients are medically and administratively prepared for extended travel on AE platforms.19 In addition to performing this vital medical regulation function, they create an efficient patient loading environment that minimizes the time that aerial platforms are vulnerable to detection and targeting on the ground.20 

The ERPSS is a modular concept that can be scaled up or down based on operational conditions or lift requirements, both afloat and ashore. The smallest block is the ERPSS-10, so-named because it organically comprises ten patient beds. Its thirteen personnel care for a maximum of 40 patients per 24-hour period, with supplies for a minimum of 72 hours of continuous operations (the associated logistical package provides 7 days of supplies).21 There are no credentialed providers (i.e. physicians/physicians assistants) in the ERPSS-10 configuration. Patients are instead expected to be triaged, resuscitated, and stabilized by DCR and DCS capabilities with the goal of force preservation to keep forces in the fight. 

A Navy and Marine Corps version of the ERPSS-10 could be the foundation piece to address the current patient staging and holding gap. As with the broader responsibilities of Navy and Marine Corps-adapted AELTs, an adapted ERPSS model will also have to package and hand off patients for maritime and ground-based evacuation platforms, which significantly increases mission complexity compared to the Air Force ERPSS. For instance, packaging a patient for high-altitude transport requires different steps than packaging a patient for heavy seas. 

Carrying over the modular ERPSS design would enable setups from 10, 50, to over 100 beds with predictable logistics and favorable conditions. Equivalent modules prepositioned at key APOD/SPOD locations with efficient, compact packaging sets will avoid the need for the Navy and Marine Corps version of ERPSS to co-locate with MTFs and make them self-sufficient. Switching from the fixed capabilities of traditional Role 2 and Role 3 units that previously supported ground operations to a scalable patient staging model based on ERPSS provides the means to rapidly prepare and package injured warfighters for egress based on theater conditions including adversary anti-access/area-denial capabilities, casualty volumes, and specific threat level at SPOD and APOD locations. 

New LOCE Medical Capabilities Will Maximize Warfighting and Patient Care Outcomes
The 37th Commandant, Gen Robert Neller, stated that “[Marines’ and Sailors’] ability to think critically, innovate smartly, and adapt to complex environments and adaptive enemies has always been the key factor we rely on to win in any clime and place.”22 As the Marine Corps makes major organizational changes to enable our combat arms brethren to maximize the use of that ability on the modern battlefield, Navy Medicine must adapt its organization and mindset to give our sailors the ability to maximize casualty survival.

We are already taking steps to enhance the ability of tactical-level providers to provide point-of-injury Tactical Combat Casualty Care and Prolonged Casualty Care in tandem with pushing DCR and DCS capabilities forward. The missing link in the survival chain are operational-level/LOCE adaptations that bridge casualty movement from the tactical EABO/DMO level to definitive care and recovery outside the enemy’s WEZ. By adapting the proven Air Force AELT and ERPSS concepts, the Navy and Marine Corps will empower our sailors to be agile and proactive, creating key nodes in the survival chain that decompress the tactical level, maximize the use of numerous long-distance evacuation modalities, and ultimately maximize our ability to keep casualties alive and maintain combat effectiveness.

The Air Force AELT and ERPSS templates will still have to be tailored to optimally support contested EABO and LOCE. The expectation of PCC within the tactical constraints of DMO and EABO is mirrored at the LOCE level by scarcity of Class VIII supplies and evacuation assets as well as the constant need to lessen vulnerability to enemy sensors and precision fire. We must recognize, though, that even as the enemy’s detection range and WEZ has expanded greatly because of the RMA, the requirements of operational-level medical teams such as Navy and Marine Corps AELT and ERPSS adaptations are distinct and separate from tactical-level medical assets such as DCR/DCS and strategic assets like MTFs. 

Creation of the proposed medical C2 and staging and holding teams to enable LOCE integration can easily occur within the existing force structure. These small new teams will require relatively modest dedicated budgets for training and communications equipment. Experimentation with the initial teams could then lead to a wider rollout of LOCE integration solutions to yield maximal combat effectiveness and casualty survival outcomes that will greatly benefit the Navy and Marine Corps as a whole.

>LCDR Keeney-Bonthrone is a General Medical Officer and the Lead Instructor of 4th MarDiv’s experimental Prolonged Casualty Care team. 

>>CDR Jaiswal is an Intensivist with 4th Medical Battalion. 

>>>CDR Ibikunle is a General Surgeon with 4th Medical Battalion. 

>>>>CAPT Delk is an Emergency Medicine Physician and the current the Commanding Officer of 4th Medical Battalion.

Notes

1. Gen David H. Berger, Force Design 2030, (Washington, DC: 2020); Kristen D. Thompson, “How the Drone War in Ukraine Is Transforming Conflict,” Council on Foreign Relations, January 16, 2024, https://www.cfr.org/article/how-drone-war-ukraine-transforming-conflict; and Caitlin Lee, “Countering China’s Military Strategy in the Indo-Pacific Region,” RAND Corporation, March 2024, https://www.rand.org/content/dam/rand/pubs/testimonies/CTA3200/CTA3273-1/RAND_CTA3273-1.pdf.

2. Mark F. Cancian, Matthew Cancian and Eric Heginbotham, The First Battle of the Next War: Wargaming a Chinese Invasion of Taiwan, (Washington, DC: Center for Strategic & International Studies, 2023).

3. Headquarters Marine Corps, Tentative Manual for Expeditionary Advanced Base Operations, 2nd Edition (Washington, DC: 2023).

4. Bureau of Medicine and Surgery, Navy Surgeon General Campaign Plan 2028, (Washington, DC: 2023).

5. Headquarters Marine Corps, Littoral Operations in the Contested Environment, (Washington, DC: 2017).

6. Navy Surgeon General Campaign Plan 2028.

7. LCDR Benjamin Chi and ENS Duncan Carlton, “The Role 2 Light Maneuver Element” in Marine Corps Gazette 105, No. 3 (2021).

8. Johannes Schmidt, “Expeditionary Medical Systems: Increasing Warfighter Survivability in Littoral Combat,” MCSC Office of Public Affairs and Communication, Marine Corps Systems Command, December 28, 2023, https://www.navy.mil/Press-Office/News-Stories/Article/3627576/expeditionary-medical-systems-increasing-warfighter-survivability-in-littoral-c. 

9. Littoral Operations in the Contested Environment.

10. Dion Moten, Bryan Teff, Michael Pyle et al., “Joint Integrative Solutions for Combat Casualty Care in a Pacific War at Sea,” Joint Force Quarterly, July 24, 2019, https://ndupress.ndu.edu/Media/News/News-Article-View/Article/1913091/joint-integrative-solutions-for-combat-casualty-care-in-a-pacific-war-at-sea.

11. Arthur M. Smith and CAPT Harold R. Bohman, “Medical Command and Control in Sea-Based Operations” in Naval War College Review 59, No. 3 (2006), https://digital-commons.usnwc.edu/cgi/viewcontent.cgi?article=1931&context=nwc-review.

12. Ibid. 

13. Andrew S. Harvey, “The Levels of War as Levels of Analysis,” Military Review, November 2021, https://www.armyupress.army.mil/Journals/Military-Review/English-Edition-Archives/November-December-2021/Harvey-Levels-of-War.

14. Secretary of the Air Force, Air Force Tactics, Techniques, and Procedures 3-42.54: Aeromedical Evacuation Liaison Team, (Washington, DC: 2020); and Rachel S. Cohen, “46 Hours: How Airmen Fought to Save Lives After the Abbey Gate Bombing,” Air Force Times, August 30, 2022, https://www.airforcetimes.com/news/your-air-force/2022/08/30/46-hours-how-airmen-fought-to-save-lives-after-the-abbey-gate-bombing.

15. Air Force Tactics, Techniques, and Procedures 3-42.54.

16. Ibid. 

17. Stig Walravens, Albina Zharkova, Anja De Weggheleire et al., “Characteristics of Medical Evacuation by Train in Ukraine, 2022” in JAMA Network Open, June 23, 2023, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2806503.

18. Secretary of the Air Force, Air Force Doctrine Publication (AFDP) 4-02: Health Services, (Washington, DC: Department of the Air Force, 2019). 

19. Secretary of the Air Force, Air Force Tactics, Techniques, and Procedures 3-42.57: En Route Patient Staging System, (Washington, DC: 2016).

20. Ibid. 

21. Ibid. 

22. Headquarters Marine Corps, The Marine Corps Operating Concept: How an Expeditionary Force Operates in the 21st Century, (Washington, DC: 2016).

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