Publishing Disclaimer: In all of its publications and products, Military Review presents professional information. However, the views expressed therein are those of the authors and are not necessarily those of the Army University, the Department of the Army, or any other agency of the U.S. government.

---

 

Major Jonathan Letterman Revisited

Anticipating Casualty Evacuation Needs in Large-Scale Combat Operations

 

Col. James Nicholson, U.S. Army
Tyler Fox

 

Download the PDF

 

Baltic region, five years from today. Exhausted from combat, soldiers stood in shock as reports of a chemical attack on the wet-gap crossing reached the division’s rear command post. Subsequent medical evacuation requests supplanted denial with dread. First two hundred, then three hundred, and finally over six hundred patients. Already overwhelmed by three thousand wounded from the previous days, this event broke the rear command post’s ability to react. Enemy air defenses made helicopter evacuation impossible. Congestion plagued ground routes as weather and fleeing civilians slowed traffic. Long-range artillery, deep reconnaissance units, and unmanned aircraft systems exploited the fragile supply network, while electronic warfare and cyberattacks complicated communication and navigation. Confounding it all, the division surgeon was unable to action patient movement. Poor rear command post integration compelled individual units to circumvent the division staff altogether, moving patients however they could without coordination or control. Culminating prior to the objective, the division transitioned to a hasty defense against an unremitting and unremorseful enemy. The surgeon felt powerless.

 

The U.S. Army faced catastrophe 162 years ago. Unchanged, it will face it again. Since Antietam, the prompt evacuation of wounded American soldiers remains an enduring expectation. With the U.S. transition from counterinsurgency to large-scale combat operations (LSCO), the Army must relearn the challenges of mass casualty movement. Analysis of recent Warfighter exercises (WFX) provides valuable context for medical personnel, staff officers, and maneuver commanders in this regard. Further contextualizing WFX data within the Army’s history reveals the scale of the casualty evacuation problem, the capacity required to meet it, and the methods needed to action it. Failing to implement change today based on this understanding will inevitably result in future disaster against a peer opponent. Should this occur, the cost in lives will erode the popular support necessary for democratic societies to unite against an existential threat, resulting in dire consequences for the Nation.

Letterman’s Dilemma

Maj. (Dr.) Jonathan Letterman became the command surgeon of the Union’s Army of the Potomac following its failure to seize Richmond in the summer of 1862. Letterman found himself with the responsibility of rebuilding the fighting strength of a 105,000-strong army that had recently suffered 15 percent casualties.¹ Complicating matters, 29 percent of the remaining soldiers were unable to fight due to illness.² As rain, fatigue, and privation attrited the force, Letterman noted the burgeoning “prevalence of malarial fevers of a typhoid type, diarrhea, and scurvy.”³

Gen. Robert E. Lee maintained pressure as he chased the Union army across Northern Virginia in July 1862. From 15 August onward, Lee delivered repeated blows against Maj. Gen. John Pope’s Army of Virginia, culminating in the Second Battle of Manassas from 29 to 30 August.⁴ Afterward, three thousand Union casualties remained on the field at Manassas where they had fallen three days prior.⁵ Numerous civilian teamsters hired by the Army Quartermaster Corps to serve as ambulances fled the battle.⁶ The situation was severe enough for Secretary of War Edwin Stanton to organize a relief, but upon losing their cavalry escort, many of the impressed wagons turned back. Those that did arrive often refused to aid to the wounded, stole provisions, or looted the pockets of the casualties.⁷ Union forces now found themselves defending Washington, D.C., after enduring 14,500 casualties in less than two months.⁸ With Lee’s army poised to invade Maryland, Letterman found himself forced to impose change with an existential threat lying just outside the beleaguered Nation’s capital.

A French physician provided the precedent for Letterman’s initiatives. A surgeon of Napoleon Bonaparte, Dr. Dominique Jean-Larrey developed the concept of the ambulance volantes (“flying ambulance”) in 1792.⁹ Light, horse-drawn carriages with two wheels, the flying ambulance included a rectangular enclosure with padded litters upon a spring suspension for improved patient comfort.¹⁰ Sufficiently fast and nimble, they markedly improved evacuation times. With accompanying surgeons on board, these ambulance volantes would maintain contact with the engaged troops to offer prompt aid and subsequent evacuation, thus minimizing the window between injury and treatment.¹¹ Letterman, understanding the benefits of rapid evacuation, outlined a similar system of dedicated wagons with stretcher-bearers as a cohesive Ambulance Corps within the Army of the Potomac.¹²

Letterman’s ambulance efforts proved timely, as 17 September 1862 marked a tragic, bloody event in American history. At Antietam, Union casualties under Gen. George McClellan for that single day totaled 12,350 out of the eighty-seven thousand-strong force (14.2 percent).¹³ Furthermore, when including all soldiers killed or wounded that day, approximately two thousand men fell per hour for twelve continuous hours.¹⁴ Fortunately, the Army of the Potomac received two hundred new ambulances a mere five days prior, which cleared the Union right wing by two o’clock in the afternoon and the left wing that evening—a stark contrast to the Second Battle for Manassas.¹⁵ Letterman’s holistic grasp of the challenge also secured prompt movement to distant, established, civilian hospitals. By coordinating with the delivery of incoming rail supplies, the Ambulance Corps transferred wounded to freshly emptied boxcars for transport to hospitals in Baltimore and Washington, D.C.¹⁶

The subsequent Battle of Fredericksburg in December 1862 distinguished the Letterman plan by demonstrating “ambulances guided and governed with perfect control … the wounded being brought without delay or confusion.”¹⁷ This dramatic improvement secured passage of the Ambulance Corps Act of 11 March 1864, which extended Letterman’s initiatives across the entire Union army. Allocating one ambulance per 150 Union soldiers, this act defined American casualty evacuation through World War I.¹⁸

The Casualty Problem Forecast

In the traditions of Letterman, understanding the operational context is crucial for upholding the first principle of Army health service support, conformity, which sets the conditions for facilitating medical evacuation.¹⁹ Casualty generation in WFXs is apocalyptic compared to Global War on Terrorism (GWOT) levels. However, LSCO represents an existential threat to national survival. Victory is mandatory, and the tolerance for casualties must be reframed given the consequences of failure.

U.S. European Command has the freshest and largest sample of WFX data from which to evaluate LSCO demands. In assessing U.S. European Command-oriented WFXs, the average casualty generation of a division-sized element during a ten-day exercise is 1,876 per day for both killed and wounded in action (see table 1). Removing killed in action and soldiers returned-to-duty within the division, 846 soldiers require evacuation daily. Considering this projected casualty volume, it is prudent to search for solutions by grounding ourselves in how the U.S. Army managed similar situations during previous conflicts.

The Evolution Prior to World War II

After the Civil War, Letterman’s Ambulance Corps essentially dissolved only to reemerge as the U.S. Army Ambulance Service in 1917. The Army Medical Department responded promptly to wartime demand, as a 1916 congressional authorization permitted the purchase of ambulances without competitive bidding.²⁰ By 1917, Army Surgeon General William Gorgas chose the General Motors model 16AA ambulance as the exclusive model, with 2,308 ambulances delivered by 15 November 1917.²¹ Ambulance sections supporting infantry divisions were located within organizations known as sanitary trains, which included four ambulance companies.²² These ambulance companies included three motorized ambulance companies, each with twelve ambulances, and one animal-drawn company, also with twelve ambulances, which was retained to navigate rough terrain unsuitable for motor transport.²³ To support the American Expeditionary Force (AEF), 6,875 motor ambulances ultimately served in Europe during World War I, assisting in the evacuation of 214,467 casualties.²⁴

Early motorized ambulances had significant limitations. Capt. Arlington Lecklider of the 168th Ambulance Company, 42nd Infantry Division, noted that “the methods of evacuation of [the] wounded in 1918 were those of our Civil War of 1865—using litter bearers from trenches to the immediate rear, then mule-drawn ambulances to the collecting-station.”²⁵ Animal-drawn ambulances were still useful due to their ability to navigate poor terrain, but, as with the 42nd Infantry Division, sodden ground and roads impassable from mines meant that casualties were periodically carried on the backs of comrades.²⁶

World War I foreshadowed two cardinal shifts in ambulance service later fulfilled in World War II: the infusion of motorized service at the lowest level and the centralization of control. On the surface, this may appear a contradiction. However, with improved evacuation speed providing the wounded faster treatment, a firm hand was required to bring efficiency from increasingly dispersed ambulance detachments. With aerial attacks and long-range artillery posing threats to both evacuees and medical corpsman, appropriately placing ambulances at locations that facilitated responsiveness and protection proved crucial.²⁷ In 1918, the III Corps surgeon demonstrated this through direct responsibility of patient evacuation from subordinate divisions during the Meuse-Argonne campaign.²⁸ Similarly, five days before the armistice, the AEF chief surgeon created an ambulance pool to ensure oversight and efficient use of all available vehicles.²⁹ This medical supervision highlighted the increasingly technical nature of warfare that necessitated effective command and control.

Post-World War II

Following World War II, evolutionary pressure to maximize speed and efficiency did not remain isolated on the ground. Korea saw earnest use of helicopters for evacuation, which rapidly accelerated during Vietnam. At the peak of operations in southeast Asia, fifteen medical evacuation (MEDEVAC) units were deployed to South Vietnam.³⁰ In total, Vietnam MEDEVAC units executed 496,573 missions moving over 900,000 patients but at the cost of 199 airframes and 470 pilots wounded or killed.³¹ Similar units permitted the Golden Hour evacuation standard during GWOT. The helicopter’s eminence came from wars where small units were decisive. The scale of combat—intense but limited in breadth at any given time—allowed the attention of this platform. More importantly, so did an enemy incapable of robust air defense. Developments pernicious to the helicopter took place after both the Vietnam War and GWOT.

The 1973 Arab-Israeli War changed U.S. Army perceptions following years of counterinsurgency fighting in Vietnam. The lethality of modern battlefields, particularly from modern surface-to-air and antitank guided missiles, forced a reassessment of fighting the Warsaw Pact in Western Europe. The resulting AirLand Battle doctrine embraced seizing the initiative to impose American will upon the enemy during high-intensity combat. By acknowledging the risks of the modern battlefield from improved enemy sensors, weapons of mass destruction, and tenuous supply lines, AirLand Battle stipulated that success depended on maintaining initiative, agility, depth, and synchronization of Army combat forces.³²

Post-GWOT, the Army finds itself at an inflection point—a renaissance of large-scale combat operations against a peer opponent. These operations are predicted to be far more expansive and destructive than recent conflicts, with concordant heavy casualties.³³ Similar to AirLand Battle, the Army of 2030 will seek to adhere to the tenants of agility, convergence, endurance, and depth to defeat enemy forces to gain a position of relative advantage.³⁴

LSCO and World War II Comparisons

Using a current active-duty infantry division as an example, fully decompressing the WFX average of 846 daily casualties per division would require every ambulance the 1st Infantry Division (1ID) possesses (see table 2). Utilizing every ground and air ambulance, 1.6 “turns” are required to fully decompress the number of wounded-in-action patients that require Role 3 treatment. Evacuating all casualties requires 2.3 “turns.” This presents a daunting task even in the best circumstances. It assumes perfect efficiency with every platform capable of duty. Not only will electronic warfare compromise both communications and navigation, but integrated air defense systems, in conjunction with long-range precision fires, will also counter U.S. advantages and impose risk to the force. Similarly, the rate of casualty flow will not occur linearly, and the allocation of resources like ground ambulances cannot be shifted across subordinate organizations without incurring concordant risk. Thus, a tenuous balance between responsiveness and protection will remain as true in future LSCO as it did for the AEF in 1918.

Lt. Col. John Ficicchy faced this problem before: hundreds of casualties, artillery observation, and limited maneuver. He also faced them with even fewer resources than the contemporary 1ID. As the 1ID division surgeon throughout 1944, Ficicchy planned medical support for D-Day, the fighting in the Marigny Breakthrough, and across northern France. But in the Hürtgen Forest and follow-on operations east of the Roer River, he found life akin to that of Lecklider in World War I; a foreshadow of the brutal contest that future LSCO also holds.

Ficicchy’s experience told him the forest would swallow more men than the sword. Weather, terrain, and road conditions conspired against the mobility of the field ambulance. He reported, “Litter carries were very difficult and averaged two-thousand yards.”³⁵ “Enemy artillery and mortar fire which create bursts in the forest caused a large number of casualties among these litter bearers.”³⁶ To keep up with their attrition, both due to casualties and physical exhaustion, 240 men were needed to maintain eighty litter bears at any given time.³⁷ Where feasible, the division established forward “Jeep” collection points to begin casualty movement toward Role 2 facilities, the collecting stations of the regimental combat teams. In a single day, 501 casualties required evacuation through the viscera of this evacuation system.³⁸

These numbers are not aberrations. They’re reality, and they validate Warfighter simulations data. The mean of daily division evacuations is 60 percent of the statistic noted in table 1. This appears reasonable given the state of the Wehrmacht in late 1944 and into 1945, accounting for the lethality of modern weapons systems and acknowledging the effects of chemical attacks, which are frequent injects during a Warfighter exercise. Historically, when the 1ID faced a chemical attack in Meuse-Argonne, it recorded 1,700 casualties at various division triage locations with “400 or so” additional wounded referred to higher echelon hospitals on 4 October 1918 alone.³⁹

Historical precedent demands large numbers of vehicles to cope with casualty volume and platform attrition. Episodes of excessive casualties also require nonmedical transportation be pressed into service. Acknowledging the distinction between ambulance movement and nonmedical transport is necessary for understanding the patient evacuation dilemma in LSCO. Doctrinally, battlefield ambulance service is synonymous with MEDEVAC, which Field Manual (FM) 4-02, Army Health System, defines as “the timely and effective movement of wounded, injured, or ill to and between medical treatment facilities on dedicated and properly marked platforms with en route care provided by medical personnel.”⁴⁰ This is not to be confused with casualty evacuation (CASEVAC), which is the movement of casualties aboard nonmedical vehicles or aircraft without en route medical care.⁴¹ CASEVAC is what the 1ID leaned on to evacuate the walking wounded, not only from across the division’s organic medical assets, but all the way through to hospital-level care. When excessive casualties required absorption, CASEVAC provided the elasticity to supplement ambulance MEDEVAC by servicing patients at minimal risk of succumbing to their injuries, thus prioritizing the specialized ambulances and crews for more severe cases.

The challenges faced by the 1ID’s eastward drive into Germany illustrate two aspects that are the LSCO norm: the scale of tragedy and measures to mitigate the subsequent human suffering. Much of Ficicchy’s experience, and that of other division surgeons, was a fulfillment of what began in World War I—reacting to the crisis at hand through motorized evacuation down to the lowest level with centralized ambulance authority.

The regimental commander wielded singular authority over everything within the area of operations. Through the regimental surgeon, the commander dictated the placement of the collecting station and the ten supporting Dodge WC-54 ambulances. After servicing the battalions, five remained to cycle all the regiment’s casualties from the collecting station to division. This exchange was the point of friction tactically and congestion medically. Ficicchy felt that two additional ambulances per regiment—an increase in six across the division—would provide more freedom to respond to terrain and tactical situations. A collecting station full is a collecting station unable to attack with its regiment.⁴²

Ficicchy’s request was stunning in modesty. The addition of twenty-four litters under the weight of hundreds of casualties is seemingly futile. Yet it was these twenty-four litters that Ficicchy felt could make the difference. Had he the current resources of the 1ID, he may not have known what to do with all the capacity—it’s more than ten times his request. The new M997A3 ambulance (HH-60 helicopters aside) is overwhelming in ability when held to the WC-54 that Ficicchy knew. It boasts air conditioning, the ability to carry advanced medical equipment, and over one hundred additional horsepower. What would this capability have meant to 1ID leaders in 1944? The essential aspect that matters—the primal aspect—is the one unchanged: they, just like the model 16AA that preceded them, each carry four litters.

Matching the World War II success of the 1ID is not a matter of the instrument, nor is it a matter of wanting capacity. The twenty-four litters Ficicchy wished for were not important for their numbers alone but for refining the practical matters of effective employment. Trained human capital, empowered with authority, is the difference. Mirroring the hands-on efforts of Letterman, the application of Army Health System principles of conformity, proximity, flexibility, mobility, continuity, and control will not occur by accident.⁴³ Akin to the increased lethality that drove AirLand Battle, the medical staff of operational and tactical headquarters engaged in future LSCO will need to effectively exploit every opportunity to maximize casualty movement. Because American forces will operate from a position of disadvantage, specifically due to extended lines of communication complicating sustainment efforts, it will be necessary to synchronize multiple domains to create and exploit relative advantages as they appear, a concept known as convergence.⁴⁴ Thus, detailed planning is required to integrate joint capabilities that enable freedom of action and mission accomplishment, particularly in regard to building unity of effort for patient movement.⁴⁵

WFXs display how MEDEVAC capacity is insufficient during convergence windows to fully decompress a division’s medical facilities, affecting the tempo of combat operations. When this occurs, not only do Role 1 and 2 facilities remain overwhelmed, thus increasing the died-of-wounds rates, but the supported combat elements are constrained in their ability to maneuver, which in turn enables enemy targeting. Given these considerations and the inevitable attrition of ambulance assets, the utilization of CASEVAC platforms to take advantage of every opportunity is essential.

However, command surgeons will be forced to compete for limited assets with multiple uses to facilitate efficient patient movement. Assets such as light medium tactical vehicles, heavy expanded mobility tactical trucks, CH-47F Chinook helicopters, C-130J tactical cargo aircraft, and Army logistics support vessels enable sustainment efforts across the joint force and can be configured for CASEVAC roles per Army Techniques Publication (ATP) 4-02.13, Casualty Evacuation. Because of the insatiable demand for these assets on the battlefield, command surgeons must effectively communicate requirements and risk to leaders. As often occurs in a WFX, medical staff ineffectively shape the casualty planning estimate into projected requirements. When this occurs, the “so what” is lost for senior leaders. With staff integration failure, organizations cannot forecast capabilities against requirements within the context of the operational plan. In doing so, the concordant risk that must be assumed by senior leaders for when requirements can or cannot be met is not communicated. A technique to forecast requirements and ensuring alignment against the operational plan could be similar to what is shown in figure 1.

From a staff planning perspective, utilizing CASEVAC platforms for patient movement harkens to the same dilemma facing Maj. Letterman; because these assets are not under the dedicated control of medical authorities, they are constantly tasked to move other critical items. Requirements, such as rations (class I), fuel (class III), ammunition (class V), repair parts (class IX), and replacement personnel all require vehicular support during combat sustainment. In addition, the demand for these resources is anticipated through running estimates from various staff elements. This requires in-depth coordination between the command surgeon team and the broader staff to ensure casualty backhaul requirements are appropriately anticipated and captured via the necessary air, transportation, and joint movement requests.

With sustainment planning aligning to the organization’s planning horizon (72–96 hours out for divisions and 96–120 hours out for corps), forecasting casualty evacuation requirements is mandatory for proper resource allocation against all the division’s requirements. This includes not only the casualty evacuation needs but also the allocation of resources for human remains backhaul and forward replacement movement. Capturing a holistic picture of the total personnel contribution to the organization’s overall combat power is vital to achieving the commander’s intent. When properly executed, synchronized staff effort enables shared understanding, efficiency, and appropriate risk assessment for commanders. When poorly executed, organizations face a sudden realization that the unit is off plan and off time. This process, which is obvious in explanation but inherently challenging in warfighting execution, can be conceptualized as shown in figure 2. This figure emphasizes how quickly the personnel aspect of combat power can be attrited to the equivalent of a battalion formation, the largest element a division can organically regenerate without external assistance.

Recommendations

Should the Nation call upon the Army to fight a peer opponent by 2030, the following actions would contribute to conserving the fighting strength and maintaining combat power during decisive action. These recommendations must be viewed within the construct of balancing sufficient platform capacity against the need to disperse those platforms so as to mitigate the effects that indirect fires and unmanned aircraft systems can impose as demonstrated in the Donbas, Nagorno-Karabakh, and the Levant.

In seeking to balance the demands of evacuation capacity against dispersion, it is necessary to implement a system that promotes unity of effort to ensure efficient resource application (see figure 3). Failure to assure sufficient dispersion will result in the direct attrition of ambulances and crews; conversely, the failure to provide sufficient evacuation capacity will result in the inevitable patient backlog at echelons of care that are easily overwhelmed due to their limited resources. Of note, these recommendations are independent of future material solutions such as autonomous evacuation vehicles, as the appropriate application and management of an evacuation system will remain platform agnostic. Fortunately, the U.S. Army today can implement change without the direct existential threat facing Letterman, and these changes can be applied promptly to prepare for challenges today independent of the Army’s broader 2030 and 2040 timelines.

Doctrine

FM 4-02 highlights the many responsibilities of command surgeons. Despite this, there are no authorities granted to these individuals at division or corps level that enables the execution of the MEDEVAC or CASEVAC mission on behalf of commanders. Indirectly, ATP 4-02.2, Medical Evacuation, does note that medical mission authority begins at the theater level in the generation of medical policies and medical rules of engagement, and medical mission authority is then accomplished via validation of the nine-line MEDEVAC request.⁴⁶

While historical examples illustrate success in facilitating large-volume patient evacuation through the sheer force of will, the lack of clear command and support relationships generates friction between the operational headquarters and the supporting medical element. With the varied array of echelons above brigade (EAB) medical assets in support, there are frequent disconnects in first defining, and then appropriately aligning, relationships across organizations to achieve maximum efficiency. This is a critical factor, as the patient movement branch within the medical brigade S-3 section is responsible for twenty-four-hour regulated patient movement within the designated area of operations, but command surgeons designate MEDEVAC policies and procedures.⁴⁷

Without doctrine to offer recommendations on how patient evacuation authorities should be allocated, the nightmare scenario from the introductory Baltic vignette will not remain hyperbole. Quite simply, when a division receives EAB ambulances, Role 2s, and even Role 3s, who do they work for? From Ficicchy’s experience in World War II, medical assets at the division level were attached to the maneuver element with only administrative control retained by the supporting medical battalion.⁴⁸ This relationship facilitated the maneuver of the clearing stations to the advancing forward lines. Because clearing companies comprised two platoons, one would be established while the other could act as a mobile reserve to establish at a more forward location. In doing so, patient care remained uninterrupted as health service support capacity could be leapfrogged in a manner consistent with local tactical considerations.⁴⁹ Ideally, the pending publication of ATPs 4-02.91, Division and Brigade AHS [Army Health System] Operations; 4-02.92, Corps AHS Operations; and 4-02.93, Theater AHS Operations, will address deficiencies in command and support relationship guidance.

Organization

Joint Publication 4-02, Joint Health Services, defines medical regulating as “the actions and coordination necessary to arrange for the movement of patients through the roles of care and to match patients with an MTF [medical treatment facility] that has the necessary HSS [health service support] capabilities and available bed space.”⁵⁰ To execute the medical regulating mission from point-of-injury to Role 2 or higher, joint doctrine states that the responsible headquarters should form a patient evacuation coordination cell (PECC).⁵¹ However, Army doctrine fails to identify or specify the PECC mission. Although ATP 4-02.2, Medical Evacuation, endorses the requirement for a medical mission authority, no entity within FM 4-0, Army Health System, is expressly designated for establishing a PECC.

Previous Army doctrine, notably FM 8-10-3, Division Medical Operations Center Tactics, Techniques, and Procedures, included the division medical operations center within the supporting division support command (DSC).⁵² The DSC was expressly tasked with coordinating support across general and direct support medical units, as well as units under tactical or operational control of the division, an important note to consider given the aforementioned doctrinal gaps.⁵³ Likewise, the DSC role included directing patient evacuation from division to corps-level treatment facilities under the guidance of the medical regulating officer.⁵⁴ Dissolving the DSC removed the tether between supply and demand. The division, on the demand side, tasks and moves the wounded by ambulance. Unaware of where to move them, wounded could be sent to an overflowing hospital. No staff arrangement links the supporting medical command and its allocated bed space—the supply of care—to the demands of the division. Appropriate delegation of personnel to facilitate the PECC mission down to division level from supporting medical brigades would enhance shared understanding of the operational plan through synchronization of EAB medical resources. Therefore, the PECC represents a critical GWOT lesson that must be institutionalized and updated for the LSCO fight to assure efficient MEDEVAC utilization for both rotary-wing and wheeled platforms.

The prolonged care augmentation detachment (PCAD) is a new medical unit of action slated to begin operational fielding in fiscal year 2025. This organization is designed to provide prolonged care and en route critical care through five prolonged care sections, each consisting of twelve personnel organized as three 4-person squads.⁵⁵ Limited in number, with one active-duty PCAD and two Army reserve PCADs templated, the precise manner in how to integrate PCAD capability down to a brigade combat team Role 2 during LSCO remains untested. Given that the PCAD does not have any organic bed capacity to supplement the Role 2, it is presumed that the prolonged care sections will be best utilized in augmenting CASEVAC platforms to maximize patient movement capacity during convergence windows that permit movement back to Role 3 care in the division rear area and beyond. An ATP that provides recommendations on methods for how PCADs will enable the supported tactical element is required.

Training

The medical planner’s tool kit is the casualty estimation tool of record.⁵⁶ At present, an Army Medical Department officer can complete basic officer leader course, captains career course, and intermediate level education and still lack access to, let alone proficiency with, the medical planner’s tool kit as it is not within any professional military education program of instruction. Given this fact, command surgeon staffs are often unable to generate independent planning and running estimates to augment G-1 staff efforts. This greatly complicates staff dynamics by making the command surgeon dependent of G-1 inputs and thus, the G-1 a single point of failure for casualty estimation and subsequent MEDEVAC/CASEVAC requirements analysis. Although appendix D of ATP 4-02.55, Army Health System Support Planning, outlines the method for manual casualty estimation, the inability to generate sufficient experience either in professional military education or during duty assignments fails to generate the requisite talent necessary for medical officers to succeed in operational staff billets.

Leadership

Because there are no established exercises to stress the leadership and staff of EAB medical organizations, there is no way to effectively validate the support that these organizations will be required to deliver to operational forces at the corps and division levels, particularly for support to intra- and intertheater patient movement. Ensuring that medical brigades and multifunctional medical battalions are allocated to upcoming WFXs as training audiences during the Forces Command Army Synchronization and Resourcing Conference will set conditions for enduring relationships between Forces Command units and EAB medical commands. This proposed course of action is dependent, however, on generating a sufficient pool of experienced observer-coach/trainers to advise the EAB medical commands as no such sourcing readily exists to provide the requisite subject-matter expertise.

Without sufficient opportunities to challenge the leadership of medical organizations with the patient volumes experienced in LSCO, the Army has no ability to effectively understand what standards for patient evacuation can be anticipated. Ficicchy reported that “the average evacuation interval from the time a casualty is picked up to the time he arrives at the clearing station is one hour.”⁵⁷ However, it has been lamented that in this post-GWOT period, this “Golden Hour” for patient movement from the point of injury to life-saving treatment, is dead. The Golden Hour will indeed be dead if Army leaders kill it before the fight begins. The U.S. Army must ultimately meet the standards it holds leaders accountable to, which was as true in 1944 as it will be in the future. LSCO battlefields will continue to be won or lost through the human dimension, and the American soldier must continue to expect the commitment forged by Letterman; that he or she will have every effort made to ensure their safe and prompt movement out of harm’s way.

---

Notes

1. Robert Doughty et al., Warfare in the Western World: Military Operations from 1600 to 1871, vol. 1 (Cengage Learning, 1995), 371.
2. Ira Rutkow, Bleeding Blue and Gray: Civil War Surgery and the Evolution of American Medicine (Random House, 2005), 127.
3. Robert Denney, Civil War Medicine: Care and Comfort of the Wounded (Sterling Publishing, 1994), 133.
4. Dougherty et al., Warfare in the Western World, 375–77.
5. George Adams, Doctors in Blue: The Medical History of the Union Army in the Civil War (Henry Schuman Press, 1952), 75–76.
6. Ibid.
7. Ibid.
8. Dougherty et al., Warfare in the Western World, 377.
9. John Haller, Battlefield Medicine: A History of the Military Ambulance from the Napoleonic Wars through World War I (Illinois University Press, 1992), 14.
10. Ibid., 15.
11. Ibid., 14.
12. Ronald Place, “The Strategic Genius of Jonathan Letterman: The Relevance of the American Civil War to Current Health Policy Makers,” Military Medicine 180, no. 3 (2015): 260, https://academic.oup.com/milmed/article/180/3/259/4160074.
13. Dougherty et al., Warfare in the Western World, 379.
14. Scott McGauch, Surgeon in Blue: Jonathan Letterman, the Civil War Doctor Who Pioneered Battlefield Care (Arcade Publishing, 2013), 114.
15. Adams, Doctors in Blue, 77.
16. Ibid., 78.
17. McGauch, Surgeon in Blue, 149.
18. Adams, Doctors in Blue, 97.
19. Field Manual (FM) 4-02, Army Health System (U.S. Government Publishing Office [GPO], November 2020), 1-8.
20. Mary Gillett, The Army Medical Department, 1917–1941 (U.S. Army Center of Military History, 2009), 33.
21. Ibid.
22. George Thompson, “Battlefield Medicine: Ambulance Section,” University of Kansas Medical Center, accessed 10 April 2024, https://www.kumc.edu/school-of-medicine/academics/departments/history-and-philosophy-of-medicine/archives/wwi/essays/military-medical-operations/ambulance-section.html.
23. Ibid.
24. Richard Ginn, The History of the U.S. Army Medical Service Corps (Office of the Surgeon General and U.S. Army Center of Military History, 1997), 51.
25. Arlington Lecklider, “Army Medical Equipment 1918 Versus 1968,” United States Army Vietnam Medical Bulletin 40, no. 11 (September-October 1968): 8–13, https://stimson.contentdm.oclc.org/digital/collection/p15290coll4/id/412.
26. Gillett, The Army Medical Department, 339–41.
27. John Haller, Farmcarts to Fords: A History of the Military Ambulance, 1790–1925 (Southern Illinois University Press, 1992), 183.
28. Gillett, The Army Medical Department, 341.
29. Ibid.
30. Darrel Whitcomb, Call Sign Dustoff: A History of US Army Aeromedical Evacuation from Conception to Hurricane Katrina (Officer of the Surgeon General, Borden Institute, 2011), 46.
31. Ibid., 55.
32. FM 100-5, Operations (U.S. GPO, May 1986 [obsolete]), 14–15.
33. FM 3-0, Operations (U.S. GPO, October 2022), 1-10.
34. Ibid., 3-2.
35. John Ficicchy Jr., Annual Report of Medical Department Activities, 1944: Division Surgeon, 1st U.S. Infantry Division (1st Infantry Division, 1945), https://achh.army.mil/history/book-wwii-huertgenforest-1stidsurgeon1944.
36. Ibid.
37. Ibid.
38. Ibid.
39. Rexmond C. Cochrane, The 1st Division in the Meuse-Argonne: 1–12 October 1918, Gas Warfare in World War I, Study Number 3 (U.S. Army Chemical Corps Historical Office, August 1957), 25–26, https://www.govinfo.gov/content/pkg/GOVPUB-D116-PURL-gpo91819/pdf/GOVPUB-D116-PURL-gpo91819.pdf.
40. FM 4-02, Army Health System, 1-7.
41. Ibid.
42. Ficicchy, Annual Report of Medical Department Activities.
43. FM 4-02, Army Health System, 1-8.
44. FM 3-0, Operations, 1-2.
45. Ibid., 3-6.
46. Army Techniques Publication (ATP) 4-02.2, Medical Evacuation (U.S. GPO, July 2019), 2-3.
47. Ibid., 2-38; FM 4-02: Army Health System, 2-25.
48. Ficicchy, Annual Report of Medical Department Activities.
49. Ibid.
50. Joint Publication 4-02, Joint Health Services (U.S. GPO, September 2018), II-5.
51. Ibid., III-21.
52. FM 8-10-3, Division Medical Operations Center Tactics, Techniques, and Procedures (U.S. GPO, 12 November 1996), 1-2.
53. Ibid.
54. Ibid., 1-4.
55. Medical Center of Excellence (MEDCoE) Pamphlet 4-02, Army Health System Doctrine Smart Book (Headquarters, MEDCoE, June 2024), 123–24.
56. ATP 4-02.55, Army Health System Support Planning (U.S. GPO, March 2020), 4-13.
57. Ficicchy, Annual Report of Medical Department Activities.

 

 

 

Back to Top

May-June 2025