Casualty Care in Combat – View on the Future

The 2018 National Defence Strategy showed that the global security environment and the nature of the threats that the United States must prepare for in future combat operations have changed.

Unlike counterinsurgency or counterterrorism operations of recent years, the Strategy prioritises the preparation for a large-scale, rapid interstate conflict. Potential adversaries – such as China, Russia, Iran and North Korea – are investing in long-range and precision missile systems that will enable them to launch major attacks against US forces at greater ranges and inflict greater casualties.

With these capabilities in the hands of US adversaries, defence planners, logisticians and senior US Department of Defense officials are exploring ways to increase the resilience of medical support for US forces in high-intensity conflict situations. Central to this planning is the Military Health System (MHS), which is responsible for both the day-to-day health insurance of service members, retirees and their families, and the care of US troops injured in combat.

What are the implications of these new threats for the care of those injured in combat, and is a reformed health care system ready to meet the challenge? There are several opportunities for the MHS to better prepare for the coming conflict environment, which may be different than in recent decades. The open source literature highlights several important considerations for MHS:

  • Are expeditionary medical facilities prepared to receive the expected number of wounded and provide the same level of care to military personnel as in recent conflicts?
  • Are units able to rapidly establish an expeditionary medical network to receive the combat wounded?
    Are current logistical and medical support arrangements adequate for future combat operations?
  • Is the MHS prepared to support a national defence operation in such a situation?
  • Will the industrial base of medical equipment be able to meet the demand for casualty care in the MHS?

Main Findings

  • The military health system needs a flexible and rapid response capability to treat the combat injured in a rapidly changing global threat environment.
  • Preparing for a potential conflict with a close adversary requires an understanding of the likely medical needs of the future battlefield – including injury types and casualty rates – following an attack using high-precision, long-range weapon systems and other advanced assets.
  • The military health system can improve its medical support system, but must assess and implement a range of mitigating measures, including:
  • Improving and expanding access to care for the injured at or near the site of injury.
  • A flexible, resilient and comprehensive network of treatment facilities, medical equipment storage facilities and transportation.
  • Adequate preparedness for defence and support missions.
  • A sustainable industrial base for medical equipment.

A vision for wound care on the battlefield of the future

Over the past decades, MHS combat casualty management capabilities have evolved to meet the medical support needs of the war zones in Iraq and Afghanistan. MHS has created a flexible and efficient healthcare network capable of stabilising, treating and evacuating injured soldiers quickly. It has proven successful in treating patients injured in the line of duty and limiting human casualties.

However, this medical base relies on relatively light patient loads in an environment where US forces had air superiority, allowing them to safely evacuate patients to a higher level of care if necessary. These assumptions are inconsistent with many of the future large-scale combat operations recommended in the 2018 National Defense Strategy.

Adversary weapon systems, such as ballistic missiles and cruise missiles, can damage air bases in a combat zone and cause many more casualties per explosion than in recent conflicts. If large numbers of personnel are injured or killed, the ability of US forces to wage war will be significantly reduced.

Treating injuries and ensuring that personnel are able to return to work as quickly as possible is critical to maintaining operational capability. In addition, the ability of deployed medical support forces to stabilize and treat serious combat injuries is critical to the recovery and long-term sustainability of the force. However, the ability to treat combat casualties is only one part of the enhanced challenge.

An adversary with advanced weapons can directly attack key infrastructure that supports military mobility: for example, parked aircraft, airfields and fuel depots. Damage to or destruction of these assets could make it difficult or impossible for US forces to move freely in the battlefield and defend against an adversary.

This unstable environment could seriously affect the ability of the United States to evacuate wounded soldiers or deliver emergency medical supplies.

In future combat operations, the large number of trauma patients and lack of evacuation transport may quickly strain or exceed the capacity and capability of military medical support.

Evacuation to a higher level of care will depend on the nature of the injury, available capabilities and the medical care strategy

Improve treatment options at and near the site of injury

The current medical care paradigm has at least three significant limitations in the anticipated conditions of future combat operations that may limit access to quality care for injured personnel:

  • The ability of field hospitals to treat and sustain large numbers of combat casualties.
  • The ability to route patients, treat them, and quickly transfer them out of military mission treatment facilities (MTFs).
  • Ability to provide high quality care using the medical resources available in multinational centres.

However, there are a number of potential mitigating measures that the MHS could take to reduce constraints in one or more of these areas. For example, increasing the capacity of field hospitals by increasing the number of beds, operating rooms and intensive care units – and the nursing staff serving them – could increase patient throughput where it is most needed.

Training first responders to improve their ability to deliver life-saving interventions at the point of injury could improve overall treatment capacity. Combining flexible deployment mechanisms, such as autonomous drones, with triage strategies specific to mass trauma can speed patient care, improve patient condition, allow service members to return to duty more quickly, and reduce the need to evacuate casualties to a higher level of care.

With the high volume of trauma casualties, the resources of multi-hospital units in an expeditionary force are very limited. Given the current emphasis on speed and efficiency of patient movement in a multimodal transportation network, attempts to reduce congestion and improve care with a single mitigation strategy may create bottlenecks further down the care network.

For example, if first responders can save more lives at the scene of an injury, an already overburdened emergency department will have to take more severely traumatized patients. Therefore, several mitigation strategies must be chosen to improve the quality of care for those injured in combat.

Given that in the future combat environment, hostilities are likely to erupt within a short period of time, it is important to ensure that the expeditionary medical network and essential medical supplies are in place before the first wave of combat casualties require treatment.

Deploying medical resources in advance

During the Cold War, military planners also recognised the importance of having a robust network of prepositioned equipment in Europe to quickly establish the necessary assets on the ground.

Today, preparedness is nowhere near as robust, so medical planners face the additional challenge of revitalising the US military's global medical supply network. To do this, they need to consider issues such as what to store, where to store it and how to transport it to potential end-use sites. Locating medical equipment in areas where it is expected to be used can speed up its deployment and demonstrate that the US is ready.

However, there are costs associated with storage, stockpile surveillance personnel, replacement of obsolete or perishable stockpiles, and transportation of stockpiles and equipment. A detailed assessment is essential to weigh the pros and cons of prepositioning and determine the most cost-effective way to transport the material to its intended end use.

Improving the flexibility of medical logistics and support

Medical logistics and support play an important role in ensuring that service personnel have continued access to medical assistance during conflict. As the operational tempo of medical assistance accelerates, so do the logistical requirements. Expanding and adapting existing approaches may not be enough; anticipated needs and solutions will need to be revisited.

Many medical devices in storage have specific handling and maintenance requirements and need to be regularly inspected, repaired and replaced. HSM has a number of workforce options to support these activities, such as on-site maintenance and mobile maintenance teams, but could also consider civilian and contract labour savings.

In determining whether and when civilian staffing may be an option, medical planners should consider the need to use these care specialists to support contingency operations. MHS could consider partnering with other countries to help fill gaps in medical logistics and treatment support capabilities and to assist the U.S. military in procuring critical medical supplies, transporting patients, and providing medical equipment and personnel needed to treat U.S. casualties.

Medical logistics support depends on the ability to maintain information on the status of medical equipment: what assets are where, what inventory is on the shelves, and the condition of supplies and equipment. Reliable and sustainable information in conflict situations requires robust information systems and communication links.

Domestic preparedness

The MHS provides medical support to service members not only on distant battlefields, but also on or near U.S. soil, and these missions are no less challenging. Protecting the homeland from attack is a national security priority.

Given the adversary's desire to employ long-range precision weapons systems, Arctic bases have received increased attention because of their importance to homeland defense. However, the climate and harsh geography of these locations make military operations particularly difficult.

If US forces are attacked in the Arctic, extreme weather conditions will have a particular impact on planning for combat casualty care, whether it is receiving equipment, evacuating patients to a higher level of care, or providing trauma care at the scene of an injury. In addition, the generally small facilities in the region tend to have small clinics and a limited number of medical staff, which would be difficult to expand quickly and cost-effectively.

In addition, the number of victims returning from the Arctic or elsewhere may be so large that US military treatment facilities may be overwhelmed. Since World War II, the United States has failed to manage the large-scale displacement of war victims and the resulting problems of providing care along the way and allocating facilities and resources for their care and recovery.

Planning for such scenarios may require the Ministry of Health to consider new partnerships, information systems, training programmes and investment in medical equipment and supplies to mitigate potential gaps in care for the wounded.

Building a sustainable industrial base

If MHS has to provide medical assistance to large numbers of combat casualties, the demand for life-saving medical supplies may exceed the capacity of the industrial base to supply them. Under normal day-to-day conditions, industry is largely capable of supplying safe and effective medicines and supplies to relief networks.

However, the industry has been under great pressure to control costs, which limits production capacity and is particularly problematic when large quantities of cheap medicines, especially generics, are needed in emergencies.

To overcome these difficulties, companies have introduced safeguards such as cooperation with international partners with lower production costs and careful adjustment of production capacity to anticipated demand.

As a result, the capacity of the industrial base to increase production in the event of a significant increase in demand is limited. However, in the event of a large-scale crisis, it may be difficult for medical service providers to supply enough essential medicines to meet the needs of all patients.

Therefore, the MHS may wish to implement a number of mitigation strategies, such as allocating resources to encourage industry investment in manufacturing capacity, diversifying the industrial base, and supporting international partners to improve their quality assurance and control processes. These measures can reduce the risk of supply disruptions by promoting flexibility in industrial supply chains.


The future threat environment anticipated in the 2018 National Defence Strategy has significantly changed the operational vision of frontline units and the capabilities they will need in a conflict against a potential adversary. Medical and other combat support functions are facing an equally impressive paradigm shift.

MHS has several opportunities to improve its ability to treat the wounded in future combat operations, including mitigating measures to prolong treatment and enable more flexible troop return, flexible logistics and robust support.

It is important to recognise that no single mitigation measure – no ‘silver bullet' – will significantly improve the performance of expeditionary medical assistance in anticipated future conflict scenarios.

It is therefore important that the MHS continues to explore combinations of mitigation measures and assess the overall cost and effectiveness of each mix of options. This will enable the MHS to better perform its assigned tasks, ensuring better support to soldiers both at home and in combat.

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