Large-Scale Combat Operations Will Bring New Medical Ethics Challenges
As the U.S. military prepares for an era of large-scale combat operations, the “golden hour” as medics know it is dead. So long as near-peer adversaries can create anti-access/area denial zones that threaten ground and rotary wing medevac units, they will not be able to get servicemembers to Role 2 surgical care within an hour after the injury.
The result will be more casualties. With initial estimates from warfighter exercises suggesting casualty rates as high as 55 percent in future conflicts, the current military medical system, regardless of service, will quickly become overwhelmed. The Center for Army Lessons Learned reached the same conclusion based on the experience of a brigade rotation at the National Training Center. During the last 20 years of conflict, the statistical category “died of wounds,” which measures those who were killed after reaching a medical treatment facility, has rarely even been discussed due to high survival rates. In Ukraine, however, this category has returned.
Large-scale combat operations will bring new ethical dilemmas to combat casualty care. The real potential exists for medical logistical needs to outpace the availability. Contested air environments will deny freedom of movement, and dedicated medevac units will need to say no to requests for evacuation. Finally, the pure volume of casualties will require difficult decisions be to made. There will be a shift from years past when we treated all casualties to deciding who is treated and who does not receive limited resources.
The way of warfare will fundamentally change from irregular warfare with infinite resources to high-intensity conflict with limited capabilities. Creative solutions will be necessary to ensure timely logistical support. Evacuation will shift to platforms of convenience, potentially supplemented with autonomous vehicles. Low-tech solutions can be taken from 1943 North Africa, such as loading casualties in trucks and continuing forward while treating soldiers on the move. Finally, training on the concept of “reverse triage” — treating those who might not be the most severely wounded but rather those that can most quickly be returned to the front — should be socialized and introduced to training plans.
Movement, Evacuation, and Logistics
Even in conflicts against non-peer adversaries, U.S. logistics and movement have been subject to interdiction. The Viet Cong cut supply lines across South Vietnam during the Tet Offensive. Somali fighters restricted the movement of convoys of Rangers and soldiers by blocking roads with burning tires. A near-peer adversary will have access to far more complicated means to restrict movement, from tactical nuclear weapons that could make certain areas of the battlefield inaccessible, to concentric and overlapping fields of antiaircraft or theater ballistic missile systems. Drones and real-time intelligence, surveillance, and reconnaissance will put actions such as movement, resupply and the evacuation of casualties at risk.
When bogged down with hundreds of casualties, the ability to move treatment units (such as battalion aid stations, treatment companies, or fleet hospitals) along main supply routes with the forward line of troops may well become impossible, further complicating care. Many NATO Role 3 medical units (those with hold capability) lack the organic transportation assets to move 100 percent of their units. For instance, per the 2023 Army Health System Doctrine Smart Book, a current 240-bed hospital center requires 46 C-17s to enter theater. To get a 32-bed early entry hospital on the ground requires 13 C-17s. For transport by ground, the full hospital needs 50 rail cars or more than 100 commercial trucks. The U.S. Air Force theater hospital’s 58 beds, in turn, require 104 pallets and six C-17s to get into theater, still a significant lift when competing with a combatant commander’s need for rockets and food. Further complications will arise when Role 1 facilities need to follow the forward line of troops. What happens when the battalion aid station needs to jump to the forward line of troops and casualties are taken while they are under way, especially if communications are degraded against a near-peer adversary?
Lack of air superiority coupled with anti-access/area denial will foster a dependence on ground-based evacuation systems, both manned and autonomous. However, these too will be degraded. A 19-year-old Fleet Marine Force corpsman, faced with a potential of 50 percent casualties, may have to decide which casualties are loaded and which will die. Main supply routes clogged with casualties flowing back and supplies flowing forward will limit the effectiveness of autonomous systems such as the Squad Multi Equipment Transport casualty evacuation platform employed by the Army and Marine Corps. Those same clogged roads will also present a robust targeting opportunity for a near-peer adversary.
Another example of potential difficult decisions arising from medical logistic shortfalls comes from the 1991 Gulf War. A General Accounting Office report on the topic discusses shortfalls in medical supplies that occurred during the conflict. All 10 hospitals reviewed for the study experienced medical supply shortfalls. This included oxygen, morphine, antibiotics, plasma, reagents necessary for laboratory tests, flu vaccines, and antibiotics. Pharmaceuticals and reagents are notoriously expensive and frequently expire before use in field units. Additionally, they can lose efficacy if not kept in environmentally controlled conditions.
While some might relegate the lessons of Desert Shield to a bygone era, medical logistics remains a significant issue today. Even civilians often wind up short of medical logistics. When adversarial forces seize family medicines, ambulances, supplies, and facilities, the civilian populace is left with few options. In the early years of the wars in Iraq and Afghanistan, locals seeking medical aid at front gates was a common occurrence. Failure to provide medical resources that are perceived to be plentiful but that are in actuality limited can help fuel insurgency. Even Ukraine, which is currently the beneficiary of a worldwide effort led by the World Health Organization, has seen shortages of medical supplies.
Within the U.S. military, there is growing concern about the ethical challenges of future conflicts. Surgeons, fleet corpsmen, medics, pararescuemen, and nurses have grown accustomed to saving lives, not losing them. Large-scale combat operations will put medical professionals in a very uncomfortable space, deciding who lives and dies. A nonpermissive environment that limits medical resupply will lead to rationing of treatment and use of medical supplies and drugs.
As I saw personally during the initial push into Iraq in 2003, the forward elements of the 86th Combat Support Hospital faced a number of difficult decisions. With limited medical supplies and only a 32-bed slice of the hospital, the small team quickly became overwhelmed with U.S. and Iraqi (civilian and enemy) casualties. Those who were shot or wounded with shrapnel required a tetanus shot, and the leadership and team had to decide which servicemembers and civilians received the very limited doses available. In the end, Iraqis were given tetanus shots, as a well-established evacuation chain ensured U.S. casualties could receive the necessary tetanus vaccination while being evacuated or upon reaching a stateside facility, while the Iraqis had no such support. This example of unpopular but ethical decision-making hints at what medics and others may face in the future, with life-and-death implications.
Returning soldiers to the fight as quickly as possible will be critical to winning the next battle. Of the over 10,000 documented cases in the Joint Trauma Registry from January 2007 to mid-March 2020, 37 percent returned to duty within 72 hours without evacuation from theater. Similarly, it may become necessary at times to have a patient with a low acuity injury who is already being evacuated carry the litter of a more severely wounded patient. The U.S. military should consider assigning servicemembers who are wounded to replacement companies, as was often the case during World War II.
Triage is derived from the French word “to sort” and has been a mainstay of military medicine in perpetuity. The process helps determine which casualties are treated first during mass casualty scenarios to save the most lives. It is founded on the ethical principle of benevolence, doing the most good for the most people. According to the Army Emergency War Surgery manual, “immediates” — those with a condition that is salvageable if they are treated expeditiously — are traditionally treated first. They normally comprise 10 percent of the wounded, and might include someone with an improvised explosive device blast wound that requires immediate surgical intervention or a gunshot wound to the torso. Such procedures could take significant medical materials as well as multiple hours of surgeons’ finite time.
Following immediates are “delayed,” those who, if not treated in a timely manner (24 to 48 hours), could progress and become “immediates.” “Delayed” require less surgical time and normally comprise 30 percent of casualties. “Minimal,” those who need scarce resources, comprise the bulk of casualties, roughly 50 percent. These people may be able to go days without significant treatment or might even be returned to battle. Traditionally, “expectants,” those who are not anticipated to be able to survive wounds, constitute less than 10 percent of casualties and receive no treatment, just comfort measures.
The most unorthodox process being quietly discussed is that of “reverse triage.” If faced with several hundred casualties from a hypersonic missile strike, should immediate patients be left to expire so medical personnel can save the larger percentage of “delayed” before running out of medical supplies? While a foreign concept over the past two decades, “delayed “casualties (often referred to as walking wounded) might be treated and immediately returned to the front lines. The first rule of tactical combat casualty care is to return fire, take cover, and establish fire superiority. The same should be considered at an operational and strategic level. These are questions the medical community is currently struggling to come to terms with.
The first step toward addressing these challenges is establishing clear expectations about future casualty rates with leaders from the squad level to the military corporate level. Company commanders from Iraq and Afghanistan are now battalion and brigade commanders accustomed to survival rates north of 90 percent. The author had the privilege of speaking with the U.S. Army First Corps’ surgeon following Talisman Sabre 23, a joint service, multinational exercise that predicted 8,500 casualties over 18 days or 1,000 casualties over 3 days among 30,000 servicemembers. That is a projected casualty rate of roughly 30 percent.
Army Techniques Publication 4-02.2, Medical Evacuation, establishes the evacuation categories of “urgent/urgent surgical,” “priority,” and “routine.” These roughly correspond to the common triage terms of “immediate,” “delayed,” and “minimal,” respectively. Lessons from Talisman Sabre 23 indicated the need to focus on saving the 30 percent delayed casualties as opposed to the time-, surgical bed–, and material-intensive 10 percent immediate casualties. In theory, this allows the medical force to save three times as many patients. Urgent (immediate) are defined as “emergency cases that should be evacuated as soon as possible and within a maximum of one hour in order to save life, limb, or eyesight.” Most urgent casualties will perish before reaching surgical care in the prolonged evacuation timelines and relatively scarce medical resources of the large-scale combat operations battlefield. Burying our heads in the ground and hoping for the best is not a method, it’s a recipe for disaster. The concept of reverse triage should be socialized and introduced to training plans.
On a more tactical level, this will require a shift in training frontline medics and caregivers on who they treat first. Given the anti-access/area denial threat and the inability to clear casualties from the battlefield to surgical facilities, prolonged field care move from a concept to a necessity. Since line medics are often limited to whatever supplies they could carry on their back, is it time to consider having each servicemember include one liter of intravenous fluids and the supplies to start a line to their ruck? This would allow for rehydration in the days following injury during prolonged field care. It would be similar to the past practice of designating soldiers to be responsible for carrying drugs to treat the medical effects of nuclear, biological, or chemical attacks, commonly known as the “Mark 1” kit. For those providers accustomed to running fluids wide open (fast), or keeping veins open (slow), longer evacuation chains make the ability to calculate fluid rates more important in order not to bust clots open and prevent hypotension and hypothermia.
Walking blood banks and the Ranger O Low Titer programs were developed as a solution to the need for frontline blood during low-intensity and counter-insurgency operations. These operations involve having support individuals not engaged on the battlefield available to transfuse others. In contrast, large-scale combat operations will need a new solution set, as donors will not have days to recover, and everywhere from the forward line to corps support areas may be held at risk. Walking blood banks have their utility, especially in an irregular warfare, forward operating base construct. But this doesn’t mean they will be able to play a role in future wars, as high-intensity conflict will require nearly all servicemembers be involved in the fight.
Logistics and timely resupply will also be important, raising a number of questions policymakers should begin to think about now. Modern aircraft have significantly more range than those of World War II. If fighting a near-peer adversary in the Pacific, where anti-access/area denial may be common, is the airdrop of medical supplies a viable option, as rehearsed in Mobility Guardian? Can medical logistics be delivered by unmanned medevac drones that are sent in to extract casualties? How could over-the-shore logistics reach the front line in large-scale combat operations? Finally, in order to bring higher numbers of casualties home, would a medical draft, in conjunction with the activation of the National Disaster Medical System, be necessary?
Large-scale combat operations will require a significant paradigm shift from past conflicts. Commanders should anticipate higher casualty rates and prepare accordingly. What will not change, however, is the medical maxim of doing the greatest good with limited supplies, so that others may live.
Michael Wissemann has been in the Army for 25 years and has served in a plethora of positions from the bedside to the field to the command suite. Many of the scenarios or examples provided in the text are the author’s firsthand experience from crossing the berm in Operation Iraqi Freedom 1. He currently serves as the deputy commander for nursing and chief nursing officer of U.S. Army Medical Activity–Bavaria. The views expressed are the author’s alone and are not representative of Army Medicine, the Army, or the Department of Defense.
The author would like to thank Col. Jay Baker, U.S. Army First Corps surgeon, for his contributions.
Correction: This article was updated to remove a quote that was taken from an off-the-record event.