Military medevacs are facing a hidden emergency

The role of the Dustoff is sacred, enshrined in both the relationship between medical personnel and their patients as well as treaties that underlie the Law of Armed Conflict, but the practical concerns of providing medical care to troops under fire will be sorely tested in a war with a modern foe.

An Army air ambulance picks up a simulated Marine casualty during a 2018 exercise in Romania.

(U.S. Marine Corps photo by Cpl. Alexander Sturdivant)

Currently, the U.S. and most of its allies — as well as many of its greatest rivals — enjoy nearly unquestioned air superiority in their areas of operations and responsibility. So, a commander of a modern military force, whether they're Italian, French, Chinese, or American, can request a medical evacuation with near certainty that the wounded or sick person can be picked up quickly.

Even in active theaters of war like Afghanistan, wounded personnel can often be delivered to advanced medical care within the "Golden Hour," the first hour after injury when medical intervention will make the biggest difference between life and death, recovery, and permanent disability.

In one recent case, military personnel in Africa were able to save an Italian woman's life after she was injured in a car crash, thanks to collaboration between medical personnel from six nations, multiple ambulance services and air crews, and a doctor-turned-linguist.

But the advanced medical capabilities available across NATO and in Russian and Chinese forces rely on an evacuation infrastructure built for uncontested environments, where the worst threat to aircraft comes from IEDs and machine gun fire.

In a new paper from RAND Europe, defense analyst Marta Kepe dovetails recent speeches from military leaders, war game results, and scholarly work. They all point to a conflict wherein troops may have to wait days or longer for evacuation, meaning that providing care at the point of injury, possibly while still under threat of enemy attack, will be the only real chance for life-saving intervention.

Take the case of war with North Korea, a much "easier" hypothetical conflict than one with China or Russia. While North Korea lacks advanced air defense assets and electronic warfare assets, that simply means that they can't jam all communications and they likely can't shoot down fifth-generation fighters.

But medevacs rely on helicopters that, by and large, are susceptible to North Korean air defenses. Fly too high and they can be targeted and destroyed by nearly any surface-to air missile that North Korea has. Fly too low and infantrymen with RPGs and machine guns can potentially kill them.

North Korean weapons and aircraft, while outdated, are numerous — there are over 1,300 aircraft in the arsenal and widely deployed anti-air missile sites on the ground. It might take months to wipe them all out during an invasion, the same period of time when ground commanders would expect to take the most casualties.

An M113 ambulance drives through the Kuwaiti desert during a demonstration.

(U.S. Army)

And that's before the helicopters' traditional escorts in Afghanistan and Iraq, AH-64 Apaches that're armed to the teeth, are tasked for more urgent missions, like taking out air defense and artillery sites.

All this combines to form a battlefield where command teams will need to use ground ambulances and standard vehicles to get their wounded far from the front lines before they can be picked up, tying up assets needed for the advance, taxing supply lines that now have competing traffic, and extending the time between injury and treatment.

Some battlefields, meanwhile, might be underground where it's nearly impossible to quickly communicate with the surface or with air assets. People wounded while fighting for control of cave networks or underground bunker systems would need to be carried out on foot, then evacuated in ground vehicles to pickup sites, and then flown to hospitals.

The hospital ship USNS Mercy pulls into port.

(U.S. Military Sealift Command Sarah Buford)

And the closest hospitals might be ships far offshore since role 3 and 4 hospitals on land take time to construct and are vulnerable to attack. While deliberately targeting a hospital is illegal, there's no guarantee that the treaties would be honored by enemy commanders (Remember, Russia's annexations of South Ossetia and Crimea were violations of international law, as were China's cyber attacks and territory seizures in the Pacific).

All of which means that a war with North Korea would see tens of thousands of injured troops die of wounds that wouldn't have been fatal in a more permissive environment. A similar story exists in Iran.

But China and Russia would be worse since they have the assets necessary to shutdown American communication networks, making it impossible for ground commanders to call for medical aid. They're also more likely to be able to pinpoint signal sources, making it risky for a platoon leader to call for medical aid for wounded troops.

And China and Russia's air forces and air defenses, while not quite as large as America's, are much more potent and well-trained that Iran or North Korea's. They could likely hold out for months or years while inflicting heavy casualties to American air assets, preventing the establishment of a permissive medevac capability for even longer.

A 2016 analysis by RAND even postulated that China would be nearly impossible to conquer by 2025. The same weapon systems expected to protect China's mainland from successful invasion would make it nearly impossible to evacuate all the personnel injured while trying to effect the invasion.

Air Force special operators render simulated medical aid during an exercise at Fort Hood, Texas, in 2017. The ability for non-medical personnel to render aid under fire is expected to become more important in the coming years.

(U.S. Army)

There is good news, though. The U.S. military has acknowledged these shortcomings and is trying to lay the framework for what a medical corps in a contested environment should look like.

The Army is expanding it's "Tactical Combat Casualty Care," or TC3, program where combat lifesavers are trained in military first aid. DARPA is working on autonomous or remotely piloted pods that can fly medical capsules with supplies in or casualty evacuation capsules out without risking flight crews. The Marine Corps already has an experimental autonomous helicopter for logistics.

Beyond that is re-building medical units to perform work closer to the front lines. This is a return to the old days to a certain extent. The only dentist to receive the Medal of Honor earned the award in World War II while acting as a surgeon in a hospital overrun by Japanese attackers.

They could also be more dispersed. Instead of building a few large hospitals with large staffs on easily targeted installations, surgical teams and other care providers could operate in small groups. That way, if one or two teams are destroyed or forced to retreat, there would still be a few groups providing medical care.

In addition to more dispersed and forward-positioned medical personnel, there's room for expanding the medical capabilities of non-medical personnel.

In 2017, then-Maj. Gen. Paul J. LaCamera, the deputy commander of the XVIII Airborne Corps, suggested that the non-medical soldiers trained in first aid could be sent on rotations with civilian paramedics and other medical personnel that treat trauma victims, building up their understanding of medical care and their resilience.

LaCamera was promoted to lieutenant general and commander of the XVIII Airborne Corps in January, 2018, increasing the chances that his directions will result in actual policy changes. He's also the commander of Fort Bragg, North Carolina, where special operations medical personnel have been sent to local hospitals to train for years.

Historically, those types of rotations have been limited to medics and other specialized troops. Medical personnel, meanwhile, would see an increased number of rotations into civilian trauma centers in the U.S. and allied countries.

But the most important aspect of medical care under fire in tomorrow's war will be the same as it is today: Achieve and maintain fire superiority. The best way to open a window to evacuate your own personnel is by killing everyone on the enemy side wounding your troops and trying to prevent it.