Opinion: The risks of prolonged casualty care for conventional forces in large-scale combat operations

The military must recalibrate and expand its focus to mastering Tactical Combat Casualty Care.
prolonged casualty care prolonged field care
U.S. Army Sgt. 1st. Class Garrett Rogers, right, and Sgt. 1st. Class Justin Gavit, tend to a simulated casualty during a Prolonged Field Care event as part of the Regional Health Command-Atlantic 2021 Best Medic Competition at Fort Bragg, North Carolina, Nov. 17, 2021. (Spc. Rhianna Ballenger/U.S. Army)

The 2018 National Defense Strategy directed the services to transition from a training posture focused on counterinsurgency (COIN) and irregular warfare (IW) operations as seen in Afghanistan, Iraq, and Syria, to a posture focused on multidomain operations (MDO). Then, a subsequent focus in addition to MDO has largely been on future large-scale combat operations (LSCO) against a near-peer. While the term “near-peer” (or peer-peer) is often unspecified, it has typically been used in reference to China and Russia

In February 2022, when Russia invaded Ukraine, the world witnessed how a modern conflict with a near-peer could unfold. Although real-world MDO scenarios have previously been described, there is angst in the military community regarding the overall response to large-scale combat operations and how the medical system will continue to provide care that, over the last two decades, has resulted in the highest survival rate in history.1

The Prolonged Casualty Care (PCC) construct of “hold and treat” as a standard approach is inappropriate for application in large-scale combat operations and multidomain operations since its requirements for manpower, equipment, and periods of immobility pose undue risk to the survival of healthcare personnel and their patients alike. The military must recalibrate and expand its focus to mastering Tactical Combat Casualty Care (TCCC) foundational skills, investing in research and development that principally enhances Tactical Combat Casualty Care-level capability and leveraging all the doctrinal echelons of care to stabilize and evacuate patients. This will simultaneously optimize casualty outcomes while providing greater freedom of maneuver to the fighting force in future combat operations where maneuver and attack capabilities will dominate the decisive actions. 

Prolonged casualty care should be recalibrated and defined as Basic Aid Station (BAS) care and provide guidelines and protocols that will allow the medical provider in an austere setting the recommendations to provide the best survival for those severally wounded casualties that need immediate advanced care before being evacuated to an MTF with surgical capability. The current TCCC guidelines provide care that is beyond the capability of many enlisted medical personnel and should remain the standard of care for those at the point of injury (POI).

The US military has enjoyed nearly total uncontested air superiority in every major combat operation since World War II. In the future, they will not have that luxury. As such, the US military medical community has invested substantial resources into combat casualty care and continues to plan and assess the need for resource-limited settings with prolonged holding times well outside of doctrinal timelines, but more importantly, outside the realm of feasibility for optimal clinical care during combat operations. 

Combat casualty care remains focused on the most common causes of battlefield death from potentially survivable injury which was identified by Eastridge et al. in 2012 after a large mortality review from 2001 to 2011. Most deaths from potentially survivable injuries were secondary to hemorrhage, airway compromise, and pneumothorax. To mitigate the risk of death, there was an intense systematic focus on the expeditious identification of patients with actionable surgical pathology and rapid transport to surgical capability.2 Foundational to this system executing effectively is effective Tactical Combat Casualty Care.  

TCCC is a critical, fundamental, and baseline capability for all permutations of battlefield medicine. That said, LSCO poses an additional challenge because rapid transfers to definitive care, which occurred in the recent permissive transport environments in Afghanistan and Iraq will unlikely be feasible. This has prompted a new fervor, and a large volume of speculation, examining the potential realities of caring for casualties for prolonged periods with minimal resources and a lack of clinical intensive care expertise. Many of the implications of this care environment have not been considered concerning overall feasibility, clinical outcomes, and the impact this might have on casualty care as well as those provisioning prolonged casualty care. 

Keenan et al, initially described “prolonged field care” (PFC), primarily with a special operations forces (SOF) focus on the austere settings within US Africa Command.3, 4  However, in recent years, the US Army’s medical community has adapted the applications of SOF PFC for LSCO; PCC includes all the principals of PFC but is directed toward conventional forces. While Keenan did not explicitly specify the PFC meaning, the definitions generally refer to the provision of field care without a surgical capability for periods up to 72 hours and it is this definition we use in this paper. In this paper, the focus is on prolonged casualty care scoped and scaled for general military medical applications.

The PFC practice is broadly applicable to the Advise-Assist and occasionally Advise-Assist-Accompany-Exploit missions in the US Africa Command area of operations (AFRICOM). To the extent that direct actions do occur, they are generally against a relatively untrained, unequipped target. It is a low-intensity, IW conflict dispersed over a vast region with little advanced medical support,5-7 hence, the need for a prolonged care treatment medical model.8  PFC acknowledges this and attempts to mitigate the effects of delayed casualty evacuation by equipping highly trained forward medical teams with advanced capabilities (knowledge, skills, resources) to temporize patient care until a higher level of clinical care can be reached.

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Like PFC, prolonged casualty care in the MDO environment accepts a delayed evacuation paradigm and necessitates bringing the casualty to a forward resuscitative care and medical management location. While surgical teams have moved far forward in recent COIN operations, there is less enthusiasm about positioning surgical teams far forward in the future MDO environment due to the risk of losing surgical capabilities in a highly lethal environment as well as the feasibility of dispersed operations and the number of surgical teams in the inventory.  

For this article, the terminology is intended to separate the SOCOM-specific PFC for the austere settings of AFRICOM and similar environments from that of prolonged casualty care being conceptualized and envisaged for conventional units in each of the services. To lay out this argument appropriately, and to outline the clear risk that service medical departments are taking with the prolonged casualty care concepts, the following assumptions are made:

  1. Prolonged casualty care applies to conventional forces
  2. The prolonged casualty care concept arose secondary to the challenges of LSCO in MDO with the intent of decreasing morbidity and mortality from survivable injury
  3. TCCC remains paramount to saving the most lives on the current and future battlefield and the services adopt, embrace and train on TCCC principles

To this end, we opine the following:

  1. The prolonged casualty care model does not fit within the framework of the MDO/LSCO operational tactics and logistics to optimize battlefield survivability
  2. Prolonged casualty care is not achievable from a Military Healthcare System (MHS) delivery perspective in the current construct of the MHS
  3. Prolonged casualty care training is taking precedence over TCCC training, and TCCC training is foundational and fundamental to any subsequent care on the battlefield, emphasizing PCC training over TCCC training demonstrates a clear lack of understanding of proven life-saving principles and a disconnect from the realities of trauma care delivery and it comes at the expense of core training of TCCC where skills remain suboptimal
  4. Research and development of knowledge and material solutions will be unable to close these capability gaps

Rather, we propose that the development and training efforts focus on highly-mobile solutions that clear the battlefield in a timely fashion, and thus an emphasis on en route care. While the discussion here applies to all the services, we are generally taking an Army-centric view as the Army is likely to bear the brunt of future LSCO ground actions.

The incongruence of prolonged casualty care and multidomain operations

The conflict between Azerbaijan and Armenia in Nagorno-Karabakh provides a historical context and insight into the nature of contemporary MDO. This conflict entailed the widespread use of unmanned aerial technology as part of conventional military operations to win a decisive action. This allowed the Turkish-backed Azerbaijani military to dominate the Armenians who were left relatively defenseless as chronicled in Colonel (ret) John Antal’s newly published book, “7 Seconds to Die.”  The title refers to the seven seconds Armenian Soldiers had to flee once they heard the loitering munition overhead before the devastating strike occurred. The ongoing Russian war against Ukraine highlights drone surveillance and attacks are not unique to the conflict in Nagorno-Karabakh and are likely to characterize all future warfare.9

During the Nagorno-Karabakh conflict, well-trained and well-equipped Azerbaijani forces utilized loitering munitions, autonomous and semi-autonomous capable drones, and advanced intelligence-surveillance-reconnaissance (ISR) to devastating effects. In particular, the Turkish-made Bayraktar TB2 and the Israeli-made Kamikaze drones rapidly closed kill chains. With this technology, the Armenians experienced attacks with little advanced warning with highly-capable, highly-destructive weapon systems. The repeated attacks led to severe degradation of morale as soldiers stopped coming to the aid of injured troops knowing that the next major strike was en route towards the areas of dense signal.  

Moreover, the advanced ISR ensured a broadcast of the destruction in near real-time on social media and news networks creating never-seen-before levels of psychological operations. Similar tactics are being employed on a vast scale in Ukraine, by both combatants, leading to casualty numbers and destruction of material and infrastructure not seen since the Korean War and WWII.  This underscores the critical need to modernize our (Army) deployed health system to ensure our medical forces are capable and ready to meet the challenges of the future battlefield.

These features of modern warfare have profound implications for casualty care. Medical teams require equipment, extensive power, and medical personnel, and will likely have to maintain casualties for prolonged periods in austere settings given the challenges of rapid aeromedical evacuation in these environments. Taken together, casualty care entails unavoidable immobility rendering healthcare personnel susceptible to attack. This is particularly true for the equipment required for combat casualty care at Role 2 and Role 3 MTFs including ventilators, surgical equipment, warming, and monitoring.10, 11  

However, the Role 2 and Role 3 missions are better described as prolonged holding as opposed to the original meaning of prolonged casualty care. This technology creates both electromagnetic and thermal signals that are nearly impossible to mask from enemy technology as seen in Azerbaijan. Presumably China, and certainly Russia and Ukraine, have capabilities equal to or greater than Azerbaijan.  

While the Geneva Convention may prohibit knowingly striking medical assets, the current conflict in Ukraine highlights what little regard potential adversaries have for the laws of armed conflict. In such a conflict, the force with superior maneuver and fires capabilities will win the decisive action. Prolonged holding at Role 2 or 3 MTFs is largely antithetical to effective maneuver which is why the concept of prolonged casualty care – or moving this level of care to the prehospital/R1 environment – was conceptualized. The challenge is that the resources and expertise to manage ICU-level patients do not exist at this level of care in the deployed trauma system. In previous conflicts, casualties were moved out of theater, to what might be considered a Role 4. The idea of reversing the process is absurd and illogical. It is a model based on keeping casualties far forward in a signal-dense area ripe for loitering munition and drone attack.  

Areas dense in casualties are immobile and create easy targets for enemy action. Even if they cannot understand the encrypted signals, the mere presence of a signal makes for a target-rich environment. In paraphrasing Antal, what you can see you can hit, and what you can hit you can kill. Additionally, prolonged casualty care results in combatants providing care to fellow service members instead of actively engaging the enemy, thereby decreasing combat end strength. Similarly, surgical capability must be highly mobile, and de-emphasize patient hold in forward locations. Concepts such as rolling stock platforms for forward resuscitative surgical detachments which allow rapid set up and tear down and unmanned evacuation, such as drone-based evacuation, need further development.12  

Such a transition from the prolonged casualty care model to a model of mobility and evacuation is desperately necessary to achieve dominance in future MDO operations. The PCC expansion and adoption by conventional forces is a suboptimal course of action and should not be considered part of mission planning as a reliable option. We instead recommend expanding evacuation speed and capabilities. In LSCO, mobility is paramount to ensure survival given widespread sensors (attended and unattended) and increasingly lethal and accurate long-range precision fires.  Essentially, forward medical units must be as mobile as artillery or infantry to survive the modern battlefield. We now expand upon this argument against the widespread adoption of PCC based on tactical disadvantages to which this health service support model leads.

Additionally, a combat unit with a substantial percentage, or any percent for that matter, of its personnel requiring prolonged casualty care will be rendered combat ineffective as an excessive amount of effort will be focused on patient care. To maintain the ability to engage the enemy a combat unit must be promptly relieved of the need to provide casualty care. Moreover, if the combat units aggregate all their casualties, the electronic profile of an immobile medical holding area potentially creates a target for enemy weapons in an operation where mobility dominates, which is particularly concerning in less ‘noisy’ areas. 

The logistical requirement to support operations where equipment and supplies are a limiting factor for movement demonstrates a gap in this framework. This is the reason that MEDEVAC’s primary mission is “clearing the battlefield.” DoD labs should pursue efforts to develop novel pharmaceutical and technological approaches to improving casualty survival during evacuation and upon arrival at definitive care. Rapid fielding of improved and simplified bundles of currently available care for resuscitation, hemorrhage control, wound care, and pain management are urgently needed to enhance survivability during prehospital management. 

Finally, we contend that current efforts should be focused on training TCCC (e.g. treatments centered around the MARCH algorithm) and developing capabilities to rapidly evacuate casualties despite a lack of air superiority.13 Potential solutions include unmanned aerial vehicles, ground-based evacuation, MASCAL evacuation teams, and forward deployment of highly-mobile physician/surgeon-led combat casualty care teams.

To this end, we must highlight the dissonance between the message of what is proposed in prolonged casualty care, and what is propagated through doctrine documents. The message that is frequently conveyed seems to be one of the 68W needing to focus on the care of complex casualties for up to 72 hours with little support and resources. This directs attention away from the core training needed which focuses on TCCC. Conversely, recent doctrine documents do acknowledge the inherent risks associated with this model from a patient care perspective and a tactical perspective.14 While we contend there may be the need to care for casualties during times of no evacuation, this must be viewed as the last resort rather than the primary or even alternate plan. Moreover, we must continue to emphasize the need for a focus on training TCCC concepts as the centerpiece for training and equipping.

Army health system PCC capability gaps

Putting aside the required equipment and logistical support, the skillset required to care for a casualty for up to 72 hours without surgical capabilities is distinct and much broader in scope than that required for initial Tactical Combat Casualty Care (TCCC); which is still not trained to standard across the force nor is it adequately sustained. 

The required logistical support is a different problem set. This becomes apparent when examining a representative example of the flow of a casualty from POI to the most definitive care available in a theater of operations. Casualties first enter the chain of care by contact with a combat medic/corpsman trained to the level of Emergency Medical Technician (EMT) per the National Registry of Emergency Medical Technicians with additional trauma training.  Medics at this training level will treat the patient from POI until arrival at an emergency department (ED). While the Army is seeking to push critical care and flight-certified paramedics to the force, we still lack sufficient numbers to staff force-wide.  

Once patients reach the ED, casualty care teams typically consist of an emergency medicine (EM)-trained physician, an EM-trained nurse, and a team medic. The EM physician has four years of undergraduate education, four years of medical education, three years of residency training (apprenticeship), and then experience through routine clinical practice. Furthermore, as part of residency, they are required to lead 45 adult medical and 35 adult trauma resuscitations, perform 20 central lines, 10 chest tubes, three cricothyrotomies, 10 dislocation-reductions, 150 clinical ultrasounds with interpretation, 35 intubations, and 15 procedural sedations, along with several other less combat-relevant procedures.  

The EM nurse has four years of undergraduate training, six to 12 months of on-the-job training, and then experience through routine clinical practice. Assuming no surgical care occurs, after evaluation using imaging likely to include point-of-care ultrasound and plain radiography, casualties will then progress to the intensive care unit (ICU). The ICU physician has the same number of years of education as the EM physician with an additional 2-4 years of critical care training. The ICU nurse training mimics that of the EM nurse. Comparatively, combat medic training has 16 weeks of initial entry training with one week per year of required refresher training.15 

Regarding the actual skills required to care for a critically injured patient, a very general overview will include hemodynamic stabilization with interpretation and treatment of vital sign trends, interpretation of a myriad of laboratory studies that will guide the interventions, maintenance of acid-base status, and an advanced understanding of physiology and quantifying the severity of physiologic derangements.

To that end, it may be an overstatement to claim that the prolonged casualty care construct requires combat medics to achieve a level of clinical proficiency commensurate with that of physicians and nurses.  Such an end-state is simply not achievable and thus such a comparison could be construed as a strawman argument. However, if we accept that the same level of care is an end-state we cannot reach, realistic risk assessments must be available to commanders, and commanders need to be willing to accept such risk if incorporating the PCC model into their mission planning.  

The proposed Prolonged Care Augmentation Detachments (PCAD) may serve as a reasonable in-between stop-gap measure, as these center around the inclusion of medical officers to perform similar duties as they do in the hospital setting, and thus skills attainment and sustainment are achievable metrics.  In practice, the use of a PCAD team led by a medical officer would result in the implementation of their routine critical care skills in an austere environment outside of the hostile area without the intent of providing such under direct threat (e.g. Role 2e, Role 3).

This could take place near the POI, however, in a large-scale combat operation, more traditional evacuation roles would likely be in place. Whereas the battalion aid station (BAS) would be more mobile and with the command element. Casualties would be evacuated to the BAS where it would be staffed with a physician assistant and/or physician. In addition, additional support from combat medics/corpsmen would provide care in an austere version of the ED. While not the ED, the BAS presents a more logical and realistic version of prolonged casualty care that is being sold to the masses. 

Implications of prolonged casualty care for TCCC

Of course, the importance of prolonged casualty care is only applicable insofar as casualties have adequate TCCC in the front end of their care. TCCC is foundational and fundamental for successful PCC. It always comes first without exceptions and therefore should be trained as such. In other words, without a solid foundation in TCCC, PCC will become a moot point as casualties will not survive long past POI. Currently, prehospital medical care in the deployed military setting lacks robust TCCC. 16,17  

Consequently, shifting focus to prolonged casualty care on a widespread scale is not currently feasible and competes with the TCCC training.  Moreover, the shift in focus to the PCC skillset detracts from the limited time to train TCCC. There is significant confusion among enlisted medical personnel as to what belongs in TCCC versus PCC. We will illustrate a few examples here focusing on simple interventions – analgesia, tranexamic acid (TXA) administration, and combat wound medication pack administration.  

Two previous studies evaluating analgesia administration under TCCC guidelines found that almost half of all casualties received no pain medications, and as few as 17% were within contemporary TCCC guidelines.16,17 In another analysis evaluating TXA administration, we found that only 1-5% of eligible casualties received TXA prehospital.18  In another analysis evaluating combat wound medication pack administration – an intervention for which even self-administration is possible – we found that <1% of casualties received this intervention.19 If documentation serves as a metric of care, these studies show that we are also lagging at this task as well.20-22 

Another study examined baseline skillsets for combat medics with cricothyrotomy and supraglottic placement. Unexpectedly, we found that many of the medic participants were uncomfortable and unprepared to perform these two procedures, even in a simulation setting.23  This finding was so pronounced that we had to completely rescope the project to a new methodology that included structured training before using any of the devices. Considering this, it is difficult to believe that in an LSCO scenario, conventional combat medics will be able to manage a ventilator, titrate blood products, and manage multiple complicated drug infusions.24

Currently, military physicians, surgeons, and nurses frequently struggle to maintain clinical currency and competency in trauma management given the lack of critically ill trauma patients presenting to most military treatment facilities. While the 2017 NDAA attempted to address this, thus far we cannot find any data substantiating a system-wide improvement. To address this challenge, hospital personnel seek off-duty employment, military-civilian partnerships, and robust live-tissue and simulation-based training despite full-time employment in a medical facility. 

Conversely, many military medics have limited patient interaction and are virtually never permitted to perform endotracheal intubation, tube thoracostomy, central venous line placement, blood transfusion, ventilatory management, vasoactive medication infusions, and other key aspects of prolonged casualty care.24 Military-civilian partnerships will not address this issue given that the civilian sectors often require independent nursing licenses or higher to perform many life-saving procedures and critical care. With failing as part of the process of learning, medics cannot be expected to be truly proficient at these skills through simulation-only skills development or glorified shadowing.

Proposed research and material solutions for closing capability gaps

Because of the lack of true understanding of the prolonged casualty care environment and the wider implications that LSCO will have on combat casualty care and overall combat end strength secondary to gaps in current capabilities, research should focus on:

  1. Doing more with less – providing clinical care in a resource-constrained environment
  2. Rapidly clearing the battlefield
  3. Optimizing return to duty adjuncts
  4. Provisioning en route care with low-profile evacuation platforms
  5. Optimizing our training and sustainment methods to ensure that maximal TCCC is delivered at the POI

Data from retrospective analyses demonstrate that conventional combat medics do not possess the skillset required to perform prolonged casualty care.25 Additionally, we believe that no current pathways exist for this population to achieve this requisite skill set. In particular, we do not believe available portable medical technology, on-the-job training, and teleconsultation would be sufficient to close the gap between what is necessary to care for a casualty in this setting and the current combat medic skillset. Moreover, due to challenges with civilian medical credentialing, the MIL-CIV partnership is also not a feasible method as most are only certified at the EMT level.

By and large, there has been a significant expectation that through the combination of training, clinical practice guidelines, and the development of technology, we will close the gap required to provide prolonged casualty care. That model entails several challenges. 

First, we currently lack well-defined requirements for reaching the endpoint we desire. This leaves scientists to their own devices to guess what the end-state is and develop data addressing that presumed end-state. The lack of specific requirements leads to an end result of disjointed efforts focused on multiple goals, which are often not well aligned. 

Second, the DOD has been investing in research related to PCC and PFC, by name, since fiscal year 2017. This includes the Defense Health Program funding, Congressional Directed Medical Research Program funding, Defense Health Agency funding, as well as service-specific intramural funding. As such, that means the DOD has been investing in PCC for over one-half decade as of the writing of this editorial. With that, there is no evidence that we are any closer to achieving the loosely defined endpoint of medics performing near-hospital-level care in remote settings. 

To that end, we take the position that the DOD R&D community should invest in carefully focused, transformational technologies, as well as near-term solutions, to be delivered by medics with TCCC skill levels that will enhance the survivability of casualties during prehospital care without the expectation that technology will fill an unreachable gap. In short, technology development should be weighted toward the enhancement of TCCC capabilities, rather than the provision of ICU care on the battlefield. To be sure, surgical and ICU capabilities at the Role 2 level also require investment, but clearly, the greatest gap in capability exists in the prehospital environment.

Potential solutions to increase battlefield survivability 

Rather than the “hold and treat” construct of prolonged casualty care, LSCO will require the MHS to instead embrace a paradigm of “rapidly stabilize and evacuate.” First and foremost, this will require a renewed emphasis on TCCC training at all levels of proficiency spanning from combat medic to physician. Military healthcare personnel must remain intensely focused on obtaining the critical skills for hemorrhage control and blood product-based resuscitation, followed by airway management and pneumothorax/hemothorax treatment. 

All personnel must also become well-versed and comfortable with triage protocols which may prove dynamic in the face of rapidly changing operational conditions. Indeed, in the most kinetic environments, healthcare personnel must be comfortable and facile with the use of reverse triage protocols to prioritize returning those troops who can return to duty on the front line to prevent further casualties.  

We must also develop the means to determine who remains unsalvageable and should not consume limited resources. The medical community must provide methods of training that will allow enlisted medical personnel to properly triage and not waste precious supplies and time on those that will die, regardless of treatment. The idea that no lives will be lost is a crutch instilled into the US military community over the last 50 years, most notably since the invasion of Afghanistan and Iraq. Research efforts and training must focus on wound management and pain control since this will facilitate returning soldiers to combat duty, optimizing their ability to sustain the fighting force. 

Next, the military must return to its historical role-based care. Casualties will no longer have the luxury of uncontested, direct movement to the highest levels of care available in theater. Role 1 facilities will once again become the frontiers of combat casualty care and the start of the casualty chain of survival.26 However, recent evidence from Ukraine and the Nagorno-Karabakh conflicts indicates we may need to rethink Role 1 from the older semi-fixed model into one that is also highly mobile. In other words, consideration for a more dynamic Role 1 which can clear the battlefield using a “treat and move” approach – picking up casualties along the way. This should be the medical equivalence of a highly mobile M777 battery.  

Conceptually this would require significant en route care which is a topic that does not appear to be a developmental priority for the Army. Optimizing casualty outcomes in these military treatment facilities will require training and technology to push blood far forward, improved hemorrhage control, and pharmaceutical options to mitigate shock and preserve organ perfusion. Thus, winning in MDO demands instead a model that focuses on increasing evacuation capabilities to clear the battlespace of immobile casualties that can no longer effectively fight. 

DISCLAIMER: The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. Army Medical Department, Department of the Army, Department of Defense, or the U.S. Government.


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