How the Army is slow to meet MEDEVAC Challenges in the 21st Century
This timeline shows important milestones in Army MEDEVAC operations in the 21st Century. On the left side of the timeline are Army/Army Medical Department actions, and on the right side are important reports and challenges faced by Army MEDEVAC operations.
The history of the MEDEVAC units in the US Army is a long and proud one – filled with acts of courage and selflessness equal to those of any combat unit. The men and women of MEDEVAC units honor their unit’s legacy and predecessors in saving the wounded no matter what the circumstances. But from the beginning, there has been tension between the MEDEVAC branch under the command and control of the Army Medical Department (AMEDD) and the combat branch (later the combat aviation branch) of the Army. By the mid-2000’s the MEDEVAC units that had earned such glory in Korea and Vietnam and numerous conflicts since then were disbanded in favor of breaking up the independent MEDEVAC units under AMEDD and replacing them as companies under General Support Aviation Battalions in Combat Aviation Brigades (CAB).
Once the units were organizationally repositioned they lost their ability to maintain and service their own helicopters, and even the ability to determine when and how MEDEVAC flights would be flown. The CAB commanders were given ultimate control over MEDEVAC missions. The only remaining control AMEDD had over its helicopters was to prevent their diversion into non-MEDEVAC missions by maintaining painted Red Crosses on white backgrounds on every flat surface of the helicopters and keeping them unarmed. The AMEDD used the Red Crosses as a talisman to ward off attempts by CAB commanders to gain the last measure of total control of the aircraft.
This tension remains to this day. The AMEDD is willing to delay life-saving MEDEVAC missions, rather than remove the Red Crosses and then arm the helicopters for self-protection. The death of SPC Chazray Clark is but one example of when an armed helicopter (such as the available USAF Pedro Pavehawk helicopters) could have saved a life, but the mission was delayed waiting for an armed escort aircraft.
The following timeline illustrates other shortcomings in AMEDD leadership in addressing in a timely way issues that have been repeatedly highlighted in published reports as well as internal documents by AMEDD doctors and field level commanders, the British Royal Army Medical Corps, and NATO. The credibility of Army assurances in January 2012 that no changes are needed in MEDEVAC policies and procedures and that no officers have raised complaints is justifiable suspect.
IMPORTANT: Under no circumstances should the comments made here or elsewhere on this site be construed in any way as being disrespectful of the extraordinary men and women conducting MEDEVAC operations in Afghanistan. They are limited by rules, process, and procedures imposed upon them by their leadership in both the medical and combat arms branches of the Army. They perform heroic missions on a daily basis as they live by the code of “When I Have Your Wounded”, and “So That Others May Live”.
| US Army Action | Challenges, Reports and Other | |
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| PRE-2000 | ||
| Army accepts specs for the UH-60 Blackhawk helicopter despite warnings that the fuselage is too narrow to accept standard length NATO litters. A 600 lb. litter carousel must be designed to hold and rotate litters in the Blackhawk. Initial UH-60A MEDEVAC helicopters will not have nightime capability due to lack of FLIR equipment. | “The high density loading of three litter patients on either side of the cabin is used if the patients are stable and the crew needs only limited access to the patients.““FLIR is an extremely important capability, given that about 40% of MEDEVAC missions occur at night.” | |
| July 1992: “The AMEDD Center and School is receiving strong support from all levels of the Department of Defense in its initiatives to transition the entire rotary wing fleet to the (UH60Q model airframe), and b) acquire a high capacity air ambulance for the long range, 12-15 litter patient mission profile justified some years ago for the V22 Osprey.” | Tactical Combat Casualty Care (TCCC) – “Prehospital Trauma Life Support” enhanced medic training program created under Assistant Secretary of Defense for Health Affairs independent of AMEDD.
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| December 1994: AMEDD Enhanced Concept Based Requirements System (ECBRS) 96-10: “Modernization of the medical evacuation system is the US Army Surgeon General’s number one near term modernization priority…The MEDEVAC modernization strategy calls for immediate modernization of the helicopter fleet…The UH-60Q Medical Evacuation Helicopter is the highest priority…Plans call for each company of 15 UH-60Qs to be issued six FLIRs… Modernization of the MEDEVAC platforms is critical to AMEDD’s ability to support the Army on the future battlefield. American soldiers expect the highest quality medical care they are entitled to. The nation will accept nothing less.” | Article published in 1999 by Army doctors criticizing inadequate training of medics. Urge they be trained to the level of USAF pararescuemen – as EMT-Paramedic rather than just EMT-Basic. | |
| 2000 | ||
| 2001 | 12 KIA 33 WIA |
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| 6 MEDEVAC helicopters deployed to Afghanistan | The first edition of the “Ranger Medic Handbook” is published. | |
| 2002 | 49 KIA 74 WIA |
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MEDEVAC Proponent COL Scott Heintz: “As I collect the respective units’ After Action Reports I find it ironic that many of the issues detailed are the same ones presented during Operation Desert Storm and, no doubt Vietnam. Comments regarding things like:
These are critical and will be worked out through the Evacuation Integrated Concept Team.” |
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TCCC Casualty Card
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| 2003 | 48 KIA 99 WIA |
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| Planners for the Army’s upcoming Aviation Transformation consider MEDEVAC operations as fundamentally no different than any other cargo hauling aviation task. Also, there is a desire by combat aviation commanders to “rein in” the “type A”, “cowboy” MEDEVAC pilots. Cutting the size of MEDEVAC units is a foregone conclusion. The commission entertains cuts in helicopters from 15 to as few as 8, before settling on 12 helicopters per MEDEVAC unit. Units will be dependent upon GSAB resouces for all fueling, maintenance and repair of MEDEVAC aircraft. | ||
| 2004 | 52 KIA 218 WIA |
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| 2005 | 99 KIA 268 WIA |
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Army aviation transformation implemented:
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| 2006 | 98 KIA 400 WIA |
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| On 1 March 1996, the AMEDD Aviation Consultant’s position was moved from the national capitol region to Ft. Rucker, AL. The Director, Medical Evacuation Proponent Directorate will now have the additional duty as the Aviation Consultant. For many years the Consultant was assigned to the Army Surgeon General’s staff, but during the process of “right-sizing” the force, the position was eliminated. | ||
| 2007 | 117 KIA 750 WIA |
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TCCC First Responder Documentation Conference 2007:
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| 2008 | 155 KIA 795 WIA |
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| Army now flying 18 MEDEVAC helicopters in Afghanistan | ||
| Army reviews MEDEVAC policies and procedures; recommends no changes be made | US Army Center for Lessons Learned report states that policy deploying MEDEVAC units with only 12 medics leaves them inadequately staffed for 24 hour sustained combat conditions. | |
| Army assigns additional 6 to 8 ground combat medics to each deploying MEDEVAC unit | Ground medics do not attend nor graduate from flight medic course prior to deployment, and there is inadequate time to train prior to deployment. | |
| October 8, 2008: DEPARTMENT OF THE ARMY, OFFICE OF THE JUDGE ADVOCATE GENERAL, INTERNATIONAL AND OPERATIONAL LAW DIVISION renders an opinion to the Surgeon General of the Army/Commanding General of the Army Medical Department (AMEDD): “While the GSAB proposal to arm MEDEVAC helicopters and employ them temporarily as escort/support aircraft is not a violation of the law of war, as long as the aircraft does not engage in “perfidy,” this action would deprive the aircraft and crew of any protections available from the GWS [Geneva Convention].“ |
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| 2009 | 317 KIA 2143 WIA |
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| AMEDD publishes its first “Combat Medic Handbook” to replace the photocopied materials medic trainees previously received in lieu of a handbook. | The 7th edition of the “Ranger Medic Handbook” is published. | |
| November 2009 update on TCCC: “No preventable deaths in war to date documented by Rangers and Army SMU in 2009 – both units have been using TCCC from the start of the war” |
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| AMEDD publishes article calling benefits of the “Golden Hour” a myth | Secretary of Defense Gates demands MEDEVAC missions be completed within the “Golden Hour” standard used in civilian trauma rescue since the mid-1970’s. USAF Pedro CASEVAC helicopters assigned to fly MEDEVAC missions, especially low illumination missions. Army MEDEVAC helicopters lack the advanced FLIR capability of the Pedro aircraft. | |
| DoD Report shows wounded survival rate rose dramatically in 2009; correlated with decrease in median MEDEVAC mission time from 2 hours to one hour. | ||
| Army reverses 2005 decision and resets MEDEVAC units to 15 helicopters | USA Today article reports that Defense Health Board estimated that nearly 1000 battlefield deaths in the wars in Afghanistan and Iraq could have been prevented if TCCC curriculum had been implemented early in the decade throughout the Army. Army states that it hopes to implement TCCC starting early in 2010. | |
| Commanding Surgeon, TRADOC Urges adoption of trauma registry based on Ranger’s PHTR to assist in tracking Point of Injury (i.e. prehospital) care of the wounded. |
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| 2010 | 499 KIA 5242 WIA |
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July, 2010 AMEDD Journal article recommends:
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| 2011 | 418 KIA 5183 WIA |
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February 2011 After Action Report to CENTCOM enumerates significant system wide issues with MEDEVAC:
While there are significant system issues within Army MEDEVAC, these need to be addressed by the OTSG and the institutional AMEDD. Issues such as training, staffing levels, medical direction, protocol and equipment standardization, and patient documentation need to undergo significant examination and revision. This process needs to be directed by the highest authorities of the AMEDD, Army and DoD leadership to be effective. Conclusion: After more than 9 years of conflict and more than 40 after action reports recommending the evolution of MEDEVAC to current civilian standards, no institutional change has been made. Continuing the legacy model has resulted and continues to result in documented sub-optimal outcomes and increased deaths among patients transported by helicopter in the current conflict.” |
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| May 2011 Secretary of Defense Gates states: “In the course of doing everything I could to turn things around first in Iraq and then in Afghanistan, from the early months I ran up against institutional obstacles in the Pentagon — cultural, procedural, ideological — to getting done what needed to get done on behalf of those fighting the wars we are in, whether it was outpatient care for the wounded; armored troop transports; medevac; ramping up intelligence, surveillance and reconnaissance support; or any number of urgent battlefield needs.” |
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| July, 2011 An article is published in the Journal Trauma by Army medical trauma experts and a DoD forensic pathologist. They reviewed the cases of 558 soldiers who died of wounds after reaching medical treatment facilities in Afghanistan between October 2001 and June 2009. They classified 51.4% of the cases as “potentially survivable“, emphasizing the importance of improved prehospital care for the wounded – especially those with severe hemorrhaging. | ||
August ,2011 The Defense Health Board in a scathing 15 page report unanimously recommended major changes in “contingency planning, the choice and staffing of [evacuation platforms], response time, provider requirements, training and oversight, and documentation of care.”The Board’s findings included:
Pertaining to this issue, the Board Recommended: “Planning should aim to optimize evacuation time for all likely tactical contingencies.
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| Army disputes video evidence of SPC Clark incident. Claims everything was within standards on that MEDEVAC mission. | SPC Chazray Clark lays in LZ for 55 minutes waiting for MEDEVAC helicopter on the ground 1-1/2 mi. away. He dies minutes after arriving at medical treatment facility 10 minutes away from the battlefield. His wounds were serious but survivable. | |
| Army tells Congress that MEDEVAC helicopters cannot be armed due to Geneva Convention rules. | USAF and British forces have flown armed helicopters for MEDEVAC missions for years. (See Judge Advocate General favorable opinion in 2008 regarding arming MEDEVAC helicopters.) | |
December 2011 Articles are published in the Journal of the Royal Army Medical Corpsthat reported that:
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| 2012 | ||
| Official Army statements say that the Army reviewed MEDEVAC policies and procedures in 2008 and determined that no changes were needed. It continues to stands by that determination. It further states that since no ISAF or US officers have complained about MEDEVAC that validates the position that no changes are needed. |  The chart shows the annual combined number of WIA and Deaths in Afghanistan from 2001-2011. Everything up to the fourth bar from the right is what the Army based its determinations on that MEDEVAC operations required no changes. To maintain that stance in light of annual casualties increasing over six fold between 2008 and 2010 (from less than 1000 KIA and WIA in 2008 to nearly 6000 in 2010)is unsupportable. |
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| Army announces that the AMEDD’s combat and flight medic training curriculum will be upgraded through a five year plan beginning in the Spring, 2012. New medics will receive EMT-Basic, EMT-Intermediate and EMT-Paramedic training. This will match the long-standing training curriculum of the USAF Pedro pararescuemen. | After over at least a full decade of urgent warnings to improve medic training, AMEDD responds. However, existing medics – even those scheduled to deploy to Afghanistan later in 2012 – may not be included in the enhanced skills training. | |
| January 2012 Official Army statements to Congress and the public state that arming MEDEVAC helicopters would be impossible due to the weight burden of the weapons and additional crew. This despite the fact that removing the unused litter carousel would reduce the incremental weight of arming the aircraft to approximately 0 lbs. | January 2012 Internal Army report reveals that the first HH60M MEDEVAC helicopters deployed to Afghanistan in August 2011 weighed 2000 lbs more than the UH60A/L helicopters they replaced. Planners also failed to account for the estimated 200 lbs of the Enroute Critical Care Nurse. The helicopters were unable to meet performance standards associated with missions in their area of operations. In response, orders were approved to remove the oxygen generation system, the heating/air conditioning unit, the electric litter lift system (which replaced the old much maligned 600 lb litter carousel system) all things touted as critical breakthroughs in MEDEVAC helicopter capabilities. Then additional orders were given to remove the entire medical package from the aircraft.It wasn’t all bad news though. As it turned out all the flight medics preferred the open floor configuration without the carousel or electric lift because it was easier to attend to patients and move around the cabin.The Army was so concerned about the weight issue that they designed and deployed aircraft that weighed over 1 ton more than existing MEDEVAC helicopters! These helicopters also had new sealed bubble windows for the crew that replaced an opening in the sides of the aircraft. These were added to keep the interior cleaner and temperature controlled. Unfortunately, the bubbles restricted crew visibility in daytime operations as the helicopter was landing and crew were assigned to detect ground and tail hazards. They were mostly useless in nighttime operations when helmet mounted night vision devices made it all but impossible to put your head into the bubble. This design flaw was first reported in 1994 in the Army Aeromedical Research Lab Report 94-10 “Technical Evaluation of the UH-6OQ Aircraft in Typical Aeromedical Evacuation Missions.” |
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| Lt. Gen. Horoho, promoted in December 2011 to Army Surgeon General and Commanding General of AMEDD, gave two speeches in January 2012 about the successes of AMEDD and its priorities. In neither speech did she utter a single comment about MEDEVAC. She did comment glowingly about the Army now running the world’s 5th largest health care organization. After a decade of continuous war in two conflicts, MEDEVAC does not merit even a mention by AMEDD’s leader. | Lt. General Horoho’s continues the AMEDD senior leadership team consisting of Generals with the following specialties:
Conspicuously missing is any representation of the MEDEVAC function. Proponecy of MEDEVAC is delegated to a Colonel in the Directorate of Medical Evacuation Proponency within the AMEDD Center and School. MEDEVAC appears to be an orphaned organization in AMEDD and the Combat Aviation branch. Those paying the price for this dysfunctional structure are the wounded soldiers waiting for rescue by an organization that is hamstrung by internal Army political battles, cultural misunderstandings, lack of data that would support continuous improvement and leadership acknowledgement of these critical deficiencies. |
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The Army wishes Congress and the public would believe its claims that it is an organization devoted to innovation and self-examination:
“Finally, it’s important to remember that the Army would change its policy if battlefield commanders wanted a change. We take our obligation to perform the MEDEVAC mission very seriously. We’re a learning organization and periodically we review our policies to make sure they remain relevant. We looked at the MEDEVAC policy in 2008, but after a review, we determined no change was necessary.
Additionally, neither the International Security Assistance Force or U.S. Forces – Afghanistan has requested a change in policy; because our MEDEVAC crews and aircraft provide the best chance at survival ever seen in warfare, and because — as commanders in Afghanistan have told us — not arming our MEDEVACs and identifying them with the red cross has had no impact on the medical evacuation mission.”
But on topic after topic, the Army leadership was informed by credible sources within its own ranks, trusted allies, and NATO partners that there are problems that need to be addressed and nothing is done for a decade – or two! The January 20, 2012 statement by the Chief Public Affairs Officer for the US Army quoted above is an affront to our service men and women and those with a genuine concern for their well-being on the battlefield.
The Army was designated as the sole source provider of dedicated MEDEVAC services for all American forces. It is failing to live up to that responsibility. The Department of Defense should exercise closer oversight of this critical function that affects the lives of service members from all branches of our military.
There is an old saying that the best time to plant a tree was 20 years ago. The next best time is today. The Army leadership has already dug the hole. The Department of Defense should plant the tree, fill in the hole and start nurturing it – starting today.
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[…] ka LV apstākļos kaujas MEDEVAC būs pieejams drīzāk teorētiski nekā praktiski, bet zelta stundas likums attiecas uz visiem vienādi, tad šādu iniciatīvu ir jāatbalsta visiem […]
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[…] MEDEVAC is but one portion of the spectrum of pre-hospital care for the wounded. As discussed in How the Army is slow to meet MEDEVAC Challenges in the 21st Century this also covers Tactical Combat Casualty Care training and doctrine, as well as pre-hospital care […]
MEDEVAC Matters 
Great delivery. Sound arguments. Keep up tthe great spirit.
I needed to thank you for this good read!! I certainly enjoyed every little
bitt of it. I’ve gott youu book-marked to look at
new things you post…
That is a very cohesive argument, backed up by facts. I had just recently read the Defense Health Board review and was not surprised that these unpredicted consequences were in addition to the predictable consequence that non-medical commanders would be the ones to make the fly/no fly/delay flight decisions.
At the inactivation ceremony of the 57th Medical Detachment in 2006 I commented that the Army, in its reorganization had decided to re-invent the wheel with respect to Medevac, but I assumed that the heart and soul of Dustoff would find a way to fly when needed. I was wrong.
In August of 2014 at the re-dedication of Charles Kelly Memorial Stadium, I spoke with a commander that was there at the inactivation ceremony as was I, and he related to me the “scoring” system used before flight was allowed. He did say that the responses were rapid, but that everyone knew they were going to fly every mission, but that this just added one more layer of delay. Then I read the article about the survivability percentages from the study, covering a decade and I concluded that re-inventing the wheel has not worked.
Army Medevac needs to be in control of the mission from top to bottom. Process changes are on the way, but are being implemented “in due course” instead of, as one unnamed Medevac team member commented, at “the speed of blood”.
Soldiers will die between now and then. Sons or daughters, fathers or mothers will die in the field of battle before “best practices” are implemented and training updated. More will die and that unknown number will continue to die as long as there are unnecessary flight delays caused by someone other than Army Medical making the decision.
My father would be pissed off at the delays and command structure change, but would be proud of the fact that in spite of these things, Army Medevac is the best lifesaving team that has ever existed. His “in case of death” letter he stated plainly that the things he accomplished in Vietnam with the 57th Medevac were accomplished “in spite of” his commanding officers. He did note a few exceptions, but consider these “dying words” in essence, of the first person ever killed in the pursuit of the Medevac, Dustoff mission. His last actual words were: “I will leave when I have your wounded”. His last written words stated that he completed his missions in spite of most of his commanders, not with their help.
So, things have changed and things are much the same. To those of you in a position to do something about it, I appreciate your relentless attention to this mission and thank you for pursuing the elusive and unknowable goal of saving every life that can be saved.
My father, Major Charles Kelly is not here to thank you, but I carry his name and I thank you. I am Charles L Kelly Jr.
Son of Dustoff
In 65, we weren’t supposed to fly into an unsecure LZ without gunship support. LZs were seldom secure, even if the ground unit said (or rather whispered) that it was, and we almost never had gunships nearby. BUT we NEVER declined a mission. Our pilots would bob & weave (they could dance in the air!) on the way in, and zoom straight out once the wounded were loaded. [During my 16-month tour, the only 498th aircraft shot down was at a secure aid station.]
Google translation: “…circumstances that battle MEDEVAC will be available in theory rather than practice, but the golden hour rule applies to all the same, then this initiative is to support all…”
What has become clear through my research is that unless there is a strong advocate for the MEDEVAC role and its state of the art practices to save lives, compromises will be made that will result in more deaths. The delays by AMEDD in implementing proven techniques and policies – even those recommended by its own senior field leaders – is unacceptable. The US Army has kept MEDEVAC representatives away from the senior leadership table for too long. The first concern of AMEDD should always be the medical well being of troops in combat.
Well said