How the Army has Failed to Solve 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
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 Ass’t Sec’y of Defense for Health Matters independent of AMEDD. Original paper published 1996 First used by Navy SEALs and Army Rangers in 1997 Updates published in PHTLS manual since 1998
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
6 MEDEVAC helicopters deployed to Afghanistan	The first edition of the “Ranger Medic Handbook” is published.
2002		49 KIA 74 WIA
	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: delays associated with launch approvals underpowered aircraft medical equipment These are critical and will be worked out through the Evacuation Integrated Concept Team.”
	TCCC Casualty Card Designed by Ranger combat medics Used in combat since 2002 Only essential information Heavy-duty waterproof or laminated paper Hospitals can transcribe into EMR [database] Army Surgeon General considering
2003		48 KIA 99 WIA
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

2005		99 KIA 268 WIA
Army aviation transformation implemented: Removed MEDEVAC unit ability to function independently Placed all MEDEVAC units as subordinate units in General Support Aviation Battalions within Combat Aviation Brigades (CAB) Cut MEDEVAC units from 15 helicopters to 12 and from 149 members to 85 members Mission and launch approvals must now be obtained from CAB commanders.
2006		98 KIA 400 WIA
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
	TCCC First Responder Documentation Conference 2007: 30,000+ Wounded in Action in OEF/OIF Less than 10% have any form of prehospital documentation of care In only about 1% of cases is the information adequate
2008		155 KIA 795 WIA
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].“
2009		317 KIA 2143 WIA
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”
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 mmid-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.
2010		499 KIA 5242 WIA
	July, 2010 AMEDD Journal article recommends: Upgrade medic training to EMT-Paramedic Develop standard triage and MEDEVAC delivery plans Improve Battalion Aid Station capabilities to include Advanced Trauma Life Saving (ATLS) care skills And notes that “there is no published comprehensive US military review of prehospital or medical evacuation data.” which limits the ability to assess the role of MEDEVAC mission timelines in patient survival.
2011		418 KIA 5183 WIA
	February 2011 After Action Report to CENTCOM enumerates significant system wide issues with MEDEVAC: “Current MEDEVAC staffing model is outdated and based on Cold War/Vietnam era doctrine. A recent study documented a 66% higher death rate at 48 hours post-injury for Regular Army MEDEVAC patients than for National Guard MEDEVAC patients. Lack of standardization across units performing rotary wing evacuations within Afghanistan. This creates a situation where different units/personnel have to be used for different missions. This degrades the MEDEVAC commander’s flexibility to respond appropriately across the full spectrum of missions. Unit flight surgeons lack the clinical skills, experience and credentials to supervise and train flight medics. No standard for documentation / process improvement measures or data basing. Process improvement measures or patient care research is not able to be conducted because MEDEVAC care data is absent from the patient’s medical record in the vast majority of instances…Lack of patient care documentation…is the greatest hindrance to developing data needed to drive improvements in MEDEVAC care. Patient Evacuation Coordinating Cells assign missions variably across the Regional Commands. 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.”
	Secretary of Defense Gates states the Pentagon has “created cultural barriers to change…including care for the wounded, MEDVAC…”
	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: “MEDEVAC missions are often not permitted to deploy to an unsecure area with a high risk of encountering hostile fire. When a dedicated MEDEVAC unit is the only platform available and evacuation is needed from a combat zone, a delay in evacuation may result.” “When casualties are sustained in areas where there is active hostile fire or a significant threat of hostile fire, flying rules may prohibit MEDEVAC aircraft from carrying out the evacuation. A contingency plan in which CASEVAC aircraft [USAF Pedro or other] may be tasked to evacuate the casualties may enable the evacuation to be accomplished. In 2003, the Special Operations Task Force incorporated this concept, along with modular medical packages that would allow for rapid transition of an armored, armed rotary wing aircraft not dedicated to MEDEVAC missions into a temporarily designated CASEVAC transport vehicle.” Pertaining to this issue, the Board Recommended: “Planning should aim to optimize evacuation time for all likely tactical contingencies. Define hostile fire evacuation options in mission planning as a supplement to dedicated MEDEVAC platforms. Consider the use of armed, armored CASEVAC aircraft to avoid evacuation delays due to ground fire. Consider the use of modular medical packages for deployment on tactical aircraft designed to perform TACEVAC duties.”
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 Corps that reported that: 88% of all MEDEVAC incidents in the research period in RC-South in 2011 had 1 to 3 patients which is the number able to be placed on the deck of a Blackhawk helicopter rather using the 600 lb. litter carousel. The Patient Evacuation Coordinating Cell which manages the MEDEVAC response effort functions best when placed in the Combat Aviation Brigade C2 building, rather than being relegated to a distant building “…there is general agreement that the [acceptable time from point of wounding to primary surgery] should be as short as possible.”
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 is unsupportable.
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.	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 rather than 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.
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: Clinical Trauma Nurse Specialist Internal Medicine/Dermatology Pediatrician Sociology/Health Administration Family practice Artillery Officer Microbiology/Immunology Veterinarian 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.

MEDEVAC Matters