Patient Regulation in a Multinational, Multi-Corps LSCO Conflict

By Lieutenant Colonel Brian A. Mason

Article published on: March 1, 2026 in the 2026 E-Edition of Pulse of Army Medicine

Read Time: < 11 mins

Abstract

Large-scale combat operations involving multiple Corps and multinational partners create evacuation challenges far more complex than those experienced during recent conflicts with reliable movement from point of injury to Role 3 and onward to CONUS. High casualty estimates, extended and unsecured lines of communication, and differing national patient regulation systems strain the Army Health System and complicate strategic aeromedical evacuation. Observations from NATO Exercise Steadfast Leada 21 highlight gaps in visibility, coordination, and multinational integration, particularly the limited effectiveness of the Multinational Patient Evacuation Coordination Center (MN-PECC) and the absence of a Theater Medical Command. To prevent backlog at Corps Role 3 facilities and maintain operational momentum, this article proposes establishing a multinational theater clearing hospital to serve as an intertheater evacuation hub. This capability, paired with a fully integrated and exercised MN-PECC, would enhance patient flow, enable return to duty decisions, and strengthen joint and allied medical interoperability.

The last two decades of patient evacuation from point of injury to a Role 3 and strategic evacuation to the Continental United States (CONUS) provided the U.S. Military a sense of security in the evacuation system. In a large-scale combat operation involving multiple Corps, the casualty estimation will be high, requiring prolonged care and long lines of communication over unsecure terrain to move patients via ground through the continuum of care. To add complexity, difficulty arises with multinational forces all conducting their own patient regulation in a contested environment to include strategic level, inter-theater Aeromedical Evacuation (AE). Grounded in a baseline definition and Army Health System (AHS) principles of planning and complexity of patient regulation, particularly those observed during a NATO exercise, we propose a theater clearance hospital to serve as a joint and allied solution to multinational patient regulation.

Baseline Definition

Although NATO roles of care differ only slightly from U.S. roles of care, the following definition refers strictly to U.S. roles of care. Large-scale combat operations (LSCO) are defined as extensive joint combat operations in terms of scope and size of forces committed, conducted as a campaign aimed at achieving operations and strategic objectives. Army Doctrine states that when LSCO is conducted on land, multiple Corps and Divisions are involved. U.S. Transportation Command (USTRANSCOM) coordinates the strategic aeromedical evacuation (AE) of patients under medical supervision, moving them by air to and between medical treatment facilities using U.S. Air Force assets. Medical planners commonly refer to this capability as Strategic Evacuation (STRATEVAC).1

Medical Planning

From a medical planning and operations perspective, the problem of evacuation in LSCO is complex and requires continual planning, coordination, and synchronization to provide the highest standard of care to wounded or ill Soldiers and to prevent unplanned culmination in the maneuver area. Complexity increases when operations are conducted by Allied, multinational, or coalition forces. Host Nations are ultimately responsible for the medical support for their deployed forces; however, the North Atlantic Treaty Organization (NATO) encourages multinational solutions when delivering medical support.

Treatment and medical evacuation from the forward line of troops (FLOT) back through Role 1 (R1) and Role 2 (R2) are a combat brigade and division responsibility. As the continuity of care progresses, such as to an echelon above brigade (EAB) medical unit, whether a Role 2 (R2) or Role 3 (R3), the art of planning based on task-organized capabilities will dictate the means of evacuation.2

Means of Evacuations:

1. Non-Medical ground vehicles/aircrafts (CASEVAC) with non-medical personnel
2. Medically marked ground/aircrafts (MEDEVAC) with medical personnel

When casualty estimates are large, patient regulation through the continuum of care is essential to enable combatant commanders’ onward movement. Patients in cots or beds prevent the R1 aid station or R2 Brigade Support Medical Company from moving, which in turn keeps the battalion or brigade from moving and risks losing tactical momentum. Efficient patient regulation planning moves patients rapidly to the highest tactical medical capability, a Role 3 (R3). This enables the sustainment enterprise to concentrate on supporting the current fight and planning for future operations.

NATO Exercise Steadfast Leada 21 Observations

During NATO exercise Steadfast Leada 21 (SL21), 3 different Corps participated either physically or notionally:

• U.S. Corps
• Spanish Corps
• Allied Rapid Reaction Corps (ARRC)

If the Corps remained consistent with their national divisions and brigades, the task of evacuation would have been simpler. However, the U.S. Corps contained two U.S. Divisions and one German Division; the Spanish Corps contained one U.S. Division and one Polish Division; and the ARRC contained a U.S. Stryker Brigade. Planning for the 10 medical functions was difficult but not impossible. The task organization increased complexity with complications to AE, proper regulation of patients through the continuum of care, and class VIII and blood distribution. Inter-theater AE proved difficult to execute due to R3 proximity to the FLOT and enemy anti-access and area denial (A2AD) systems

Clearing beds is essential in a largescale combat operation because it keeps patients moving through the continuum of care and allows tactical commanders to maintain momentum. If these beds are not cleared, patients in lower roles of care will remain in place where prolonged care is vital but will stall maneuver. However, if R3 beds are cleared, patient flow occurs as planned. In the SL21 scenario, multiple nations converged on not just the U.S. Role 3, but the Spanish and ARRC field hospitals. This convergence made medical regulation difficult, especially because the U.S. Corps lacked full visibility of patients being evacuated by the other Corps.

Multinational Patient Regulation

NATO utilizes the Multinational Patient Evacuation Coordination Center (MN-PECC) for this specific purpose. However, the MN-PECC was not staffed as an adequate response cell during SL21, and there was no U.S. representation in the MN-PECC. The Theater Medical Command (TMC) did not exist, and U.S. Army Europe and Africa (USAREUR-AF) did not participate in the exercise. This raised two unresolved questions throughout the exercise: who is responsible for coordinating patient evacuation, and at what echelon that responsibility should reside? The absence of clear answers highlighted a significant gap in multinational medical command and control.

In theory, the TMC is structured for this task. However, the TMC is a U.S. pure organization and, at least in 2021, the MN-PECC was established as needed, not as a standing organization trained and validated on the task of patient regulation. If the TMC can integrate the MN-PECC, then an established patient regulating capability would be fully operational to provide theater level understanding of patients across the Corps. Further, the TMC must be involved in LSCO scenario exercises, whether digital or in the field. The only way to test the medical system is to have all the medical capabilities involved with exercises.

Clearing Role 3 Hospitals

To alleviate some strain on the Corps Role 3 facilities, planners often look to Host Nation Medical Treatment Facilities (HN-MTF). In practice, however, HN-MTFs are rarely a reliable option unless they are coordinated in advance and specifically designated for Military use; otherwise, they are typically filled with civilians or Host Nation force, leaving little or no capacity for Allied patients.

A more feasible approach is the establishment of a theater clearing hospital which can also serve as an inter-theater AE Casualty Collection Point (CCP), referred to as “clearing hospital,” in the Joint Support Area. This concept places a multinational clearing hospital in the Land Component Command support area where patient continuity of care would progress up from the Corps R3. Theater assets would then be responsible for moving patients from the Corps R3s to the clearing hospital by whatever multimodal evacuation means possible.

The space requirements at the clearing hospital would be substantial and require ready access to an airfield with enough space to park multiple military transport aircraft. This larger medical facility must also allow for prolonged care and rehabilitation. Medical planners widely agree that returning Soldiers to duty is essential in LSCO. The MN-PECC can work with echeloned Surgeon Cells and human resource G1 Casualty Operations Divisions directly to manage return-to-duty patients and ensure they are reintegrated into the force.

The TMC would be best postured to Command and Control in vicinity of the clearing hospital where the MN-PECC can coordinate effectively for each nation’s AE. To be successful, the MN-PECC must have representation from all Joint, Allied, Multinational, and Coalition forces to coordinate with their respective nation. This will require policy, multi-lateral agreements, and rehearsals for success.

Sustaining Momentum in LSCO

Evacuation in large-scale combat operations is inherently complex and demands continuous planning, coordination, and synchronization to provide the highest standard of care and prevent unplanned culmination in the maneuver area. Without coordinated aeromedical evacuation or a theater clearing hospital to manage return-to-duty patients, Corps Role 3 facilities quickly become congested. This backlog cascades down to lower roles of care, slowing patient movement, stalling maneuver, and straining sustainment operations. Exercising command and control of the MN-PECC through the Theater Medical Command is essential to preserving continuity of care, relieving corps-level medical units, and maintaining operational momentum. These concepts must be integrated early and rehearsed well before a crisis. Integrating them into training and exercises ensures they function effectively when required. Further discussion and working groups are required to solidify a fully integrated Allied, multinational, and coalition medical system capable of supporting the demands of LSCO.

Notes