Adapting Military Medicine

Preparing for Prolonged Care in Large-Scale Combat Operations

By MAJ Alexander Kennedy and CPT Phillip Carman

Article published on: July 1, 2025, in the July 2025 Issue of The Pulse of Army Medicine.

Read Time: < 10 mins

ABSTRACT:

In Large-Scale Combat Operations (LSCO), military medicine faces unique challenges, particularly in delivering prolonged care to casualties who may need extensive treatment over extended periods. As conflicts become more protracted and geographically spread out, especially in the USINDOPACOM Area of Responsibility (AOR), preparing for these scenarios requires adaptive planning, flexible strategies, and robust coordination. The primary focus of this adaptation is ensuring the availability of medical care from the point of injury (POI) through all echelons of care—Role 1 through Role 4—without interruption.

Prolonged care involves providing medical treatment beyond the initial trauma care, extending into long-term recovery or rehabilitation. In a maritime environment like USINDOPACOM, this challenge is intensified due to the dispersed geography of islands, extreme weather conditions, and the diverse nature of military operations. Telemedicine and advanced evacuation platforms, such as hospital ships or aircraft, will be essential for maintaining continuity of care across vast distances.

The integration of emergency medicine, trauma care, and post-trauma rehabilitation must be planned with foresight, especially when the conflict may prevent immediate access to higher care facilities. Field hospitals, combined with forward surgical teams, will be essential to ensuring that casualties receive life-saving interventions and be stabilized for further treatment at theater hospitals.

Military medical planners should also prioritize the training of non-medical personnel in trauma care. Programs like Tactical Combat Casualty Care for All-Service Members (TCCC-ASM) and Combat Lifesaver (TCCC-CLS) should be integrated into all units preparing for deployment to ensure a well-prepared force capable of addressing battlefield casualties until they can be evacuated for further care. Joint planning for the logistics of prolonged care, including mobile medical units and stockpiling necessary supplies, is necessary to support both front-line and follow-on care in extended conflict environments.

Integration with Joint Health System Principles

While adapting to prolonged care scenarios, military medical planners must continuously apply the principles of the Joint Health System (JHS). These principles, which include Conformity, Proximity, Flexibility, Mobility, Continuity, and Control, are foundational to delivering healthcare and minimizing the loss of life in combat settings.

Conformity in Prolonged Care

Conformity, in the context of prolonged care, requires ensuring that the medical operations plan aligns with the overall mission objectives and that the medical concept of support (MED CoS) reflects the evolving nature of LSCO. From the early stages of deployment, medical planners must develop an adaptable medical support plan that aligns with campaign and operational orders while maintaining the ability to scale up resources as casualties increase over time.

For a Role 2 and Role 3, ensuring conformity in prolonged care involves integrating training support with other companies within the unit during exercises to enhance realistic training standards. This process reinforces mass casualty (MASCAL) standard operating procedures (SOPs), ensuring that when a real event occurs, every squad, platoon, and company understands their role in the MASCAL operation, ultimately minimizing loss of life. Unit training management should include synchronization and coordination with a MEDEVAC Company to conduct real world HH60 – Blackhawk MEDEVAC training, enabling the understanding and livelihood of calling 9-line MEDEVACs in the reception and evacuation of patients from the aircraft. This ensures that medical assets can be shifted between units and roles, preventing any gaps in care.

Proximity in Prolonged Care

In LSCO, proximity is vital for ensuring that medical assets are positioned within a reasonable distance of the point of injury (POI), ensuring rapid treatment and transportation. Medical planners must account for prolonged evacuation distances in maritime environments, where casualty evacuation (CASEVAC) might take much longer than in more traditional land-based environments. In 2011, while deployed to Bagram, Afghanistan, our unit conducted MEDEVAC missions. The moment a 9-line came across the radio, we’d drop everything, launch within 10–15 minutes, and, upon tower approval, head straight to the pick-up zone. Unfortunately, those days are behind us. Facing the future near-peer threat, air superiority is no longer guaranteed. Sending MEDEVAC aircraft now means a high likelihood of encountering air defense systems or drones, increasing the risk of being shot down. As a result, the proximity of medical assets for prolonged care will be critical in Large-Scale Combat Operations (LSCO).

Whether through sea-based assets such as hospital ships or aerial platforms, proximity ensures that initial care is available quickly, and that casualties can be evacuated effectively to higher care facilities, such as Role 3 hospitals.

Flexibility in Prolonged Care

Flexibility is one of the most important principles when preparing for prolonged care in LSCO. Medical planners must anticipate varying medical needs and remain prepared to adjust care protocols based on resource availability, changing operational conditions, and logistical constraints.

Flexibility in prolonged care requires an awareness of host nation hospitals, including their clinical, ground, and air evacuation capabilities in the event of the necessity of authorization for life, limb, or eyesight emergencies. In 2019, the 82nd Airborne Division, along with allied forces from Canada, Bulgaria, Italy, Spain, France, and the United Kingdom, conducted a combined swift response training exercise—Joint Forcible Entry (JFE)—into Bulgaria, Romania, and Croatia. During the operation, numerous Paratroopers sustained severe injuries beyond the capabilities of Role 1 care, necessitating evacuation to host nation hospitals. Due to restrictions on the use of tactical vehicles on public roads, we had to rely on rental vans for patient transport.

In a 20-soldier Forward Surgical Team (FST), operational flexibility was often constrained by the need to strategically position the sole orthopedic surgeon, which limited the team’s ability to address complex blast injuries across multiple locations. With the updated TOEs now including two specialists for each critical role, FRSDs have gained the capability to conduct GHOST missions with greater efficiency and adaptability. This enhanced structure ensures that specialized expertise is readily available to support the dynamic demands of battlefield medicine, allowing for improved responsiveness and coverage in high-pressure scenarios. This includes adapting care strategies for prolonged operations on remote islands, where medical teams may need to improvise using limited resources.

Furthermore, flexible planning means ensuring that rehearsals and training exercises are conducted regularly to adapt to different casualty scenarios. Medical teams must remain prepared for shifts in operational focus, which could result in surgical operations needing to transition from field hospitals to hospital ships or specialized Role 3 facilities as the situation changes. Prolonged care in LSCO must therefore be flexible in its execution and response.

Mobility in Prolonged Care

Mobility remains a key principle, as casualties in LSCO will often be evacuated over long distances and across challenging terrain. Ensuring that medical teams can remain mobile, with access to evacuation platforms, will be critical.

Expedient mobility at Role 1 can be achieved by setting up one or two trauma beds in a woodland area, in the back of a Family of Medium Tactical Vehicles (FMTV), or beneath camouflage netting. This setup ensures that when the need arises to relocate quickly, medical personnel can swiftly pack up and move to the next position without delay.

Expedient mobility at Role 2 can be achieved by utilizing a Two-Side Expandable Containerized Shelter, transported and deployed using a Palletized Load System (PLS) or Load Handling System (LHS). Instead of requiring hours for setup, this approach cuts the time in half, ensuring units are rapidly operational and ready to receive patients. It is important to note that, in the maritime environment, mobility challenges are amplified by issues like rough seas, tropical weather, and inaccessible terrain.

The principle of mobility ties closely to supply chain logistics, where medical teams must have the ability to mobilize quickly, relocate to different geographic areas, and maintain the continuity of care throughout. The integration of airborne platforms, such as helicopters or drone-assisted evacuation, can be part of the medical mobility equation, ensuring that casualty evacuation is possible even in remote or hard-to-reach locations.

Continuity in Prolonged Care

Continuity of care is essential in ensuring that once a casualty begins receiving medical attention, they remain under continuous, uninterrupted care through all phases of evacuation, treatment, and rehabilitation. This can be particularly difficult in maritime operations, where gaps in resources and extended evacuation times might disrupt care continuity.

Medical planners must establish clear protocols for patient movement and ensure that communication systems (including telemedicine) are in place to link lower-echelon medical teams with specialists at higher echelons. Seamless coordination between Role 1 through Role 4 facilities is critical, ensuring that patients receive the appropriate care no matter the distance or location.

Traditional telemedicine, once a cornerstone of interoperability for clinicians during the GWOT era, is at risk of losing its efficacy in future military operations. In 2018, during my deployment to Iraq, medical personnel leveraged telemedicine to seamlessly communicate with healthcare professionals across the country, enabling vital consultations in real time. However, this capability is poised to become a luxury as emerging technologies such as drones dominate the battlefield. Advanced targeting cycles and heat signature tracking will expose American and NATO positions, underscoring the urgent need to rethink and reform telemedicine frameworks. One possibility that should be considered would be the integration of AI into Roles 1 and 2. AI must take center stage in Army Medicine, acting as a transformative force by providing sophisticated matrices to enhance critical thinking among medical personnel and amplify their efforts in complex, high-stakes scenarios. Preparation and clinical training during stressful times will never be eliminated, but an AI tool that complements a medical solder’s current knowledge could potentially allow them to act accordingly without the face to face or phone call telemedicine is known for providing.

Control in Prolonged Care

The principle of control in prolonged care revolves around coordination and command of medical assets in support of the larger tactical and operational objectives. As casualties increase in a prolonged conflict, maintaining control over medical resources—whether personnel, equipment, or evacuation platforms—becomes a monumental task.

Successful control in prolonged field care relies on effective integration with the sustainment Warfighting Function, ensuring the reception, management, and distribution control of Class VIII medical supplies, equipment, and blood products. These critical resources will be transported to operational units via fixed-wing aircraft or ships, while division sustainment support battalion ground convoys and combat aviation brigade aircraft will handle deliveries to tactical echelons. Since the Army Medical Department (AMEDD) lacks the personnel and equipment necessary to move Class VIII supplies for Large-Scale Combat Operations (LSCO), collaboration with sustainers is essential. This integration enables medical units to continue stabilizing patients as they await evacuation, ensuring they have the necessary medical resources readily available.

To achieve this control, planners must use centralized tracking systems that allow for real-time updates on medical assets and patient movement. AI-driven logistics, medical evacuation management, and patient care tracking can significantly improve the efficiency and responsiveness of medical operations in LSCO. Control also involves ensuring that all medical personnel and facilities are fully equipped to handle the increased burden of care over time, as patient load and resource strain grow.

Conclusion

In conclusion, Adapting Military Medicine: Preparing for Prolonged Care in Large-Scale Combat Operations underscores the critical need for military medical planners to be well-versed in the principles of the Joint Health System. The evolving dynamics of large-scale combat operations (LSCO), particularly within the challenging environments of the USINDOPACOM area of responsibility, require medical planners to be adaptable, proactive, and capable of integrating advanced technologies, multidisciplinary teams, and innovative approaches to care delivery.

As warfare continues to evolve, so too must our approach to military medicine. The lessons learned from past conflicts, such as Operation Iraqi Freedom and Operation Enduring Freedom, reveal the importance of preparing for prolonged care, not only in the immediate aftermath of injury but throughout extended operations. With the advent of new technologies like telemedicine, AI-driven triage systems, and advanced field care protocols, military medicine has the opportunity to mitigate the risks associated with long-duration combat care and improve outcomes on the battlefield.

To succeed in LSCO, it is imperative that all members of the joint medical team—across services, allies, and non-medical personnel—are equipped with the knowledge and training to provide effective, continuous care in the face of shifting operational priorities. Key elements such as flexibility, mobility, conformity, and proximity will be indispensable in ensuring that medical support is timely and appropriately scaled to the needs of the mission.

Ultimately, the success of prolonged care in future conflicts hinges on more than just medical capability—it requires the integration of operational and logistical systems, the training of personnel at all levels, and the ability to adapt to rapidly changing conditions on the ground. As the US military continues to prepare for future threats, prioritizing these aspects of medical readiness will not only minimize the loss of life but will also ensure that our forces remain operationally effective, even in the most challenging environments.

In preparing for these complex scenarios, military leaders and planners must remain committed to continuous improvement, embracing innovation, and fostering collaboration across all branches of service. During peacetime, partnerships with commands within an installation should be leveraged to conduct realistic training to provide proof of concepts that maneuver elements can provide medical forces. During these events, medical units should prioritize the stress-testing of Class VIII plans through tabletop exercises or simulating prolonged field care structures during a Joint Field Training Exercise (JFTX). Leaders gain invaluable opportunities to visualize, refine, and validate standard operating procedures (SOPs). Such proactive measures ensure that systems and processes are not only efficient and effective but also resilient and reliable under the pressures of real-life operations. In fact, I personally believe this should be targeted at MMB and HC’s.

In 2017, I was assigned a DCRF mission with the local MP unit on FT. Campbell. Running through TTX’s with this allowed for protection capabilities to be enhanced as we gained a better prospective for what MPs are able to provide. This only solidifies the fact that we, as medical personnel, need to understand the mission of others as isolation within the medical community inhibits the building of well-developed plans.

Through rigorous training, strategic planning, and the relentless pursuit of excellence in care, the Joint Health System will continue to play an indispensable role in safeguarding our nation’s military personnel and enhancing mission success in large-scale combat operations.