The Evolution and Modern Challenges of Medical Evacuation

Lessons from History and Insights for the Indo-Pacific (INDOPACOM) Region

By CPT Ashley M. Matta

Article published on: June 1, 2025 in the The Pulse of Army Medicine June issue

Read Time: < 10 mins

Banner source: U.S. Army by Spc. Ryan Lucas.

Dr. Jonathan Letterman made significant contributions to military medical practices during the Civil War. His approach to battlefield medicine introduced several critical innovations that have had a lasting impact on military medical care. One of the key lessons learned from Letterman’s approach was the establishment of a dedicated and organized ambulance corps, essential for the efficient and timely evacuation of wounded soldiers from the battlefield. His focus on structured medical evacuation and centralized control resulted in a system that drastically reduced battlefield mortality rates. This system was not only a breakthrough in military medicine but also set a precedent for modern ground ambulance companies, such as the Medical Company Ground Ambulance (MCGA). In contemporary settings, such as in Korea where the 65th Medical Brigade operates in a forward-deployed, armistice environment, the principles established by Letterman continue to be applied. These principles address contemporary challenges in casualty evacuation and multi-service cooperation, demonstrating the relevance of Letterman’s innovations in modern military medical practices.

Many of the fundamental tenants of Army Medicine today can be traced to Letterman. He is buried in Arlington National Cemetery.

CHALLENGES IN JOINT AND MULTINATIONAL OPERATIONS

Medical units in Korea, especially those operating under the 65th Medical Brigade, face significant challenges in communicating and collaborating with joint and multinational partners. Recent exercises, such as Freedom Shield and Ulchi Freedom Shield, have highlighted critical gaps in operational communications, equipment interoperability, and procedural differences.

These gaps have led to delays in casualty evacuation and inconsistencies in mission execution. As MSgt Walker, USAF 51st FW Superintendent of Wing Exercises, explained, “Rapid evacuation is key to patient survival. No matter how much care you can provide in the field or at small facilities, you must get patients to the level of care they need.” He emphasized the unique challenges in this region, noting that “Here in this theater, it would be extremely challenging if things went sideways. We need more joint training on how to support one another.

While flight paramedics are equipped for high-acuity enroute care, ground medics in similarly austere prolonged scenarios are not.

Resources are limited, and I don’t think most Soldiers and Airmen at the tactical level understand how we integrate during conflicts.” The inability to fully integrate platforms across services and nations demonstrates the importance of interoperability in high-threat environments, particularly when the need for rapid casualty evacuation is paramount. As urban warfare becomes increasingly likely in future conflicts, evacuation efforts must also evolve to address the challenges of densely built environments, limited mobility corridors, and high civilian presence. South Korea provides a vivid example of these challenges with its dense population centers, high-rise infrastructure, and narrow congested roads that severely limit access for evacuation vehicles during combat operations. To address these issues, training exercises should reflect urban-specific scenarios, and vehicle platforms must be equipped to handle narrow streets and vertical extractions.

A UH-60 Black Hawk helicopter is assisting with the movement of National Urban Search and Rescue task force teams to storm damaged aread in New York and New Jersey. Source: U.S. Air Force by Tech. Sgt. Parker Gyokere/Released.

Amid these obstacles, the exercises also highlighted key opportunities for improvement. Integrating shared platforms, restructuring MCGA units, and developing theater-specific evacuation procedures hold the potential to significantly enhance joint and multinational interoperability. Continued collaboration and adaptability among service partners will be essential to reducing delays in casualty evacuation and improving the overall efficiency of medical evacuation operations in the region. Conversely, failure to address these interoperability and communication gaps could negatively affect mission outcomes, erode trust between coalition partners, and lead to preventable loss of life. Such outcomes would ultimately diminish the U.S. military’s strategic credibility in the Indo-Pacific.

THE ROLE OF THE 65TH MEDICAL BRIGADE

Recognizing these challenges, the U.S. Army relies on specialized units to bridge critical gaps and ensure effective operations. Among them is the 65th Medical Brigade, which serves as the Army’s only forward-deployed medical brigade in an armistice environment. Operating across the Korean theater with two MCGAs, the brigade plays a crucial role in ground casualty evacuation, especially when air evacuation becomes contested or impractical. Lessons learned from ongoing conflicts, such as the war in Ukraine, underscore the critical need of robust ground evacuation systems when air assets are unavailable. The lessons from Large-Scale Combat Operations (LSCO) highlight the urgency of ensuring ground-based capabilities to evacuate casualties effectively.

To address these challenges, the brigade conducts its annual exercise, Pacific Medic Focus (PMF), in collaboration with the Air Force. This exercise simulates multi-modal patient evacuation scenarios, combining air and ground operations. While patient transfer and enroute care were successfully executed, the most recent exercise revealed deficiencies. Medical evacuation vehicles struggled to navigate through flooded, unpaved terrain, and communication failures hampered coordination. These challenges emphasize the need for reevaluating the MCGA doctrinal framework to incorporate more diverse vehicles designed for varied terrains.

IMPROVING COMMUNICATION SYSTEMS --- RECALIBRATING THE MCGA DOCTRINAL FRAMEWORK

The PMF exercise demonstrated that existing infrastructure and communication systems are inadequate for the demands of modern warfare. The failure of the Joint Battle Communication Platform (JBCP) in severe weather conditions exposed the vulnerabilities in current systems, especially when operating in unpredictable environments. As General LaCamera emphasized at the 2024 LANPAC/TECHNET, technology must enhance operational effectiveness without compromising human oversight. Integrating advanced technology into the JBCP can improve coordination across multinational and joint forces. However, this process must be achieved in a way that retains the commander’s decision-making authority and mitigates the risk of over-reliance on technology in complex environments.

Beyond communication platforms, emerging technologies present promising solutions to enhance MEDEVAC capabilities. The use of unmanned aerial systems (drones) can complement traditional evacuation methods by delivering medical supplies or executing short-range casualty extraction in contested areas. Telemedicine platforms and AI-assisted triage systems further aid medics by enabling remote oversight and informed decision-making during transit, particularly in environments where communication is compromised.

ENHANCING TRAINING STANDARDS --- MEDICAL PROFICIENCY

However, technology alone cannot bridge all the gaps. One pressing concern lies in the standard of medical proficiency among combat medics assigned to ground ambulance units. While air evacuation requires paramedics with advanced certifications, ground medics currently only need a basic Emergency Medical Technician (EMT) certification. This disparity poses significant risks in high-threat environments where ground evacuation may be the only viable option. Elevating the certification requirements for ground medics – through programs such as the Combat Paramedic Program or incorporating Joint Prehospital Emergency Care Protocols – can substantially strengthen the capabilities of MCGAs in these settings.

The importance of enroute care in reducing mortality rates cannot be overstated. As the military faces increasing numbers of casualties in large-scale combat operations, equipping ground medics with advanced skills and lifesaving equipment is crucial to ensuring effective care during transport. These capabilities were highlighted during the recent PMF 25-1 exercise, where the 568th MCGA and 560th MCGA successfully rehearsed Ambulance Exchange Point (AXP) operations during blackout conditions, demonstrating adaptability and preparedness in challenging scenarios. Throughout

“Modernization isn’t about comfort, it’s about survivability...”

the training, combat medics were able to stabilize simulated critical patients for over 30 minutes while navigating diverse terrains. They managed airway control, hemorrhage management, and intravenous access while under significant stress, all without immediate oversight. Their actions were lifesaving within the limits of EMT-level training. However, had they possessed advanced paramedic skills they could have provided more definitive interventions during that crucial window, potentially improving the patient’s condition before reaching higher care. This exercise also revealed a broader issue: while flight paramedics are equipped for high-acuity enroute care, ground medics in similarly austere prolonged scenarios are not. While combat medics are fully trained in foundational lifesaving skills, they are not equipped to deliver the advanced interventions expected of flight paramedics such as endotracheal intubation, cardiac monitoring, or administering a wider range of medications. Addressing this gap by raising the training standards for combat medics and implementing paramedic-level certification would enable MCGAs to standardize care across evacuation platforms. This improvement would elevate the overall quality of patient care, ensuring consistent and effective treatment, regardless of proximity to higher medical echelons.

FlyingBasket drone being used to assess the viability of drones for transporting equipment and injuries. Source U.S. Army by Elena Baladelli.

RESTRUCTURING EVACUATION PLATFORM --- IMPROVING ENROUTE CARE

Additionally, expanding ambulance crews from a two man-crew to a three-man crew and embedding medical providers within MCGAs would provide the necessary expertise to handle complex casualties during evacuation. Currently, the MCGAs ambulance crews are comprised of an Ambulance Aide/Driver per Field Litter Ambulance (FLA) and one Emergency Care Sergeant per Squad. This configuration accounts for the driver and TC, (unit SOP dependent) but does not account for the enroute care medic that can provide immediate interventions during transport. This oversight can significantly affect the mortality rate of both the patient and the medics in contested environments. “Modernization isn’t about comfort, it’s about survivability – both for our patients and our crew,” said 568th MCGA 1SG Hickman. On the other hand, medical providers can assist with guiding complex interventions, administering medications, and serve as a vital lifeline for junior medics--ultimately multiplying the reach across the battlefield. With the proper connectivity and communication platform, these providers can offer remote oversight and real-time guidance. Both approaches would align with the evolving nature of modern battlefield medicine, where the point of injury and enroute care are equally critical to survival. “Medics carry a tremendous emotional weight and are expected to be masters of their craft. I’ve too often seen talented medics lose their drive when denied opportunities to practice medicine,” Hickman added. Theater commanders must be ready to assume risk if the medical evacuation organizations are not capable of providing the required intratheater enroute care capabilities.

INNOVATION THROUGH CROSS-SERVICE COLLABORATION

Despite the challenges, Korea offers significant opportunities for innovation through collaboration. A prime example is the partnership between the 568th MCGA and the 51st Medical Group, which has fostered an exchange of expertise in both operational and clinical environments. This partnership has not only improved the effectiveness of casualty evacuation operations but also strengthened the synergy between ground and air MEDEVAC units. As SPC McAlister from the 568th MCGA aptly described, “Just as veins transport blood to the heart for processing and nourishment, we serve as the lifeline ensuring our wounded reach the care they need to survive and return.”

U.S. Army Sgt. Ricardo Blancarte, an animal care specialist, teaches Ghanaian soldiers how to provide aid to their working dogs. Source: U.S. Army by Cpl. Clara Soria-Hernandez.

One notable success has been the integration of K9 medical care. Through joint efforts involving the 568th MCGA, Air Force paramedics, and the 106th Medical Detachment Veterinary Service Support (MDVSS), Tactical Combat Casualty Care (TCCC) and MEDEVAC training for military working dogs have been successfully implemented. This collaboration demonstrates the adaptability and innovation required in joint environments, ensuring comprehensive care for all personnel and canine assets under high-stress conditions.

ADVANCING MEDEVAC OPERATIONS

The complexities of medical evacuation in the INDOPACOM region demand forward-thinking approaches and continued innovation. The lessons of Dr. Letterman’s groundbreaking work in medical evacuation continue to inform modern practices, ensuring that casualty evacuation remains a priority in military operations. By enhancing training standards, improving communication systems, and re-structuring evacuation platforms, MCGAs can better adapt to the challenges of modern warfare.

As military operations evolve, so too must our commitment to be flexible, responsive, and technologically integrated MEDEVAC systems capable of sustaining life-saving care under the most austere conditions. To meet these demands, military planners and policymakers must prioritize investments in terrain-capable evacuation platforms, fund widespread implementation of paramedic training for ground medics, and modernize doctrinal approaches to reflect lessons learned from exercises and ongoing global conflicts.

The 65th Medical Brigade’s commitment to collaboration, innovation, and readiness will ensure that U.S. forces are prepared to meet the demands of large-scale combat operations while saving lives on future battlefields. The enduring legacy of medical evacuation in the U.S. military is strengthened through continued adaptation to the evolving operational environment in the INDOPACOM region.