COMMENTARY

MILITARY MEDICINE, 185,9/10:e1343, 2020

Time to Update Army Medical Doctrine

LTC Ryan M. Knight, MD, MC USA* ; MAJ Charles H. Moore, MD, MC USA* ;

Downloaded from https://academic.oup.com/milmed/article/185/9-10/e1343/5829705 by guest on 08 May 2023

2LT Montane B. Silverman, BA, MSC USA†

BATTLEFIELD CARE THROUGHOUT HISTORY Letterman’s echelon of care system, which began at the point
Battlefield medicine was pioneered at the turn of the 19th of injury (POI), incorporated aid stations and field hospitals,
century by Napoleon’s surgeon-in-chief, Dominique-Jean and ended at established medical centers created the founda-
Larrey. Larrey transformed a disorganized system that tion of American military medical doctrine.
relied on untrained civilians and self-evacuation to clear the
wounded from the battlefield to one with dedicated “flying
ambulances.”1 This structured ambulance corps moved all CURRENT ARMY DOCTRINE
casualties, friendly and enemy, 3 miles back from the front Current Army and Joint Service doctrine for evacuation and
line to designated field hospitals.2 There, surgeons would treatment of wounded personnel from the battlefield uses
triage the patients and provide the most up to date care before a similar tiered approach to these 18th and 19th century
moving them again by designated ambulances to hospitals in models. Treatment facilities are separated into Role 1, 2, 3,
France.1 Larrey moved the surgeon to the field, adopting the and 4, which define their capabilities.3 Role 1 care is the
“24 hour principle” to wound care. Instead of completing treatment provided prior to surgical intervention and includes
amputations days later through gangrenous and infected self-aid, buddy-aid, combat lifesaver, tactical combat casu-
tissue, popular at this time, Larrey’s surgeons operated alty care (TCCC), tactical evacuation, medical evacuation
promptly with increased survival using these techniques.1,2 (MEDEVAC), and treatment at the battalion/brigade aid sta-
At the start of the American Civil War, the disorganized tion (BAS). Role 1 aid stations are staffed by physicians,
Union Army took days to clear the First Battle of Bull Run physician assistants (PA), and medics (combat medics—68W,
because of reliance on quartermaster wagons and civilian special operations combat medics (SOCM), special forces
drivers. Recognizing the need to bring order to this process, medical sergeants that are assigned to the unit).4 The modified
Major (Dr) Jonathan Letterman designed a similar system to table of organization and equipment (MTOE) for a battalion
efficiently evacuate and treat wounded casualties with over- or brigade surgeon is designated as an operational surgeon—
sight removed from the quartermaster and replaced by medical immaterial (60A). This means these physicians are not always
officers. Trained and dedicated ambulance teams would move specifically trained in trauma medicine and instead are often
onto the battlefield and evacuate the wounded to forward residency trained in primary care or other nontrauma focused
aid stations. Triage, lifesaving interventions, and stabilization specialties.5,6 Role 1 doctrine is further defined by separate
of the wounded was conducted at these aid stations before ambulance and treatment teams to help transport patients from
casualties were moved further behind friendly lines to field a linear battlefield through the echelons of care prior to the
hospitals that could provide more advanced surgical care.2 Role 1. The ambulance teams, staffed by 68W medics, move
forward from the aid station to receive patients treated by
the integrated unit medics, and casualties are handed off at
* United States Army Special Operations Command, 75th Ranger Regi- designated ambulance exchange points. The ambulance teams
ment, 6510 Dawson Loop, Ft. Benning, GA 31905 transport the patients back, behind the forward line of own
† F. Edward Herbert School of Medicine, Uniformed Services University,
troops, to the Role 1 aid station. This Role 1 aid station
4301 Jones Bridge Road, Bethesda, MD 20814
Guarantor: LTC Ryan Knight treatment section is the first place the wounded encounters
The views expressed are solely those of the authors and do not reflect the a medical provider with an advanced scope of practice. The
official policy or position of the U.S. Army, the Department of Defense, or treatment section is divided into two teams with the physician
the U.S. Government. leading one and the PA leading the other, in order to maximize
doi:10.1093/milmed/usaa059
Published by Oxford University Press on behalf of the Association of the amount of lifesaving interventions. In this linear battle-
Military Surgeons of the United States 2020. This work is written by (a) US field, the ambulance teams then take the stabilized patients
Government employee(s) and is in the public domain in the US. to designated ambulance exchange points to hand off the

MILITARY MEDICINE, Vol. 185, September/October 2020 e1343

 Time to Update Army Medical Doctrine

TABLE I. U.S. Army, Navy and Air Force Role I and II Level Care

U.S. Army Role I/II U.S. Navy/Marine Corps Role I/II U.S. Air Force Role I/II

Focused on basic combat casualty care Echelons of care increase in capability Limited implementation of Role I/II
Field care often affected by operational Utilization of advanced life support in austere Far-forward deployability of advanced
limitations environments emergency medical care
Advanced life support not conducted in MEDEVAC provides advanced life support level MEDEVAC provides advanced life support
far-forward settings care level care
Evacuation medical care may be conducted by Far-forward, independent surgical capabilities Far-forward, independent surgical capabilities
lower level providers
System focused on medic bringing patient to Lacking dedicated tactical MEDEVAC resources Deployability limited by existence of secured
surgeon airstrip

Downloaded from https://academic.oup.com/milmed/article/185/9-10/e1343/5829705 by guest on 08 May 2023

MEDEVAC, medical evacuation.

casualties to the next ambulance team that will transport them instructing EMS crews to bypass closer hospitals in order to
to the next echelon of care further behind friendly lines.6 take the most severe patients to the hospital with the proper
Table I, as adopted from Gerhardt et al7 , summarizes the Role capabilities for that patient.11
1 and 2 echelons of the Army, Navy, and Air Force. Though civilian EMS has continued to advance, the great-
Role 2, also known as forward resuscitative care, has the est evolution has arguably occurred in the helicopter emer-
capability to manage more advanced trauma patients and gency medical services (HEMS) community. HEMS units
continue more advanced resuscitative measures. Forward Sur- showed the benefit of staffing with advanced paramedics,
gical Teams and Forward Resuscitative Surgical Teams can flight nurses, and even physicians. European HEMS is often
be colocated at a Role 2 or operate independently. Role 3 is staffed with an emergency trained physician because of the
a theater hospital, which is able to provide treatment for all clear and validated benefits in patient outcomes with this
types of patients. Lastly, Role 4 are brick and mortar hospitals staffing model. These teams of advanced medical providers
established both in the continental United States (previously are able to provide a higher level of care to the patient and
referred to as Role 5) and outside the continental United States decrease the time to lifesaving interventions. In addition, they
that provide definitive care.3,4 provide the experience and knowledge for early identification
and management of life-threatening disease processes.12

CHANGES TO THE CIVILIAN TRAUMA SYSTEM

Army doctrine has minimally changed since the Napoleonic
days and has used the same models, with increasing success, THE CHANGING BATTLEFIELD
throughout the 19th and 20th centuries in conflict. However, The global war on terrorism, being fought on the nonlinear
over this same time, the civilian model for delivering trauma battlefields of Iraq and the great expanse and nonlinear bat-
care has continuously evolved. Prior to the 1970s, hospitals tlefields of Afghanistan, Africa, and the Arabian Peninsula
staffed their emergency rooms with physicians of any spe- presented the military medical community with a great chal-
cialty but largely with primary care physicians. This lack lenge. Current Army medical doctrine is designed for a linear
of specifically trained physicians to properly intervene and battlefield with clear friendly and enemy lines as well as the
treat life-threatening conditions led to the birth of emergency movement of patients through an echeloned system. Role 1 aid
medicine as a specialty and with it came better patient out- stations were often located further away than Role 2 or even
comes. When emergent patients are cared for and treated by Role 3 facilities. Units quickly adapted and began taking their
emergency trained physicians when compared to general med- casualties directly to the facility with the highest capability
ical officers or primary care physicians, the result is reduced rather than through the echeloned system. This has caused
mortality.8 the Role 1 echelon to become rarely used on this modern
Emergency medical services (EMS) have also evolved and battlefield.
became more specialized. Medical directors were assigned In 2009, Secretary of Defense Robert Gates issued the
who wrote treatment protocols, trained state and nationally Gates Doctrine mandating that all approved missions must
licensed EMS personnel, professionally staffed the ambu- be able to transport casualties to a surgical facility within
lances, and provided both direct and indirect medical direction 60 min. By adopting the “Golden Hour” concept from civilian
to the prehospital providers.9 The civilian system also began medicine, he improved mortality on the battlefield.13 However
designating trauma centers based on their capabilities and with this mandate, Role 1 care became even more irrelevant
proved transporting patients to the facility with the proper as commanders no longer considered getting their wounded
capability led to a significant mortality benefit rather than to their unit medical personnel. Instead, mission planning was
merely transporting to the nearest hospital.10 The EMS sys- conducted against the “Golden Hour” and increasingly relied
tem began implementing national guidelines, which included on MEDEVAC rings to enable these operations.

e1344 MILITARY MEDICINE, Vol. 185, September/October 2020

 Time to Update Army Medical Doctrine

Although the civilian HEMS sector had continued to personnel already present on the battlefield and maximize
advance, the Army MEDEVAC system did not keep pace. their lifesaving competencies and capabilities. This optimal
As the role of MEDEVAC increased in the operational and maximized Role 1 utilization will be paramount in a near-
environment the MEDEVAC community began to slowly peer combat environment. The Damage Control Resuscitation
evolve. In 2008, a National Guard MEDEVAC unit began Team (DCRT) is a modular concept that can be adapted to
showing improved survivability with their transports as a linear or nonlinear battlefield. The core of the team will
compared to conventional, regular Army MEDEVAC.14 The be comprised of a physician, PA, and senior SOCM medic.
MEDEVAC personnel in this National Guard unit also worked This core can work as one or split into one, two, or three
casualty evacuation in their civilian jobs. They replaced 68Ws teams augmented by the BAS medics to provide advanced
with trained and experienced flight paramedics and flight resuscitation on the battlefield. The DCRT will be equipped to
nurses. be mobile enough to move alongside their fellow Rangers but
In addition, the British Medical Evacuation Resuscitation are agile enough to be employed in any CASEVAC platform

Downloaded from https://academic.oup.com/milmed/article/185/9-10/e1343/5829705 by guest on 08 May 2023

Team (MERT) demonstrated improved survivability with even or in a traditional Role 1 BAS. Their capability is to care for
more complex patients and longer transports. The MERT is a two critically injured Rangers for up to 6 h before logistical
MEDEVAC unit operating out of a CH47 Chinook helicopter constraints become limiting.
composed of a flight nurse and flight paramedic team. The In a traditional linear battlefield, these teams can move
MERT-enhanced model incorporates a physician provider. forward to meet the combat medic and begin resuscitation en
This physician involvement, usually emergency medicine or route back to the Role 1 BAS, decreasing the time to advanced
anesthesiologist trained, was associated with increased sur- team-based resuscitative care. They can also be employed on
vival.15 In this sector, online medical direction was utilized to the non-linear battlefield, as they are organic to the unit and
triage and launched the MERT for the most critically wounded can accompany assaulters on a mission. Here, combat medics
patients even if it meant a longer evacuation time. MERTs will provide the immediate TCCC and hand off to the DCRT
brought the resuscitation capability to the patient instead of at the casualty collection point, allowing the medic to return to
simply transporting the patient back to a facility for resusci- the fighting formation. The DCRT can continue care, evacuate
tation. Termed “scoop and play,” MERT is able to conduct with the patient, or hand off to a MEDEVAC platform for
resuscitation while transporting instead of having to decide transportation to a Role 2 or 3 facility.
between the conventional “stay and play” or “scoop and run” The key to this restructuring is in equipping and training.
paradigms. By doing so, they significantly reduced the time to Physicians and PAs must be trained in emergency and critical
resuscitation even if this meant flying a longer distance than a care medicine. The emphasis of all medical training for these
conventional MEDEVAC. positions must remain focused on providing advanced care
Upon analyzing these two scenarios, the U.S. military in an austere environment. Although courses and training
MEDEVAC community began to evolve and make changes in rehabilitation, infectious disease, tropical medicine, and
to match these modern concepts of HEMS. For example, in sports medicine are important, they are not critical to emer-
2012, the Army converted flight medics to flight paramedics, gently saving lives on the battlefield and should not be the
increasing the capability of the provider transporting the focus of DCRT members. In addition to courses and train-
patient. ing, DCRT members must receive patient care experience
through different evacuation platforms in order to apply the
lessons learned to real life patients. Finally, the team will
ANSWERING THE NEED FOR CHANGE be worked into the training cycle and support the battal-
Through this revolution in medical evacuation, the Army has ion during all training events to develop tactics, techniques,
not changed its doctrine, training, or concept for Role 1 care. and procedures for employing on a variety of terrains and
The model is largely the same as it was after Letterman made missions.
his changes and demonstrated their effectiveness at the Battle The DCRT will be specifically equipped to provide Dam-
of Antietam in 1862. The doctrine has ignored this evolution in age Control Resuscitation (DCR) and Advanced Resuscitative
the civilian landscape regarding specialty trained emergency Care (ARC). DCR and ARC can be defined as whole blood
providers, bypassing facilities to deliver the patient to the resuscitation, abdominopelvic hemorrhage control, advanced
most appropriate hospital rather than the closest facility, dedi- airway/monitoring, and resuscitation driven by labs (lactate).
cated medical directors, standardized protocols for prehospital The traditional American College of Surgeons Advanced
providers, and a quality improvement process. Trauma Life Support course, which currently serves as the
The 75th Ranger Regiment proposes to change this foundation for Role 1 care in the Army, does not provide
paradigm and follow the MEDEVAC community in acknowl- the sufficient methods for battlefield resuscitation and will
edging the need to evolve and learn from our civilian not be the focus for the DCRT. The basic load out for the
counterparts. The time has come to dissolve the traditional DCRT includes ventilators, invasive/noninvasive monitors,
ambulance and treatment teams and form a new DCRT. The blood/fluid warmers, ultrasound, vasoactive medications,
DCRT will utilize organic and MTOE’d Role 1 providers and sedation medications, and blood products. These are all small,

MILITARY MEDICINE, Vol. 185, September/October 2020 e1345

 Time to Update Army Medical Doctrine

lightweight, and portable to allow for ease of carrying and 3. U.S. Department of Defense. Joint Health Services. Joint Publication 4-
mobility. Large equipment, such as full size monitors, oxygen 02. Arlington, VA. 2018 Sep 28: I-1 - GL-16.
tanks, and traditional ventilators, suitable for a traditional Role 4. U.S. Department of the Army. Army Health System Support Planning.
Army Techniques Publication 4-02.55. Washington, DC. 2015 Sep 16:
1 BAS is not practical for a mobile team. 1-1 - G-3.
5. Mulvaney S, Kim TS. Tactical Field Skills for the Military Physician.
SUMMARY In: Fundamentals of Military Medicine. Fort Detrick, Borden Institute,
2019. pp 153–64.
Whereas civilian medicine has continuously evolved, Army 6. U.S. Department of the Army. Casualty Care. Army Techniques Publi-
doctrine for battlefield care has remained largely unchanged cation 4-02.5. Washington, DC. 2013 May 10: 1-1 - G-5.
since the Civil War. The MEDEVAC community, when pre- 7. Gerhardt RT, Mabry RL, De Lorenzo RA, Butler FK: Fundamen-
sented with statistics demonstrating the improved survivabil- tals of Combat Casualty Care. In: Combat Casualty Care: Lessons
ity in adapting the civilian model to the modern military, Learned from OEF and OIF. Fort Detrick: Borden Institute, 2012;
447–469.

Downloaded from https://academic.oup.com/milmed/article/185/9-10/e1343/5829705 by guest on 08 May 2023

made changes to the training of medics to more appropriately 8. Bailey H, Bond MC, Reiter M et al: The value of board certification and
match the civilian HEMS model. However, the Role 1 echelon residency training in emergency medicine. Common Sense — Newsl Am
has not changed even when faced with little utility on the Acad Emerg Med 2011; 18: 18–20.
modern battlefield. Instead, Role 1 care has evolved to provide 9. Shah MN: The formation of the emergency medical services system. Am
preventative care, basic urgent care, and sports medicine for J Public Health 2006; 96: 414–23. doi: 10.2105/AJPH.2004.048793.
10. MacKenzie EJ, Rivara FP, Jurkovich GJ et al: A national evaluation of
a largely healthy, homogenous population without improve- the effect of trauma-center care on mortality. N Engl J Med 2006; 354:
ment of battlefield survivability. With discussions regarding 366–78. doi: 10.1056/NEJMsa052049.
care in a near-peer conflict, attention has turned to training 11. Centers for Disease Control and Prevention: Guidelines for field triage
prolonged field care as the solution. The 75th Ranger Regi- of injured patients recommendations of the National Expert Panel. 2012;
ment proposes to change this model by resourcing, training, 61: 1–21.
12. Den Hartog D, Romeo J, Ringburg AN, Verhofstad MHJ, Van Lieshout
and employing DCRTs at each battalion by restructuring EMM: Survival benefit of physician-staffed helicopter emergency med-
the training and equipment for the Role 1 BAS to provide ical services (HEMS) assistance for severely injured patients. Injury
emergency and critical care resuscitation at or near the POI, 2015; 46: 1281–6. doi: 10.1016/j.injury.2015.04.013.
en route during CASEVAC, or in a traditional Role 1 BAS 13. Kotwal RS, Howard JT, Orman JA et al: The effect of a golden hour
model. policy on the morbidity and mortality of combat casualties. JAMA Surg
2016; 151: 15–24. doi: 10.1001/jamasurg.2015.3104.
14. Mabry RL, Apodaca A, Penrod J, Orman JA, Gerhardt RT, Dorlac
WC: Impact of critical care trained flight paramedics on casualty
REFERENCES survival during helicopter evacuation in the current war in
1. Ortiz JM: The revolutionary flying ambulance of Napoleon’s surgeon. Afghanistan. J Trauma Acute Care Surg 2012; 73: S32–7. doi:
US Army Med Dep J 1998; 4: 17–25. 10.1097/TA.0b013e3182606001.
2. Kharod CU, Shackelford BM, Mabry RL. Casualty transport and evac- 15. Calderbank P, Woolley T, Mercer S et al: Doctor on board? What is the
uation. In: Fundamentals of Military Medicine. Fort Detrick: Borden optimal skill-mix in military pre-hospital care? Emerg Med J 2011; 28:
Institute, 2019. pp 603–20. 882–3. doi: 10.1136/emj.2010.097642.

e1346 MILITARY MEDICINE, Vol. 185, September/October 2020