In times of conflict and crisis, the safety and wellbeing of military personnel is of paramount importance. When troops are injured on the battlefield or fall ill in remote and hostile environments, time becomes a critical factor in their chances of survival and recovery. This is where military air medical evacuation, often referred to as ‘medevac’, plays a crucial role in ensuring that wounded or sick service members receive the necessary medical attention in a timely and efficient manner.

One of the most significant advantages of military air medical evacuation is the speed at which medical care can be delivered to those in need. Time is often a critical factor in the survival and recovery of injured service members. The ability to transport casualties swiftly to medical facilities equipped with specialized personnel and equipment vastly improves their chances of receiving life-saving treatment.

Moreover, air medical evacuation enables injured service members to access medical facilities that offer a higher level of care than what may be available in field hospitals or combat zones. These advanced medical facilities have the resources to handle severe injuries and complex medical conditions, increasing the likelihood of a positive outcome for the patient.

Recent capabilities

In its most basic context, military air medical evacuation involves the rapid tactical and strategic transportation of injured or sick personnel from the battlefield to higher-tier medical facilities. Sad as it is, there is no better learning environment than an active combat theatre in which new approaches to air medicine and air medical evacuation tend to evolve. The reality is that these skills are perishable, so in times of peace, military air medical specialists often train at civilian trauma centers to keep their skills current.

In addition to air medical evacuation in times of conflict, many military services are also tasked with air medical evacuation of

These skills are perishable, so in times of peace, military air medical specialists often train at civilian trauma centers to keep their skills current

civilians as military units are often the only resource that can provide such capability. The Covid-19 pandemic was another instance where military air medical evacuation came to the fore, as exhibited by numerous efforts to safely airlift contagious patients. One example is the United States Air Force (USAF)-led effort to acquire and repurpose a shipping container into a Negatively Pressurized CONEX (NPC), which is an isolated, safe space to transport afflicted individuals while protecting the aircrew and preventing contamination of the aircraft. According to the Air Force Medical Service, the NPC represents a larger version of a similar Air Force capability called the Transport Isolation System (TIS) – an infectious disease chamber developed to transfer individuals during the 2014 Ebola crisis.

Examples of military air medical evacuation operators who regularly aid civilians include the Royal Norwegian Air Force and the Royal Canadian Air Force (RCAF), both of whom use variants of the AW101 for search and rescue and air medical evacuation, as required.

Speaking to their capability, a member of 330 Squadron of the Royal Norwegian Air Force said: “The SAR equipment carried on board enables us to operate safely in all the different environments, including rough sea hoisting, mountain rescue, waterfalls, glaciers and more. When casualties are on board, the medics have the essential equipment of a hospital emergency room to treat the patients in flight.”

When casualties are on board, the medics have the essential equipment of a hospital emergency room to treat the patients in flight

On the Canadian front, the RCAF has embarked on its Cormorant Mid-Life Upgrade project, which will address obsolescence, increase the fleet size, and add new capabilities to the airframe. The RCAF has also embarked on a path to build on its forward air medical evacuation (FwdAE) capability that it developed for its CH-147F Chinook fleet, and is now bringing a similar, albeit more compact version of the Canadian Medical Emergency Response Team (CMERT) capability to the CH-146 Griffon helicopter. The full CMERT capability provides advanced pre-hospital care including damage control resuscitation involving fresh whole blood and advanced airway management. Depending on the operational and environmental conditions, crews will pick up casualties as far forward as tactically possible.

Major Ryan Malvern, who works in the Directorate of Air Requirements 9 for Tactical Aviation in the RCAF, said: “The air medical evacuation capability that the RCAF developed was built on the lessons learned from our European allies, and was implemented for Canada’s contribution to the United Nations efforts in Mali. That capability includes a physician, a critical care nurse, two medical technicians, and a force protection team of four. We now want to go forward with a Griffon CMERT model. It will be similar to what we have on the Chinook, but scaled to a smaller package. What that package is, and what the tactics, techniques and procedures will look like is still in development as we just started this process in the spring.”

Medical advancements

Of all the operators in the world, the US military has the largest fleet of rotary-wing tactical and strategic aircraft that are able to conduct medevac. Air medical evacuations from the battlefield are typically carried out using rotary-wing aircraft like the UH-60 Black Hawk, CH-47 Chinook and CV-22 Osprey, or fixed-wing aircraft like the C-130 Hercules, which is a ubiquitous intratheater airlifter. Medical evacuation does not end there, however, as seriously wounded patients are usually repatriated to home countries on strategic airlift aircraft, of which the C-17 has become a go-to platform for the USA, but it is certainly not the only one as the venerable KC-135 and KC-10 aircraft, and the newer KC-46 are all capable of air medical evacuation when appropriately configured.

Lieutenant Colonel Steve Soliz (Retired), former Commander of 433 Aeromedical Evacuation Squadron of the USAF and currently the HEMS Segment Manager at Bell, stated: “One of the things that doctors did in the desert was damage control resuscitation. It was less about keeping blood pressure around 120/80bpm, and was more about mean arterial pressure to perfuse the brain. That’s what was really needed to keep patients alive, because you didn’t want to blow out any temporary measures that were taken for homeostasis – which was usually emergency surgery. So, you’d keep pressures low as long as the brain and kidney were perfused, after which you’d evacuate to Ramstein Air Base.”

Whole blood gives you red blood cells for oxygenation / oxygen securing capacity, it gives you plasma for your volume expander, and the most important thing it gives you is all the clotting factors

Soliz added: “We saw a lot of advancements from that time, and still today there is an evolutionary change in the military to giving fresh whole blood, and that’s trickling to civilian practice. San Antonio AirLIFE – a not-for-profit air ambulance service that partnered about 10 years ago with Brooke Army Medical Center and University Hospital in San Antonio – was one of the first programs in the USA to start giving fresh whole blood out in the field. That’s because we learned that whole blood gives you red blood cells for oxygenation / oxygen securing capacity, it gives you plasma for your volume expander, and the most important thing it gives you is all the clotting factors. That is a big game changer because it increased survivability greatly, and it decreased the need for transfusions in the hospital significantly as well. There are still parts of the USA that don’t have a robust trauma system who are just getting that going, and that’s a good thing, better late than never because they will save people.”

Another game changing medical capability which has found its way into air medical evacuation is extracorporeal membrane oxygenation (ECMO). “Having a small ECMO machine and the ability to cannulate in an austere location, and then evacuate patients to tertiary care facilities really changes the game when it comes to trauma care,” said Soliz.

Speaking about ECMO was USAF Colonel Terence Lonergan, ECMO Director at Brooke Army Medical Center: “There was a team at Landstuhl Hospital in Germany during the Iraq and Afghanistan wars that noticed that, every once in a while, we would have someone in theatre that was too sick to move using conventional ventilatory support. Those physicians trained with the Germans because the Europeans were very forward thinking in their development of this – more than Americans at the 2005 to 2010 timeframe – so they trained in Germany and stood up a team that was called the Acute Lung Rescue Team that ended up doing 10 evacuations at the height of the war with 90 per cent surviving. That was really the first evidence that we had that it was combat applicable. That number may not sound like a lot, but That number may not sound like a lot, but ECMO wasn’t readily available for most of the war … This has really become part of modern critical care, and we’re going to need to project this to our sickest subset of casualties … We can take someone who’s got 90 per cent mortality and give them a two-thirds chance of survival with the application of ECMO. What I think is unique about the military is our ability to go long distance and scale it.”

The ability to scale up depends on numbers of trained personnel and the availability of adequately configured platforms. Many allied air forces along with NATO are acquiring the Airbus A330 Multi-Role Tanker Transport (MRTT) for strategic airlift. In fact, the Royal Canadian Air Force announced on 25 July 2023, that it is acquiring nine A330 MRTT aircraft, which will be designated as the CC-330 Husky. The CC-330 will conduct various lines of tasking, including air medical evacuation as needed.

Based on experience with military aircraft such as the A330 MRTT and A400M, Airbus has developed a new Intensive Care Transport Module for its C295 aircraft. “Our main objective is for it to be a low-cost, modular solution, allowing the same aircraft to be used for various types of missions, either with all the equipment as a mobile intensive care unit (ICU) or a more basic configuration,” said Ángel Sánchez Franco, Project Lead at Airbus Defence and Space.

According to an Airbus release, the development of the mobile ICU is the result of Airbus’ experience designing different types of medevac solutions over the years and discussions held with the Spanish Air Force’s Aero Evacuation Medical Unit (UMAER) and other areas’ military forces, such as Portugal and Czechia. “We have integrated direct feedback from medical teams such as varying the placement of oxygen cylinders to stay out of the way or having a greater number of plugs. In addition, we have designed a new quick-attach mechanism so that the module can be quickly assembled and disassembled,” said Franco.

A sobering reality

This article began with the statement that in times of conflict and crisis, the safety and wellbeing of military personnel is of paramount importance. It is, therefore, essential to have a robust military air medical evacuation capability. However, the biggest revelation in researching this article wasn’t the medical advances that are percolating through tests and trials, rather it is the sobering reality that the potential of a near-peer or peer conflict – think Indo-Pacific region – will be one that will have large numbers of severe casualties, coupled with the immense challenge of negotiating vast distances and remote areas. In this theatre, the lauded ‘golden hour’ will be utterly unattainable.

Military experts raised alarm bells about the lack of funding directed towards military air medical evacuation capability, both in terms of trained personnel and platforms

Military experts who spoke on the condition of anonymity raised alarm bells about the lack of funding directed towards military air medical evacuation capability, both in terms of trained personnel and platforms. The problem is enormous, and although a service like the USAF has the capacity to scale up, the reality is that this capacity is limited, and a kinetic conflict will obligate the vast majority of airlift aircraft to ‘beans and bullets’ logistics, and to support functions like air-to-air refueling.

Despite all the advances, there simply aren’t enough air medical evacuation resources available, and the consensus is that although modern medical technology vastly improves patient survival, there would not be enough of any of it in a peer conflict, and there certainly would not be the type of exquisite care that allied forces have become accustomed to from decades of counter-insurgency operations in largely permissive environments.

The potential conflict that was described will be one where air medical evacuation will, by necessity, have to be a scoop-and-go effort, and that should give everyone pause to wonder if enough resources will be available for this worst case scenario.