Page 12 - JSOM Winter 2025

Invasion in World War II, the U.S. Army evacuated over and restore homeostasis. At the tactical level, the physics of
65,000 casualties by land, air, and sea across the English Chan- resuscitation (restoring homeostasis, preventing hypothermia,
nel to England, leveraging networks of existing ports and air- mitigating coagulopathy, and deterring acidosis) and mechan-
ports, landing ship tanks (LST), trains, aircraft, and ground ics of injury (penetrating trauma, burn and blast injuries) has a
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MEDEVAC. Meanwhile, the Allies in the Pacific theater faced significant impact on saving lives. At the operational and stra-
less-than-ideal conditions. The area was dominated by a vast tegic levels, physics will determine the time, space, and flow
ocean dotted with thick jungle, poor road conditions, and required for casualty movement across the continuum of care;
rocky terrain that favored Japanese defenders. Casualty num- this is where CASEVAC plays an important role. Finally, re-
bers at Iwo Jima and Okinawa surpassed 18,000, and over- source and risk analysis will determine the approach or action
all casualty rates exceeded the invasion of Normandy during (or non-action) required to perform a function. In the case of
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Iwo Jima. The Battle of Saipan resulted in higher casualty casualty survivability, with all other factors considered, such
rates, nearing 20%, with 14,111 of 71,034 personnel killed, as risk to mission and risk force, action favors inaction.
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wounded, or missing. Under these demanding conditions, the
Navy employed multi-modal CASEVAC, using rubber boats, During a large-scale combat operation, mass casualty inci-
Navy light tankers, flying boat planes, half-tracks, tanks, and dents will be frequent and exceed the resources necessary to
motor torpedo boats to evacuate casualties in rugged ter- evacuate patients to definitive care in the time required to
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rain or areas with heavy fighting. Until the islands’ airfields maximize patient survival. Other considerations are oper-
were secure, many patients were evacuated by LST from the ations or circumstances where large volumes of patients are
beachheads, often without medical equipment or markings, created and a mismatch between patient carrying capacity
to hospital ships, then taken by hospital ship for several days and volume occurs. For example, past division and corps-level
or evacuated by air, sometimes over 2,400 miles. This exten- exercises conducted by the U.S. Army’s Mission Command
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sive evacuation network required regulated patient movement Training Program (MCTP) averaged 50-55,000 casualties per
from the tactical level to the strategic level to ensure the right 100,000 personnel assigned over 8 days across multiple ex-
resources were available to evacuate large numbers of casual- ercises. This high volume of casualties would require a di-
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ties (Table 1). 6 vision or corps staff to plan CASEVAC versus MEDEVAC as
the primary means of evacuation, leveraging a diverse array
TABLE 1 Cross-Channel Evacuation Numbers by Air and Water of platforms to maximize survivability. The Ukraine conflict
Month Air Water Total shows that mass casualties, enemy targeting of medical facili-
June 6,469 20,923 27,392 ties and casualties, and significant evacuation delays caused by
area denial with indirect fires and lethal drones illuminate the
July 19,490 18,195 37,685 increasing lethality of modern warfare.1 The U.S. will have to
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Total 25,959 39,118 65,077 ruthlessly think, plan, act, and exploit our capabilities in a way
Source: Evacuation Branch, Operations Division, OofSurg, HQ, that we have not before.
ETOUSA, Annual Rpt, 1944, encl.10.
Adapted from Cosmas GA, Cowdrey AE. The Medical Department: CASEVAC Needs Reprioritization in Doctrine
Medical Service in the European Theater of Operations. US Army
Center of Military History; 1992. Modern warfare requires the Army to reconsider the current
relationship between CASEVAC and MEDEVAC as defined
CASEVAC is one of the three forms of patient move- in doctrine. Army Training Pamphlet (ATP) 4-02.13, Casu-
ment ( CASEVAC, MEDEVAC, and strategic evacuation alty Evacuation, states, “CASEVAC supports the Army Health
[ STRATEVAC]) and is defined as the “unregulated move- System by providing a means to augment MEDEVAC.” The
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ment of casualties aboard any platform.” CASEVAC includes demands of recent conflicts have created a need to balance
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planned and unplanned patient movement and may not include maximizing lives saved versus saving those who are most
medical personnel or equipment unless precoordinated. More likely to return to their units to fight. During the GWOT, IEDs
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recently, CASEVAC proved itself in a study of 28,222 casual- accounted for 79% of injuries, with most personnel injured
ties (of which 498 underwent CASEVAC), spanning Operation able to recover. 14,15 In Ukraine, Russian antitank, artillery,
Enduring Freedom, Operation Iraqi Freedom, Operation New and thermobaric weapons significantly led to mortality rates
Dawn, and Operation Freedom’s Sentinel. In that study, most as high as 75%.1 The stark differences in casualty numbers,
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U.S. military service members undergoing CASEVAC survived combined with differences in mortality rates, indicate that CA-
hospital discharge. Though this study is promising, recent SEVAC will become the primary means to evacuate patients to
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uses of CASEVAC are mainly limited to tactical employment, match demand.
and the CASEVAC capabilities and capacity demonstrated
during World War II are primarily forgotten due to decades of While not doctrinally defined, the authors contend that regu-
low-intensity conflict. As a result of focusing on MEDEVAC lated movement of casualties is defined as planned and con-
over planned CASEVAC, the Army is unprepared to meet the trolled movement of casualties using dedicated evacuation
demands of a large-scale conflict that will be violent, long, and assets from the point of injury to a definitive level of care. The-
beyond a scale and scope this generation has experienced. ater armies, corps, and divisions require a unified approach
that ensures CASEVAC is planned, controlled, and resourced
Discussion using multiple means of transport to effectively evacuate enor-
mous numbers of casualties. Ensuring commanders have the
Two sets of factors ensure casualty survivability: time, pres- flexibility to plan, resource, and execute CASEVAC requires
sure, and physics (e.g., mechanics of injury and treatment), a proponent to provide a unified approach across the contin-
risk (e.g., the balance between medical and tactical risk). Time uum of doctrine, organization, training, material, leader and
to intervention plays a significant role in mitigating mortality education, personnel, facilities, and policy (DOTMLPF-P)
and morbidity, while pressure is required to arrest bleeding analysis.

10 | JSOM Volume 25, Edition 4 / Winter 2025