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* ;
2LT Montane B. Silverman, BA, MSC USA†
BATTLEFIELD CARE THROUGHOUT HISTORY
Battlefield medicine was pioneered at the turn of the 19th
century by Napoleon’s surgeon-in-chief, Dominique-Jean
Larrey. Larrey transformed a disorganized system that
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
casualties, friendly and enemy, 3 miles back from the front
line to designated field hospitals.2 There, surgeons would
triage the patients and provide the most up to date care before
moving them again by designated ambulances to hospitals in
France.1 Larrey moved the surgeon to the field, adopting the
“24 hour principle” to wound care. Instead of completing
amputations days later through gangrenous and infected
tissue, popular at this time, Larrey’s surgeons operated
promptly with increased survival using these techniques.1,2
At the start of the American Civil War, the disorganized
Union Army took days to clear the First Battle of Bull Run
because of reliance on quartermaster wagons and civilian
drivers. Recognizing the need to bring order to this process,
Major (Dr) Jonathan Letterman designed a similar system to
efficiently evacuate and treat wounded casualties with over-
sight removed from the quartermaster and replaced by medical
officers. Trained and dedicated ambulance teams would move
onto the battlefield and evacuate the wounded to forward
aid stations. Triage, lifesaving interventions, and stabilization
of the wounded was conducted at these aid stations before
casualties were moved further behind friendly lines to field
hospitals that could provide more advanced surgical care.2
* United States Army Special Operations Command, 75th Ranger Regi-
ment, 6510 Dawson Loop, Ft. Benning, GA 31905
† F. Edward Herbert School of Medicine, Uniformed Services University,
4301 Jones Bridge Road, Bethesda, MD 20814
Guarantor: LTC Ryan Knight
The views expressed are solely those of the authors and do not reflect the
official policy or position of the U.S. Army, the Department of Defense, or
the U.S. Government.
doi:10.1093/milmed/usaa059
Published by Oxford University Press on behalf of the Association of
Military Surgeons of the United States 2020. This work is written by (a) US
Government employee(s) and is in the public domain in the US.
MILITARY MEDICINE, Vol. 185, September/October 2020
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Letterman’s echelon of care system, which began at the point
of injury (POI), incorporated aid stations and field hospitals,
and ended at established medical centers created the founda-
tion of American military medical doctrine.
CURRENT ARMY DOCTRINE
Current Army and Joint Service doctrine for evacuation and
treatment of wounded personnel from the battlefield uses
a similar tiered approach to these 18th and 19th century
models. Treatment facilities are separated into Role 1, 2, 3,
and 4, which define their capabilities.3 Role 1 care is the
treatment provided prior to surgical intervention and includes
self-aid, buddy-aid, combat lifesaver, tactical combat casu-
alty care (TCCC), tactical evacuation, medical evacuation
(MEDEVAC), and treatment at the battalion/brigade aid sta-
tion (BAS). Role 1 aid stations are staffed by physicians,
physician assistants (PA), and medics (combat medics—68W,
special operations combat medics (SOCM), special forces
medical sergeants that are assigned to the unit).4 The modified
table of organization and equipment (MTOE) for a battalion
or brigade surgeon is designated as an operational surgeon—
immaterial (60A). This means these physicians are not always
specifically trained in trauma medicine and instead are often
residency trained in primary care or other nontrauma focused
specialties.5,6 Role 1 doctrine is further defined by separate
ambulance and treatment teams to help transport patients from
a linear battlefield through the echelons of care prior to the
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
designated ambulance exchange points. The ambulance teams
transport the patients back, behind the forward line of own
troops, to the Role 1 aid station. This Role 1 aid station
treatment section is the first place the wounded encounters
a medical provider with an advanced scope of practice. The
treatment section is divided into two teams with the physician
leading one and the PA leading the other, in order to maximize
the amount of lifesaving interventions. In this linear battle-
field, the ambulance teams then take the stabilized patients
to designated ambulance exchange points to hand off the
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 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
Field care often affected by operational
limitations
Advanced life support not conducted in
far-forward settings
Evacuation medical care may be conducted by
lower level providers
System focused on medic bringing patient to
surgeon
Echelons of care increase in capability
Utilization of advanced life support in austere
environments
MEDEVAC provides advanced life support level
care
Far-forward, independent surgical capabilities
Lacking dedicated tactical MEDEVAC resources
Limited implementation of Role I/II
Far-forward deployability of advanced
emergency medical care
MEDEVAC provides advanced life support
level care
Far-forward, independent surgical capabilities
Deployability limited by existence of secured
airstrip

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MEDEVAC, medical evacuation.

casualties to the next ambulance team that will transport them
to the next echelon of care further behind friendly lines.6
Table I, as adopted from Gerhardt et al7 , summarizes the Role
1 and 2 echelons of the Army, Navy, and Air Force.
Role 2, also known as forward resuscitative care, has the
capability to manage more advanced trauma patients and
continue more advanced resuscitative measures. Forward Sur-
gical Teams and Forward Resuscitative Surgical Teams can
be colocated at a Role 2 or operate independently. Role 3 is
a theater hospital, which is able to provide treatment for all
types of patients. Lastly, Role 4 are brick and mortar hospitals
established both in the continental United States (previously
referred to as Role 5) and outside the continental United States
that provide definitive care.3,4
instructing EMS crews to bypass closer hospitals in order to
take the most severe patients to the hospital with the proper
capabilities for that patient.11
Though civilian EMS has continued to advance, the great-
est evolution has arguably occurred in the helicopter emer-
gency medical services (HEMS) community. HEMS units
showed the benefit of staffing with advanced paramedics,
flight nurses, and even physicians. European HEMS is often
staffed with an emergency trained physician because of the
clear and validated benefits in patient outcomes with this
staffing model. These teams of advanced medical providers
are able to provide a higher level of care to the patient and
decrease the time to lifesaving interventions. In addition, they
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,
throughout the 19th and 20th centuries in conflict. However,
over this same time, the civilian model for delivering trauma
care has continuously evolved. Prior to the 1970s, hospitals
staffed their emergency rooms with physicians of any spe-
cialty but largely with primary care physicians. This lack
of specifically trained physicians to properly intervene and
treat life-threatening conditions led to the birth of emergency
medicine as a specialty and with it came better patient out-
comes. When emergent patients are cared for and treated by
emergency trained physicians when compared to general med-
ical officers or primary care physicians, the result is reduced
mortality.8
Emergency medical services (EMS) have also evolved and
became more specialized. Medical directors were assigned
who wrote treatment protocols, trained state and nationally
licensed EMS personnel, professionally staffed the ambu-
lances, and provided both direct and indirect medical direction
to the prehospital providers.9 The civilian system also began
designating trauma centers based on their capabilities and
proved transporting patients to the facility with the proper
capability led to a significant mortality benefit rather than
merely transporting to the nearest hospital.10 The EMS sys-
tem began implementing national guidelines, which included
THE CHANGING BATTLEFIELD
The global war on terrorism, being fought on the nonlinear
battlefields of Iraq and the great expanse and nonlinear bat-
tlefields of Afghanistan, Africa, and the Arabian Peninsula
presented the military medical community with a great chal-
lenge. Current Army medical doctrine is designed for a linear
battlefield with clear friendly and enemy lines as well as the
movement of patients through an echeloned system. Role 1 aid
stations were often located further away than Role 2 or even
Role 3 facilities. Units quickly adapted and began taking their
casualties directly to the facility with the highest capability
rather than through the echeloned system. This has caused
the Role 1 echelon to become rarely used on this modern
battlefield.
In 2009, Secretary of Defense Robert Gates issued the
Gates Doctrine mandating that all approved missions must
be able to transport casualties to a surgical facility within
60 min. By adopting the “Golden Hour” concept from civilian
medicine, he improved mortality on the battlefield.13 However
with this mandate, Role 1 care became even more irrelevant
as commanders no longer considered getting their wounded
to their unit medical personnel. Instead, mission planning was
conducted against the “Golden Hour” and increasingly relied
on MEDEVAC rings to enable these operations.

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 Time to Update Army Medical Doctrine
Although the civilian HEMS sector had continued to
advance, the Army MEDEVAC system did not keep pace.
As the role of MEDEVAC increased in the operational
environment the MEDEVAC community began to slowly
evolve. In 2008, a National Guard MEDEVAC unit began
showing improved survivability with their transports as
compared to conventional, regular Army MEDEVAC.14 The
MEDEVAC personnel in this National Guard unit also worked
casualty evacuation in their civilian jobs. They replaced 68Ws
with trained and experienced flight paramedics and flight
nurses.
In addition, the British Medical Evacuation Resuscitation
Team (MERT) demonstrated improved survivability with even
more complex patients and longer transports. The MERT is a
MEDEVAC unit operating out of a CH47 Chinook helicopter
composed of a flight nurse and flight paramedic team. The
MERT-enhanced model incorporates a physician provider.
This physician involvement, usually emergency medicine or
anesthesiologist trained, was associated with increased sur-
vival.15 In this sector, online medical direction was utilized to
triage and launched the MERT for the most critically wounded
patients even if it meant a longer evacuation time. MERTs
brought the resuscitation capability to the patient instead of
simply transporting the patient back to a facility for resusci-
tation. Termed “scoop and play,” MERT is able to conduct
resuscitation while transporting instead of having to decide
between the conventional “stay and play” or “scoop and run”
paradigms. By doing so, they significantly reduced the time to
resuscitation even if this meant flying a longer distance than a
conventional MEDEVAC.
Upon analyzing these two scenarios, the U.S. military
MEDEVAC community began to evolve and make changes
to match these modern concepts of HEMS. For example, in
2012, the Army converted flight medics to flight paramedics,
increasing the capability of the provider transporting the
patient.
ANSWERING THE NEED FOR CHANGE
Through this revolution in medical evacuation, the Army has
not changed its doctrine, training, or concept for Role 1 care.
The model is largely the same as it was after Letterman made
his changes and demonstrated their effectiveness at the Battle
of Antietam in 1862. The doctrine has ignored this evolution in
the civilian landscape regarding specialty trained emergency
providers, bypassing facilities to deliver the patient to the
most appropriate hospital rather than the closest facility, dedi-
cated medical directors, standardized protocols for prehospital
providers, and a quality improvement process.
The 75th Ranger Regiment proposes to change this
paradigm and follow the MEDEVAC community in acknowl-
edging the need to evolve and learn from our civilian
counterparts. The time has come to dissolve the traditional
ambulance and treatment teams and form a new DCRT. The
DCRT will utilize organic and MTOE’d Role 1 providers and
MILITARY MEDICINE, Vol. 185, September/October 2020
personnel already present on the battlefield and maximize
their lifesaving competencies and capabilities. This optimal
and maximized Role 1 utilization will be paramount in a near-
peer combat environment. The Damage Control Resuscitation
Team (DCRT) is a modular concept that can be adapted to
a linear or nonlinear battlefield. The core of the team will
be comprised of a physician, PA, and senior SOCM medic.
This core can work as one or split into one, two, or three
teams augmented by the BAS medics to provide advanced
resuscitation on the battlefield. The DCRT will be equipped to
be mobile enough to move alongside their fellow Rangers but
are agile enough to be employed in any CASEVAC platform
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or in a traditional Role 1 BAS. Their capability is to care for
two critically injured Rangers for up to 6 h before logistical
constraints become limiting.
In a traditional linear battlefield, these teams can move
forward to meet the combat medic and begin resuscitation en
route back to the Role 1 BAS, decreasing the time to advanced
team-based resuscitative care. They can also be employed on
the non-linear battlefield, as they are organic to the unit and
can accompany assaulters on a mission. Here, combat medics
will provide the immediate TCCC and hand off to the DCRT
at the casualty collection point, allowing the medic to return to
the fighting formation. The DCRT can continue care, evacuate
with the patient, or hand off to a MEDEVAC platform for
transportation to a Role 2 or 3 facility.
The key to this restructuring is in equipping and training.
Physicians and PAs must be trained in emergency and critical
care medicine. The emphasis of all medical training for these
positions must remain focused on providing advanced care
in an austere environment. Although courses and training
in rehabilitation, infectious disease, tropical medicine, and
sports medicine are important, they are not critical to emer-
gently saving lives on the battlefield and should not be the
focus of DCRT members. In addition to courses and train-
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
be worked into the training cycle and support the battal-
ion during all training events to develop tactics, techniques,
and procedures for employing on a variety of terrains and
missions.
The DCRT will be specifically equipped to provide Dam-
age Control Resuscitation (DCR) and Advanced Resuscitative
Care (ARC). DCR and ARC can be defined as whole blood
resuscitation, abdominopelvic hemorrhage control, advanced
airway/monitoring, and resuscitation driven by labs (lactate).
The traditional American College of Surgeons Advanced
Trauma Life Support course, which currently serves as the
foundation for Role 1 care in the Army, does not provide
the sufficient methods for battlefield resuscitation and will
not be the focus for the DCRT. The basic load out for the
DCRT includes ventilators, invasive/noninvasive monitors,
blood/fluid warmers, ultrasound, vasoactive medications,
sedation medications, and blood products. These are all small,
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 Time to Update Army Medical Doctrine
lightweight, and portable to allow for ease of carrying and
mobility. Large equipment, such as full size monitors, oxygen
tanks, and traditional ventilators, suitable for a traditional Role
1 BAS is not practical for a mobile team.
SUMMARY
Whereas civilian medicine has continuously evolved, Army
doctrine for battlefield care has remained largely unchanged
since the Civil War. The MEDEVAC community, when pre-
sented with statistics demonstrating the improved survivabil-
ity in adapting the civilian model to the modern military,
made changes to the training of medics to more appropriately
match the civilian HEMS model. However, the Role 1 echelon
has not changed even when faced with little utility on the
modern battlefield. Instead, Role 1 care has evolved to provide
preventative care, basic urgent care, and sports medicine for
a largely healthy, homogenous population without improve-
ment of battlefield survivability. With discussions regarding
care in a near-peer conflict, attention has turned to training
prolonged field care as the solution. The 75th Ranger Regi-
ment proposes to change this model by resourcing, training,
and employing DCRTs at each battalion by restructuring
the training and equipment for the Role 1 BAS to provide
emergency and critical care resuscitation at or near the POI,
en route during CASEVAC, or in a traditional Role 1 BAS
model.
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