In a conference room of the U.S. Army Medical Research and Materiel Command (USAMRMC) headquarters at Fort Detrick, Maryland, in January 2017, leaders and staffers listened intently as Gen. David Perkins, commander of the U.S. Army Training and Doctrine Command, outlined the future of the Army--the multidomain battlefield.The multidomain battlefield operational concept is built upon the premise that the joint force will not be able to assume uninterrupted superiority in any domain (land, sea, air, space and cyberspace) during future operations. The Army and Marine Corps are developing concepts and strategies for future ground combat operations in the 2025-2040 timeframe that require highly capable and dispersed units to create and exploit temporary windows of advantage."In future widespread combat operations and in dispersed 'self-sufficient force icons' characteristic of the type of multiple-domain battle discussed by Gen. Perkins, and considering the limitations of supplies and equipment, complex acute and critical care, and minimal medical personnel, force health protection and health services support to the warfighter will be challenging," said Gary R. Gilbert, program manager of the USAMRMC Telemedicine and Advanced Technology Research Center's (TATRC) Medical Intelligent Systems.The joint force is likely to leverage manned-unmanned teaming (MUM-T) capabilities to penetrate high-risk areas and to provide support in contested environments to increase reach, capacity and protection. In the future, commanders will employ unmanned systems as force multipliers in mobility- or resource-constrained or denied environments. Future multipurpose unmanned system platforms could assist in medical operations in such environments. "The growing planned use of unmanned systems and robotics on the future battlefield affords both great opportunities for medical force multipliers as well as significant operational medicine and medical research challenges," Gilbert said. Medical support from unmanned systems could provide emergency medical resupply, delivery of blood products, and aid in the delivery of telehealth or teleconsultation to support prolonged field care when evacuation is not possible. Unmanned systems also could offer expedited casualty evacuation when immediate evacuation is not possible with manned assets.TATRC is working to prepare the Army for this uncertain future. TATRC's Operational Telemedicine Laboratory, which is headed by Gilbert, is a robust group of research scientists and technologists from the fields of artificial intelligence, engineering, computer science, telecommunications and robotics, as well as experienced research managers and field operators in combat health services support and force health protection.The laboratory's goal is to leverage enabling technologies in diverse scientific domains such as artificial intelligence, robotics, mechanical engineering, linguistics, cognitive psychology, computer science, telecommunications, biomonitors, sensors, medical diagnosis and treatment, in order to enable force health protection mission command and virtual health support for the multidomain battle at the point of injury, during pre-hospital evacuation and at medical treatment facilities in remote locations and in hazardous or denied areas.TATRC UNMANNED SYSTEMS TESTSFuture operations in megacities and dense urban areas provide an example of an environment that presents significant challenges to freedom of movement and protection. Adversaries in megacities will be able blend in with a dense population of noncombatants and will exploit vertical, surface-level and subterranean spaces to conceal threats. Securing and sustaining safe routes for troop transport, medical evacuation and logistics support will be extremely difficult because of the highly complex threat environment. The future operational environment, which could be anything from a megacity to an austere environment, is likely to cause severe restrictions on the mobility of vehicles used for medical missions, including both air and ground platforms used for medical evacuation (MEDEVAC), casualty evacuation (CASEVAC) and medical logistics missions resulting from area denial challenges. CASEVAC differs from MEDEVAC in that neither the CASEVAC vehicle nor its operators are necessarily dedicated medical assets. In situations where medical resources are already spread thin, the mobility of medical resources becomes of paramount importance."Unmanned and autonomous platforms have the potential to completely rewrite the medical doctrine for how we conduct emergency resupply of unmanned and autonomous platforms, including whole blood products delivered directly to the point of need, as well as monitored CASEVAC missions when dedicated medical evacuation assets are unavailable or are otherwise denied entry due to weather, terrain or enemy activity," said Col. Daniel R. Kral, TATRC commander.To develop medical platforms for the warfighter, TATRC leverages and exploits emerging robotic and unmanned systems from other government laboratories, academic and industry partners. Employing existing systems enables TATRC to save money and resources while developing solutions for service members more quickly.INTEGRATION OF TELEMEDICINE AND UNMANNED SYSTEMSThe Army and the other services are currently developing unmanned aerial system (UAS) capabilities for logistics operations. These capabilities probably will be extended to CASEVAC missions in future operational environments where conventional medical assets are denied access or are otherwise unavailable. In order to realize the potential benefits of an unmanned CASEVAC and medical resupply mission capability, a human-computer interface (HCI) and command-and-control (C2) infrastructure needed to be developed for the combat medic to effectively interface with unmanned vehicle platforms. TATRC has used two Small Business and Innovative Research (SBIR) contracts to develop two prototype HCI and C2 applications to enable combat medics to use existing Nett Warrior-type end user devices to interact with emerging UAS logistics platforms assigned to medical resupply and CASEVAC missions.The overall goal of this project was to develop an application on a handheld device that would provide the capability to a medic, with little or no training in a vertical takeoff and landing operation, to interact with UAS to complete unmanned CASEVAC and resupply missions. The application provides the medic in the field situational awareness of the aircraft's mission status and the ability for the medic to provide high-level commands to the UAS, such as permission to land after arriving at the specified landing zone and permission to take off after the supplies have been unloaded or the casualty has been secured. Because of the high mental demands placed on the medic in the field, the human-computer interface, which is how the user uses the system, needs to be both intuitive and efficient, and require only supervisory-level control from the field medic.TATRC and Neya Systems conducted a successful field demonstration in August 2016 of a casualty evacuation mission using Lockheed Martin's K-MAX UAS employing the Vertical Takeoff and Landing (VTOL) Evacuation and Resupply Tactical Interface, or VERTI. During the demonstration, the VERTI application was used to plan and execute a CASEVAC mission using an unmanned ground vehicle (UGV) and the KMAX UAS platform. The UGV was utilized to assist in casualty extraction to the UAS evacuation point, where the simulated casualty was secured on the KMAX UAS and evacuated to a medical treatment facility. During casualty transport on both the UGV and UAS, the VERTI application enabled tactical information flow from an operational telemedicine patient monitor to a medical care provider at the receiving medical treatment facility. Telemedicine data was integrated with the existing tactical radio network used for command and control of the unmanned systems through the VERTI application. This capability allows seamless medical data exchange for medical operations using unmanned systems from the point of injury through arrival at the medical training facility, including transmission of an electronic Tactical Combat Casualty Care Card DD Form 1380 as well as live streaming of vital signs while en route.BY LANDAnother SBIR program that Gilbert and his team are sponsoring is a robotic technology to assist combat medics in the field when using emerging UGV platforms for casualty transport. Future UGV platforms, like the Army Squad Multi Equipment Transport (SMET) UGV, are designed to support multiple mission payloads and to fill a secondary role for providing CASEVAC. The goal of the SMET program is to develop a UGV that can follow an infantry squad to help carry its equipment and supplies during dismounted operations, enabling the squad to sustain itself over longer intervals of both time and distance.An additional mission of SMET is to transport a casualty from at or near the point of injury back to a safe location for further assessment and treatment. TATRC initiated two SBIR projects aimed at demonstrating an innovative and novel medical module payload for future military UGVs that would provide CASEVAC capability for the SMET and enable patients to be loaded and secured for movement by just one first-responder Soldier instead of the normal two. This would help save lives while minimizing diversion of warfighters from their primary duties.The SMET UGV CASEVAC module prototyping effort is in Phase II of development. Two different companies are prototyping SMET CASEVAC systems, and while the basic SMET vehicle is intended to be the same, these companies are each following different approaches to prototyping the CASEVAC module and loading patients onto the vehicle.BY AIRThe TATRC team is developing a UAS research platform that is much smaller than traditionally piloted vertical takeoff and landing aircraft. It has the potential to provide some unique capability for medical logistics compared with larger aircraft. Because of the increased mobility of the smaller aircraft, for example, it requires a much smaller landing zone footprint, which increases the number of available landing zones in difficult terrain.TATRC is currently testing this UAS research platform to address operational gaps in future medical mission areas and to mature the capability of using UAS for emergency medical resupply and CASEVAC. This UAS is intended to be used as a platform to aid in the development and test of innovative methods of providing en route care and limiting patient exposure to harmful environmental conditions during unmanned system CASEVAC. This research project aims to develop technologies and procedures to ensure that unmanned systems can be safely and effectively employed to provide medical logistics support or expedited CASEVAC in future operational environments in which manned assets are not available or are denied access."We are partnering with the U.S. Army Aeromedical Research Laboratory and Dragonfly Pictures Inc. to test this system," said Gilbert. (Dragonfly is a U.S. industry leader in small rotary wing unmanned aerial vehicles). "With funding from the Defense Health Agency Joint Program Committee for Combat Casualty Care, we are currently initiating a research project to provide a cost-effective UAS research platform for the operational testing and evaluation of emerging en route care and medical resupply technologies."CONCLUSIONThe medical application of unmanned systems and robotics in future environments has the potential to evolve health support throughout the range of military operations, and this includes peacetime humanitarian support missions.In the not too distant future, according to Gilbert, unmanned aerial systems are likely to be used heavily in combat operations in dense urban environments because of the increased freedom of movement that they afford to a wide range of mission types. These unmanned systems will be multipurpose in nature. They could be called upon in support of critical medical missions if certain medical-specific considerations are addressed as these future unmanned systems platforms are being developed. Support from unmanned systems could become increasingly important in other situations in which mobility is restricted, such as during a natural disaster or other mass casualty event."We have heard everything that Perkins said, and we are already conducting research in how to use these unmanned systems to support medical missions on the multidomain battlefield," Gilbert said. "While the formulation of the doctrine, tactics, techniques and procedures that would provide these types of capabilities to medics to use in combat are still in their infancy, our research is focused directly on identifying and providing the enabling technologies that will be needed, and that is the primary mission of TATRC."This article is scheduled to be published in the April -- June issue of Army AL&T Magazine.