Multiple documents identify the Army’s intra-theater medical evacuation (MEDEVAC) capability as insufficient to meet the challenges of multidomain operations (MDO) and large-scale combat operations (LSCO) against near-peer threats. This inadequacy is distinctively evident in the U.S. Indo-Pacific Command (USINDOPACOM) area of responsibility. Due to the large number of casualties sustained during the invasion of Normandy, the Battle of Iwo Jima, and the mass casualty events predicted during littoral wargames, the U.S. military must modernize and develop MEDEVAC capabilities uniquely suited for amphibious operations.
Since World War II, multiple military revolutions have transformed warfare, the weapons used, and the types of injuries sustained. Technological advancements have produced equipment capable of vertical lift at high speeds, night vision, advanced navigation and global positioning, and medical devices with advanced life support capabilities that sustain critically injured patients for extended periods. However, while civilian aeromedical services modernized and expanded, it took the Army 11 years of the war on terrorism to matriculate its first Critical Care Flight Paramedic (CCFP) class. This delay followed a 2012 study cited in the Journal of Trauma and Acute Care Surgery that revealed that patients’ risk of 48-hour mortality when treated by National Guard CCFPs was 66% lower than when treated by the traditional MEDEVAC system.
Once developed, the Army’s CCFP program demonstrated that specially trained 68W combat medics, providing pre-hospital critical care on dedicated air MEDEVAC platforms, increased survivability by 25%. Within five years of implementing the program, casualties during Operation Enduring Freedom who reached Role 3 medical treatment facilities (MTFs) alive had a survival rate of over 98%. This indicates that CCFPs equipped with portable, advanced life support equipment on dedicated and highly mobile MEDEVAC platforms are essential to reducing mortality. It also emphasizes the importance of MEDEVAC system mobility.
As shown in Joint Publication (JP) 4-02, Joint Health Services, the essential principle of mobility “ensures medical assets remain within supporting distance of maneuvering forces” so they can promptly transport patients from the point of injury to forward care facilities. As outlined in Army Techniques Publication (ATP) 4-02.55, Army Health System Support Planning, and ATP 4-02.2, Medical Evacuation, the mobility and proximity of medical assets allow medical teams to clear casualties from the battlefield and facilitate freedom of movement (FoM) and maneuver for tactical commanders. FoM then supports and is supported by air superiority.
Unfortunately, the air dominance and air MEDEVAC capabilities experienced in the war on terrorism are unlikely to persist during LSCO due to MDO’s constraints on FoM and adversarial anti-access and area denial systems’ ability to degrade air capabilities. Prolonged casualty care (PCC) is often proposed as the solution to these limitations, but PCC is not suitable or acceptable at Role 1 and 2 MTFs due to the logistical burdens it imposes and the associated risks to battlefield mobility for patients and medical personnel.
As we prepare for conflicts with contested logistics, the military must learn from the experiences of the war on terrorism and apply these lessons to develop capabilities suited for the next generation of warfare and MDO. To increase patient survivability, the joint force must develop amphibious MEDEVAC platforms and expand paramedic training for use during en route combat casualty care (ERCCC). By undertaking these initiatives, the military enhances interoperability, modernizes its forces, and stands prepared for littoral operations in a contested environment (LOCE).
Possible Approach
Integrating established air and ground MEDEVAC systems into existing ship-to-shore connectors is one approach to accelerate the development and fielding of a new amphibious MEDEVAC platform. As part of its Force Design 2030 initiative, the U.S. Marine Corps (USMC) is replacing its tracked Amphibious Assault Vehicle with the Amphibious Combat Vehicle (ACV). However, the ACV lacks a medical-specific variant.
By equipping a standard ACV with medical equipment from platforms such as the HH-60 Blackhawk, M1133 Stryker Medical Evacuation Vehicle (MEV), and the M1284 and M1285 Armored Multi-Purpose Medical Evacuation (AMEV) and Medical Treatment (MT) vehicles, the capability gap for amphibious MEDEVAC is solved. Additionally, using feedback from the production and deployment of ACVs and the systems aboard HH-60s, MEVs, AMEVs, and MTs significantly reduces the development time of an ACV-MEDEVAC (ACV-M) variant. This feedback also increases the ACV-Ms’ suitability for amphibious MEDEVAC and makes their creation more feasible through targeted development and reduced production costs.
Given the maturity of existing ACV platforms, the need for extensive parameter and attribute development is reduced, with contemporary vehicles meeting most key performance parameters and system attributes. These include net-centric communications systems that are interoperable in a joint environment; protection against light cannon fire, shrapnel, and 14.5-millimeter armor-piercing rounds; a mine-resistant hull and energy-absorbing seats; smooth operation during Sea State 3 conditions; heating, ventilation, and air conditioning; internal and external blackout lights for nighttime operations; amphibious movement (rated at top speeds of 65 mph on land and 6.9 mph on water); and a combined amphibious-land range of 13.8 miles and 250 miles.
Future requirements must focus on medical-specific modifications and enhancements to optimize treatment and evacuation capabilities. These include counter-drone and improvised explosive device systems; medical equipment sets that meet established standards of care for primary surveys; and reconfigurable compartments that allow for three crew members and six ambulatory or four litter patients, or three crew members and a combination of three ambulatory and two litter patients. Once complete, ACV-Ms provide land component commanders with an expeditious amphibious MEDEVAC capability that enables battlefield clearance of casualties from the littorals to higher levels of afloat medical care with adequate defense, protection, and patient survivability during LOCE. ACV-Ms also increase FoM and improve the amphibious forces’ ability to continually deliver landing teams, vessel waves, and logistics over-the-shore operations.
Operational and Organizational Concept
As a concept, during an amphibious assault, a MEDEVAC is required. Landing-force ACV-Ms travel from amphibious assault ships in the rear area across the maritime environment using defilade provided by deep waters to reduce the risk of decisive enemy engagement. Upon arriving at the beachhead (close area), littoral casualties are collected and evacuated to casualty receiving and treatment ships. As landing teams push beyond the beachhead, their ACV-Ms follow in support or remain with shore-based battalion aid stations (Role 1) once established.
Army Role 2s, equipped with ACVMs and embarked on amphibious task force (ATF) ships, remain in the rear area supporting Role 1 to Role 2 MEDEVAC until they can establish shore-based MTFs. Role 3 field hospitals or hospital ships located in the support areas of maritime environments or on neighboring islands retrieve casualties from Role 2s via division-organic air MEDEVAC assets. During periods of low threat or when increased speed is necessary, ACV-Ms are delivered directly to beachheads or conduct maritime ambulance exchanges via light maneuver support vessels and other landing crafts, reducing MEDEVAC travel time.
Concept of Change
The need to “sustain the fight across long distances” is one of six operational imperatives highlighted by former Defense Secretary Christine Wormuth to provide a “survivable, agile, and responsive” joint force during her remarks at the 2023 McAleese Annual Defense Programs Conference. This modernized force is critical to deterring Russian aggression, maintaining a free and open Indo-Pacific, and outpacing the People’s Republic of China. Integral to this is the emerging need to prepare for anticipated contingencies by developing an amphibious MEDEVAC solution. To facilitate such a platform’s rapid development, production, and deployment, commanders in USINDOPACOM and U.S. Army Pacific must recognize this joint operational need and have it validated by the joint staff. These steps will ensure emergency funds are allocated for the materiel and that the joint force receives the capability in two years, allowing units to maximize the materiel’s integration and training before armed conflict arises.
If LSCO occur, the Army can expect most casualties to die of wounds before they arrive at a Role 2 facility, as demonstrated through war on terrorism data. Of these casualties, roughly 25% will die of potentially survivable injuries. The mortality rates could be even higher if the Army does not resource this solution and provide improved combat care to Soldiers. This statement is supported by World War II data recorded in ATP 4-02.55, tables D-4c, d, and f, which depict amphibious operations accounting for the most casualties in Europe and the Pacific. Such high casualty rates will destroy the morale of America and deny her victory over her adversaries.
Impacts
If adopted, ACV-M fielding requires updates to existing Army doctrine due to present limitations. Current Army doctrine detailing shore-to-ship ERCCC is narrow in scope, with no field manuals or ATPs addressing amphibious MEDEVAC operations. ATP 4-15, Army Watercraft Operations, contains limited information on patient movement and only provides a paragraph on casualty evacuation (CASEVAC). ATP 4-02.2 identifies Army helicopters as the primary means for shore-to-ship MEDEVACs without specifying their role in support of amphibious operations. JP 3-02, Amphibious Operations, states landing forces must maximize patient movement through “use of ground and surface means,” though it notes that “the preferred mode [is] via aircraft.” This preferred mode involves non-medical “lift(s) of opportunity,” since ATFs lack dedicated MEDEVAC platforms. While these CASEVACs may include Marine En Route Care System personnel, this is not explicitly stated.
Despite these doctrinal updates, ACV-M manning, sustainment, and deployment integrate seamlessly into current ambulance and evacuation teams’ organizational structures, leaving them relatively unchanged and demonstrating the materiel solution’s suitability and acceptability. Equipping, stationing, and training Soldiers on the vehicles require detailed planning to minimize friction during force integration. Units can begin training medical personnel and maintainers on the equipment now through the USMC Assault Amphibian Center of Excellence at Camp Pendelton, California.
Maritime and land components may update Service-specific policies to detail platform integration and usage across the joint force. Additionally, educating Army leaders on the employment, capabilities, and limitations of ACVMs is necessary. Facilities to house the platforms are not needed, but updates to maintenance bay equipment may be necessary as dictated by the platform’s maintenance requirements and capabilities. Being amphibious, ACVMs must be organized into all land-based MEDEVAC and ambulance teams, prioritizing divisions where MEDEVAC is more likely from ashore to afloat roles of care. These include light and joint forcible entry airborne and air assault divisions, which are in development.
Readiness
This synchronized execution of ACV-M integration preserves Army readiness through the Regionally Aligned Readiness and Modernization Model, providing predictability and stability through deliberate modernization, training, and missions. This materiel solution fulfills the strategic goals of the DoD. ACV-Ms also immediately enhance military training and mission readiness by sustaining MEDEVAC capabilities and enabling tactical-level commanders to conduct a range of military operations across the competition continuum. ACV-Ms may also face momentary cultural resistance to integration, since most 68Ws are unfamiliar with the Army’s mariner culture.
Despite their enduring presence aboard logistics support vessels, as a primarily land component, combat medics may struggle to identify with operating across maritime environments. In the long term, this paradigm shift toward amphibious operations increases warfighter readiness and cultivates agile formations. ACV-Ms will also conserve fighting strength and reduce mortality in the long term, supporting the Army’s medical operational planning factors by saving lives, clearing battlefield casualties, and ensuring an early return to duty. These objectives depend on external support from the USMC and the Navy, who by design assist in the deployment of Soldiers to and from maritime environments, thus fostering and developing joint interoperability between the Services to ensure mission success.
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MAJ Robert Gipson serves as the 25th Infantry Division Artillery brigade surgeon at Schofield Barracks, Hawai’i. He was commissioned as an Infantry officer from the U.S. Military Academy and served as a physician assistant in infantry, cavalry, and field artillery units across airborne and light brigade combat teams in the U.S. Indo-Pacific Command. He has a Master of Physician Assistant Studies degree from the University of Nebraska Medical Center via the Interservice Physician Assistant Program, and a Global Health and Global Health Engagement Certificate from the Uniformed Services University.
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This article was published in the summer 2025 issue of Army Sustainment.
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