During one of the annual Saber Strike rotations at the Joint Multinational Readiness Center (JMRC), a medic team brought a soldier onto a trauma table in the Role 2 with his casualty card attached. The doctor took a look at the injuries listed on the card, examined the interventions in place, and studied the line of Soldiers waiting for treatment. Satisfied, the doctor shouted, “We can’t save him, send me someone else!”

Saber Strike is an annual, combined-joint exercise, conducted throughout Europe, designed to enhance readiness and interoperability between allies and regional partners. In 2018, there were 18,000 participants from 19 allied and partner nations.

The Observer Coach/Trainers (OC/T) examined the casualty card of the previously mentioned soldier. The card listed multiple gunshot wounds to the chest (several hours old), without personal protective equipment, uncontrolled bleeding from the chest, unconscious, and an incomplete Tactical Combat Casualty Care (TC3) card . We came to the same conclusion. The patient was placed in the expectant category. This was exceptional because, up until that point, we had never seen a doctor turn away a patient in a mass casualty (MASCAL) scenario.

US and British medics work side by side during a simulated MASCAL during Saber Strike in Swidwin, Poland (photo by SPC Aaron Good)

This unit trained to make that call, and they made the correct decision. After we observed this, the Adler Team determined every future MASCAL simulation must include a certain number of expectant category patients. Triaging those patients correctly is just as important as finding those who could be saved.

The “Golden Hour” is Dead On Arrival

The Global War on Terrorism (GWOT) and the counter insurgency (COIN) fight have lulled us into a false sense of medical reality. Waging war against a peer or near-peer adversary will produce significantly more casualties than we have experienced during the last 18 years of combat. The belief that we have the assets available to evacuate every Soldier from point of injury (POI) to the appropriate medical care in less than one hour is a fallacy that must be stricken from our tactical mindsets. The “Golden Hour” is a non-doctrinal construct suited for the limited wars of Iraq and Afghanistan, not Large Scale Combat Operations (LSCO).

Reflecting on historical battles provides insight into what Army leaders must plan for should we have to engage in LSCO. The Battle of Antietam and Operation Overlord hold distinction as some of the bloodiest days in American history. Thousands of Soldiers lay dead or dying after days of close quarters combat. At the battle of Antietam, Federal forces rallied every wheeled conveyance to evacuate the wounded to hospitals. On the beaches of Normandy, the Allies converted landing craft into makeshift hospitals and used every wheeled vehicle to move the wounded to hospital clearing companies to evacuate Soldiers back to England.

Both examples illustrate the logistical expertise required to move large numbers of wounded Soldiers off the battlefield. No single medical unit, or combination of medical units, has the capability to move hundreds of patients a day. Operations in Iraq and Afghanistan did not present similar challenges to Coalition forces. However, any future LSCO will require the medical preparation and logistical capability to accomplish medical evacuation on a scale not seen since D-Day.

Medics from the US and UK treat a simulated casualty in Bemowo Piskie, Poland (photo by SPC Hubert Delany)

Responsibilities

A MASCAL is a large number of casualties in a short period of time which exceeds local logistical or medical capabilities. Medical planners tend to plan in a vacuum and mistakenly rely on pure medical capability as a MASCAL response. To plan appropriately, leaders must recognize that a MASCAL is a sustainment problem requiring the collective efforts of brigade and battalion S4 and S1 shops to leverage all assets to alleviate the burden on the medical system. Aircraft and vehicles must be re-purposed as casualty evacuation (CASEVAC) platforms to transfer the wounded to other medical elements on the battlefield.

At the Joint Multinational Readiness Center (JMRC), we coach sustainment planners to consider the:

• 

  First Aid is rendered to a simulated casualty in Poland while MEDEVAC is requested (Photo by SPC Robert Douglas)

  Number of aircraft allocated to the Brigade Combat Team (BCT)

• Quantity of ambulances at all roles of care
• Number of vehicles at the battalion S4’s disposal
• Quantity of non-medical personnel who can perform duty as a combat lifesaver (CLS)
• Casualty Estimate

The numbers produced by these considerations provide a rough idea of who must be transported and the number of seats available to move casualties to the next echelon of care.

Brigade Medical Planner

The brigade medical planner must perform the analysis to synchronize the S1 and S4, prioritize evacuation, and determine the single lift capacity of the brigade. The S1 coordinates the legal, finance, and administrative response to a MASCAL. The S4 coordinates the rapid movement of medical personnel, supplies, and equipment required to respond to the casualty producing event. The S4 cannot coordinate for vehicle support without first understanding on-going missions. The Logistics Common Operating Picture (LOGCOP), movement tracker, and air movement tracker are just as important to MASCAL responsiveness as the Medical Common Operating Picture (MEDCOP) or Medical Concept of Support (MEDCOS).

Division Medical Planner

A 2CR Soldier renders aid to a simulated casualty during Saber Strike in Bemowo Piskie, Poland (photo by SPC Hubert Delany)

The division medical planner must prioritize medical evacuation, track holding capacity, and coordinate patient transfer between brigades in the division area of operations. The division medical cell must consider the main zone of attack and plan to allocate resources after the division accomplishes its primary mission. Current holding capacity status inform brigade and division decisions regarding patient regulation and acquisition. Lastly, the division medical cell plans for the swift movement of casualties to other facilities outside of the affected brigade.

The medical annex must determine evacuation priority and identify which facilities are responsible for support. Typically, the brigade and division surgeon cells do not have the requisite communications capabilities to reach individual medical units. Consequently, the strength of the MASCAL plan relies on the base order and medical annex to provide the framework for sound, timely decisions during the fight.

Recommendations for Planning

Plan and train for Soldiers to die. The determination to allow a casualty to die to save another is gut wrenching. The MASCAL scenarios we observe at JMRC depend on the unit providing the most good for the most Soldiers, not saving all of them. When was the last time the brigade surgeon made an evacuation priority decision where he knew one Soldier would die? Do your MEDEVAC requests provide enough information for the brigade surgeon to make this determination? Start with the end in mind. When assigning casualty role players, begin with the number most likely to die. Properly identifying casualties as expectantant is just as important as delayed or immediate treatment results.

Specific recommendations include:

Overwhelm Logistic and Medical Capability

The simplest way to flood the sustainment system is with walking wounded. The walking wounded are at exceptionally high risk to switch categories while awaiting treatment. As an example, walking wounded may go into shock while awaiting treatment or suffer from hidden trauma.

Precisely define MASCAL conditions in unit Standard Operating Procedures (SOP) per ATP 4–02.2, Medical Evacuation.

When every medical hand is on a patient, and every casualty evacuation vehicle is outbound while Soldiers are still dying in the sun, it’s a MASCAL. Even more precise, when the number of patients exceeds the number of medical, CLS, and aircraft/vehicle seats, it’s a MASCAL.

Delegate the MASCAL approving authority.

Doctors and surgeons are not always in the best position to declare a MASCAL. Radio operators, battle captains, and battle staff must equip themselves with precise MASCAL conditions to declare a MASCAL. Waiting for the doc to call it is often too late, and the staff will be the entity to coordinate inbound resources.

Determine the required paperwork per ATP 4–02.5, Casualty Care.

The Tactical Combat Casualty Care (TC3) card is perfectly adequate for all casualties prior to damage control or primary surgery. Lengthy trauma forms confuse non-medical personnel who may provide record keeping, and slow casualty treatment.

Implement a numbering system.

A number system ensures patient accountability and saves treatment time. Leaders place this number on the soldier’s TC3 card, the patient’s clothing, and a roster to ensure accountability. Medical personnel record treatment and medications and gather personal information when time permits.

Summary

During LSCO, a MASCAL event means you will lose multiple soldiers. The very definition of the MASCAL implies this tragic reality. A well-rehearsed and synchronized plan will mean the most when you’ve exceeded your medical and logistical capability. The two most important documents during MASCAL operations are the medical Annex F and the MASCAL SOP. Planning during the MASCAL or waiting on prioritization will needlessly cost lives. Annex F and the SOP must provide the necessary decentralization to provide the most efficient response to the casualty producing event. Remember, it’s not about saving all lives, it’s about saving the most lives with available resources.

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