The Secret Weapon to Dominating Medical Support on Future Battlefields

The Secret Weapon to Dominating Medical Support on Future Battlefields

In an article titled "The "Survival Chain" - Medical Support to Military Operations on the Future Battlefield" proposes the "Survival Chain" as opposed to the "Kill Chain", and how to improve point-of-injury care in future large-scale combat operations. In the face of future large-scale combat operations, how to improve the capability of the three most important phases, namely immediate treatment, evacuation and surgical treatment, is the basis for closing the chain of survival. The following is an excerpt.


In April 2020, "The Kill Chain: Defending America in the Future of High-Tech Warfare" by Christian Brose was officially published, sparking widespread attention in the American military and political circles. In the book, the author describes a concept wherein the effectiveness of a combat unit's ability to "close the kill chain" will determine its success or failure in warfare. Brose suggests a redesign of the U.S. military's operational infrastructure to enable faster understanding, decision-making, and action-taking compared to adversary nations, thereby gaining a strategic advantage in combat.

Under the influence of this book, researchers from various institutions including the Joint Trauma System of the U.S. Department of Defense, the U.S. Army's Telemedicine and Advanced Technology Research Center, the Uniformed Services University of the Health Sciences, and the Defense Health Agency collaborated to propose the concept of the "Survival Chain." They conducted studies indicating that the "Survival Chain" could provide medical support to the "kill chain," thus enabling and maintaining medical superiority on future battlefields.


The Joint Trauma System (JTS) of the Department of Defense was established to provide optimal care for casualties on the battlefield. Current defense strategies anticipate future Large-Scale Combat Operations (LSCO) against adversaries of comparable strength, which may limit the overall mobility of medical evacuation, increase the survival risks for medical teams, and constrain the timeliness and robustness of critical medical logistics. Therefore, the JTS must continuously optimize its medical support under the guidance of Medical Performance Optimization (MPO) to meet future needs. The JTS functions as a "continuously learning and optimizing medical system," enhancing the efficiency of battlefield casualty care through near-real-time data collection, analysis, and adjustments to knowledge, skills, and material solutions.

Similar to the "understand, decide, and act" process of the kill chain, conducting MPO through the JTS will evolve into a survival chain, swiftly achieving MPO through the observe, orient, decide or understand, and act (OODA) loop. The purpose of this paper is to report to military leadership the risks associated with achieving optimal casualty care in potential future domestic combat command systems, with a focus on discussing potential solutions to attain and maintain medical superiority within the survival chain of the 21st-century battlefield.


Reassessing and Planning for Current Challenges Ahead

Combat casualty care is improved in accordance with the Joint Trauma System's operational improvement cycle and aligns with NATO guidelines for casualty care. The mission of the Joint Trauma System includes optimizing the entire casualty care system through the collection and analysis of clinical data, providing closed-loop feedback to medical commanders, and identifying theoretical and knowledge gaps between research, guideline development, education, training, quality improvement, and practical needs. Continuous rapid optimization of casualty care within the Joint Trauma System is essential to address the potential influx of casualties in large-scale combat operations by strengthening the survival chain to achieve medical superiority.

key challenges currently is the concentration of conflicts in the past two decades of Middle Eastern wars, where robust medical resources and fixed three-tiered casualty care facilities (equivalent to comprehensive hospitals) have been established to provide operational support. These field hospitals are situated in relatively secure locations, facilitating the gradual evacuation and increasingly enhanced care of casualties.

The Joint Trauma System has demonstrated commendable performance in recent conflicts. However, future large-scale onshore or offshore combat operations pose new challenges that require enhanced data integration and technological capabilities. Data integration and technology are indispensable in optimizing medical support, where the Joint Trauma System plays a crucial role by observing (collecting real-time relevant data), orienting (or swiftly understanding through rapid data analysis), deciding (improving the speed and accuracy of decision-making), and acting (treating casualties) to meet leadership expectations, minimize force losses due to casualties, and maximize combat effectiveness.

As Brose pointed out, "The problems the U.S. military faces now have a fundamentally different, greater urgency that transcends emerging technologies." This paper focuses on the three most urgent challenges in providing the survival chain for future military operations:

  1. Data Integration and Interoperability: Ensuring seamless integration and interoperability of medical data across various platforms and systems is critical for timely and informed decision-making in casualty care.

  2. Technological Advancements: Embracing and leveraging emerging technologies such as artificial intelligence, telemedicine, and advanced diagnostics to enhance medical support capabilities on the battlefield.

  3. Adaptability and Flexibility: Developing agile and adaptable medical support systems capable of quickly adjusting to evolving operational environments and requirements, whether onshore or offshore, to ensure optimal casualty care delivery.

Addressing these challenges will be essential for the Joint Trauma System to continue its exemplary performance and effectively support future military operations.

Challenge 1: Immediate Casualty Care at Point of Injury

In traditional Role 1 casualty care, there may be numerous challenges arising from force-to-force battlespace encounters. According to data from counterterrorism operations, 88% of preventable deaths occur between the point of injury and the transition to Role 2 care. Thus, elucidating the gaps in education, training, and research at this stage is critical for gaining an advantage in large-scale combat operations.

Risk Points and Countermeasures:

Risk of Fatal Hemorrhage

  1. Increase Tactical Combat Casualty Care Training for Non-Medical Personnel:

    • Provide training to non-medical personnel to control bleeding, allowing frontline medics to focus on treating more severe injuries.
  2. Equip Combat Medics and Provide Training:

    • Equip combat medics with necessary tools and provide training to perform blood transfusions, establish field blood banks, and utilize other bleeding control techniques.
    • Research and develop new hemostatic and transfusion technologies to enhance capabilities.
  3. Develop New Medical Interventions:

    • Develop new drugs, blood products, or substitutes to combat shock.
    • Advance clotting techniques to reduce fatalities caused by bleeding.

By addressing these points, the risk of death due to severe bleeding can be mitigated effectively.

Mass Casualties

Ensure Comprehensive Triage Training for Medical Personnel:

  • Provide medical personnel with enhanced triage classification knowledge and skills, prioritizing injuries based on severity.
  • Transition consciously from optimal treatment for each casualty to the principle of "doing the greatest good for the greatest number" in mass casualty situations where resources are exceeded.

Establish Simplified and Robust Triage Models:

  • Develop simpler yet more effective triage models capable of quickly identifying ambulatory (minor injuries) or deceased casualties.
  • Rapidly identify stable or unstable patients, enabling triage personnel to efficiently apply relevant knowledge for classification.

Develop Best Practices for Mass Casualty Care:

  • Formulate best practices for treating hundreds or thousands of casualties on the battlefield, maximizing the utilization of medical personnel resources.

Resource Scarcity

Utilize Technology for Medical Logistics in Hostile Environments:

  • Utilize remote-controlled drones or other technologies to provide medical logistics support in adverse and hostile environments.
  • Develop clinical decision support tools for personnel with limited medical resources.

Real-time Monitoring and Decision Support Tools for Medical Assessment:

  • Develop real-time monitoring and decision support tools for medical assessment and intervention, aiding in efficient allocation of limited medical resources.


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