USAF Execution of AE, Blood, & Class VIII Sustainment in a Contested INDOPACOM Published June 17, 2024 By Maj. Jack P. Craven Wild Blue Yonder--Maxwell AFB -- Imagine—an Airman presents on the battlefield in INDOPACOM with a significant limb injury and has profused a lot of blood. Meanwhile, a field hospital in the Pacific has received several trauma patients with critical injuries, and the hospital has limited amounts of supplies, minimal units of blood and a small number of medics. There are extensive discussions of the logistics and implications of waging war with China, but little has been said about healthcare delivery during an engagement of that magnitude. How will the United States Air Force deliver quality healthcare in the Indo-Pacific region? By leveraging a robust aeromedical evacuation (AE) system, implementing a necessary blood program, and delivering pivotal class VIII supplies. Aeromedical Evacuation System To understand the comprehensive scope and capability of the aeromedical evacuation system, it is essential to describe its organizational structure and operational processes. AE exists to provide time-sensitive patient movement to higher echelons of medical care, preventing loss of life, limb, or eyesight. Using various fixed-wing aircraft of opportunity, AE crews can operate effectively in a broad spectrum of environments. AE patient movement is currently executed within the USAF by four active-duty AE Squadrons (Scott AFB, Travis AFB, Ramstein AFB, Kadena AFB), 18 Air Force Reserve Command (AFRC) squadrons and nine Air National Guard (ANG) squadrons. These squadrons vary in size, training and operational capabilities, and areas of responsibility. Air Mobility Command’s (AMC) 618th AOC Tanker Airlift Control Center at Scott AFB coordinates and executes inter-theater and CONUS AE missions. Pacific Air Forces (PACAF) and US Air Forces in Europe (USAFE) are responsible for coordinating and executing intra-theater AE missions. The AE enterprise flows through AMC/A3, ensuring aircrew operations’ readiness and efficiency.[1] At the same time, the Surgeon General for each respective MAJCOM provides patient staging and the Critical Care Air Transport Team (CCATT) compliment. Aeromedical Evacuation Control Teams (AECT) with AMC to direct the use of available aircraft, aircrews, and AE crews to meet validated AE requirements. AE is a method of transporting sick or injured patients over long distances safely and securely. Typically, AE movements involve regulated patients, but unregulated patient transport during wartime or emergency operations is the unwritten expectation. Patient movement begins when a request for AE is generated utilizing a system known as TRANSCOM Regulating and Command & Control Evacuation System (TRAC2ES), which allows the medical personnel and/or center to input patient information and route a request for AE to the respective Theater Patient Movement Requirements Center (TPMRC).[2] Once TPMRC has validated the required patient movement request, AECT begins coordinating the patient movement request. This involves establishing or communicating mission requirements, assigning aircraft (although there are several other aircraft that AE crews can operate within, the C-17, KC-135 and C-130 are the primary aircraft of opportunity), and coordinating with AE Squadron Chief Nurses to identify the best AE Team/Crew compliment for the mission (three to seven person teams of nurses and medical techs, and/or Independent Duty Medical Technicians (IIDMT)). Depending on the number of patients and level of care required during transport, critical care air transport teams (CCATT) may also be assigned to the mission to support the AE team (CCAT generally include a physician, nurse, and cardiopulmonary technician or IDMT). CCATT is primarily employed for situations where the patient has an increased risk of death or worsening injury during flight, like patients with lung issues, burn victims, neonatal or premature babies. AE requests involve routine patients (movement within seven days), priority patients (movement within 24 hours), and urgent patients (movement within 12 hours).[3] The complex system described above offers a baseline of how AE is utilized, but patient movement during an engagement with a peer, such as China, would be distinctly different. Addressing the unprecedented challenges of patient movement in a potential engagement with China requires a strategic reassessment of our current capabilities and processes. Patient movement during an engagement with China would be unlike anything the United States has ever seen. Considering the likelihood of thousands of conventional weapons used and the possibility of an ICBM, chemical, or nuclear attack leveraged by either country, the level of death and destruction to US Forces and our allies would be difficult to quantify. Unregulated patient movement would have to be employed, or the death toll would rise to an even higher level. The time that it would take to validate large patient loads through traditional means would guarantee more death to our forces and our allies and would, therefore, require both innovation and no small amount of calculated risk by the USAF and our allies in the Pacific. We would accomplish this by employing all our active duty, AFRC, and ANG AE forces from CONUS in a concerted effort to immediately supplement our OCONUS capabilities as quickly and effectively as possible. Moreover, the USAF would utilize aircraft of opportunity for stable patients. According to our Joint Publication 4-02[4] , from the point of injury to Role 4 capability of care, the ideal flow is as follows: stabilize/sustain life of the patient with tactical combat casualty care (TCCC); get patient to a Ground Surgical Team (GST) or field hospital if able, for further stabilizing care by medical staff; once patient is stable to fly, move patient to an en route patient staging system (ERPSS) which is typically attached to a flight line; finally, fly patient to a Role 4 facility for specialized care.[5] Additionally, it is no secret that the US military has been training and exercising with our allies in the Pacific at an increased frequency every year for the past several decades. Primarily, the U.S. exercises with our Australian, Japanese, and South Korean allies in the Pacific theater to leverage all regional capabilities. Across our allied and partner militaries, the response would be swift and coordinated, establishing a new standard for unregulated patient movement within the US military and from a multi-national standpoint. At the core of these exercises is the lesson learned from WWII that “more than one million patients were successfully moved by air during World War II. Although most patients in the war still traveled by ground and water transport, aeromedical evacuation clearly showed a potential for expansion in future wars.”[6] Critical to this lesson learned is the understanding that the Navy and Army will be pivotal to evacuating patients in the Joint Operational Environment. Strengths-- The US military has been involved in numerous conflicts overseas where casualties had to be transported to various echelons of care. Through these conflicts, military medicine has evolved. It continues to evolve in its clinical practice guides and operational planning and execution to expedite a patient's evacuation out of the combat environment and increase the patient's life expectancy after sustaining any injuries. For example, a recent handbook for frontline medical care documents a 25-year-old soldier who suffered multiple penetrating wounds to his lower extremities from an improvised explosive device (IED) blast in Afghanistan. At the point of injury, his fellow comrades-in-arms and a combat medic applied Tactical Combat Casualty Care (TCCC) to control his bleeding and secure his airway while defending their posture. After being loaded into a Humvee and transferred to a predetermined helicopter landing, the patient was launched onto an HH-60M Black Hawk to a Role 2 medical facility, where the patient received his initial resuscitative trauma care. The Role 2 medical facility included a forward surgical team with Advanced Trauma Life Support (ATLS) training, where the patient received lifesaving surgery and a blood transfusion. When the medical team determined that the patient was stable enough to fly, a Critical Care Air Transport Team (CCATT) received the patient to be moved to a Role 3 facility, a US Air Force Theater Hospital, and eventually to the US for more definitive and long-term care. This medical capability demonstrates the effectiveness of modern military medicine and combat casualty care, where initial trauma care and prepositioned resources are vital to saving a patient's life. Because the military invested in TCCC training and prepared the medics with advanced skills to render trauma care and position them forward to the combat zone, the patient arrived from the point of injury to Role 2 facility within 67 minutes and from Role 2 facility to Role 3 within 48 hours post-injury.[7] The U.S. military has a robust land, air, and sea fleet to provide regulated and unregulated CASEVAC and MEDEVAC anywhere. Multiple medical war reserve materiel (WRM) are maintained worldwide to resupply medical facilities at various echelons of care. Finally, medics continue to train to elevate their competency. In addition to the requirements to be credentialed for peacetime healthcare, medical professionals may also complete advanced training at the Center for the Sustainment of Trauma and Readiness Skills (CSTARS) or participate in joint exercises such as Guardian Response, Keen Sword, or Freedom Shield.[8] Weaknesses - Despite the US military's proven capability to transport injured patients in wartime and peacetime operations, medical evacuation manifests some risks due to the volatility in the military medicine landscape and the uncertain level of healthcare cohesion between military services. The Defense Health Agency was established in 2013 to manage the Department of Defense's (DoD) medical enterprise worldwide.[9] In 2017, due to congressional mandates, DHA assumed complete operational control to manage all military treatment facilities (MTF), along with integrating TRICARE network providers in the continental US (CONUS) and overseas installations. Therefore, healthcare delivery for each military branch shall operate under centralized guidance and policies, and adapting to these changes has been challenging. For instance, realigning manpower to MTF utilization led to resizing medical billets.[10] Downsizing the number of medical personnel could lead to smaller footprints in aeromedical evacuation or fewer trained IDMTs. Envision how the future medical force might unfold if staffing cuts were coupled with current military recruiting woes. Moreover, DHA expects MTFs to maximize access to care, which could limit readiness posture. To achieve desired efforts and tangible results in military exercises, units require at least one week to execute training objectives, evaluate performance, and identify gaps. However, according to DHA, MTFs may be closed a maximum of three days, and MTFs may not schedule a training day adjacent to a weekend or federal holiday.[11] While this maximizes access under everyday circumstances, it has the important secondary effect that this requirement has and will continue to hinder operational cohesion with partner units outside the medical enterprise. Worse, this could degrade the medics' competency and ethos in performing healthcare in a stressed environment. A recent study of US Navy Flight Surgeons (FS) revealed an alarming lack of confidence to perform en route care, as the respondents feel uncomfortable working with their hospital corpsmen (HM) due to their limited shared training sessions in prehospital and in-flight care, as well as the FS's and HM's deficiencies in paramedic certification.[12] From personal experience, when Misawa Air Base conducts weeklong operational drills, the medical group often seeks workarounds to satisfy DHA policy and wing objectives by enabling access to care while fully immersed in the exercise scenarios. Not only does this take away valuable tactical opportunities from the medics, but it also trips up the desired en route care algorithm, i.e., from the point of injury to the higher echelon of care caused by simulations or inadequate medical participation. Opportunities - The US cannot achieve an advantaged position—operationally and politically—in an international conflict on its own. As history manifests, the US will require the support of its allies and coalition partners to win a war. Similarly, patient movement in a contested environment will require more than just US efforts. Through security cooperation, the US can build defense and security relationships with other nations to bolster allied and friendly military capabilities for self-defense while providing US forces with peacetime and contingency access to host nations.[13] Leveraging security cooperation would allow US forces to strategically preposition medical assets on foreign lands and permit patient transport on land, air, and sea. Also, maximizing education exchange and training opportunities with host nations' medical forces can develop advancements in clinical practice and reduce healthcare delivery nuances, especially during combat. As political tensions continue to rise in the Pacific, so do the integrated training events with foreign host nations. Last March in Japan, the 31st Marine Expeditionary Unit collaborated with the Japan Self-Defense Force (JSDF) to conduct amphibious exercise operations, including a mass casualty treatment and evacuation scenario, where JSDF forces served as the first responders.[14] JSDF personnel teamed with US hospital corpsmen to perform en route care via JSDF helicopters and, in turn, transferred the patients aboard the amphibious assault ship USS America. In 2022, the US Air Force medics trained more than 500 Malaysian service members on executing TCCC.[15] This initiative taught Malaysian forces lifesaving and trauma care techniques to respond to natural disasters or hostile situations. Investing in modern technology can enhance military medicine's capabilities. These technological ideas may be ambitious but not far-fetched, as technological advances have made tremendous strides in the past 20 years. The Battlefield Assisted Trauma Distributed Observation Kit (BATDOK), a smartphone application that replaces the traditional pen and paper records, serves as a game changer in military medicine, where casualties' medical condition and documentation can be tracked in real- time—anytime, anywhere.[16] BATDOK’s wireless sensor connection can process metadata at any point of care, e.g., while being transferred from Role 2 to Role 3, so the receiving medical providers can anticipate triage priorities and determine the most appropriate courses of action to effectively and efficiently save lives. Imagine seeking "Siri's" or "Alexa's" assistance to process vital signs data on a patient with wireless automated external defibrillator (AED) sensors. Artificial intelligence (AI) has gained popular applications in several industries. Military medicine can use AI when seeking information on how to apply first aid to a patient suffering from an insect-inflicted allergic reaction, for instance, while in an austere environment, or when directing AI to send a 9-line MEDEVAC request. Threats - The People's Republic of China (PRC) has emerged as the greatest threat to US national security because of its growing economic influence and increasing military capabilities, which the PRC has capitalized on to coerce and exploit neighboring nations and underdeveloped countries. According to the Department of Defense's report to Congress, the PRC activated its first overseas military base in Djibouti in August 2017 to preposition logistical supplies and shore its Navy aircraft carriers.[17] The PRC's military presence in Djibouti has interfered with flights by lasing pilots and operating drones, and the PRC even sought to restrict the nation's own sovereign airspace over the facility. Elsewhere, the PRC secured an alliance with the Solomon Islands, northeast of Australia.[18] Because of this alliance, the Solomon Islands has increased its law enforcement armaments and upgraded its telecommunication services as part of the Sino-Solomon modernization pact. Ultimately, the PRC has a substantial interest in gaining military access along the sea lines from China to the Strait of Hormuz, Africa, and the Pacific Islands; thus, the Chinese Communist Party has ramped up its political campaigns in Burma, Thailand, Indonesia, Pakistan, Sri Lanka, the United Arab Emirates, Kenya, Equatorial Guinea, Seychelles, Tanzania, Angola, Nigeria, Namibia, Mozambique, Bangladesh, Papua New Guinea, and Tajikistan.[19] Should the PRC gain the favor of these geographically critical nations, securing physical space to maneuver patient transport would become very difficult. And if a major conflict occurs, unnecessary casualties could spill across borders. Blood Program Shifting our focus to another vital logistical aspect, the management of blood supplies emerges as a critical concern in the Pacific theater. The potential of extensive blood loss in combat scenarios underscores the urgency of this issue. Losing more than 40% of one’s blood can be fatal.[20] A conflict in the Pacific would rapidly exhaust existing stocks, as the blood supply on hand is limited; blood resupply will become more challenging, and blood has a short shelf life. Frozen red blood cells (RBC) have a shelf life of 42 days. RBCs are needed to treat patients with severe blood loss. Platelets have an even shorter shelf life of five days. Medical providers administer platelets to patients to supplement their blood clotting. An average RBC transfusion requires about three units. Worse, a victim of a motor vehicle accident can require as many as 100 units of blood.[21] A key limiting factor is that an average donor can donate only two units of blood every 56 days.[22] In a regional conflict, INDOPACOM may face uncertainty regarding blood supply. In Japan, although the Status of Forces Agreement (SOFA) permits military personnel to use the host nation's "facilities and areas," such as medical facilities, Japanese blood banks are not obligated to provide donations to US personnel.[23] The Armed Services Blood Bank Center manages the only American blood bank in Okinawa, which the US Navy leads. The US military should consider expanding and evolving its Walking Blood Bank (WBB) program to mitigate the blood supply gap.[24] The WBB is not a new concept. In fact, WBB has been primarily used during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF), with great survivability rates. Special operators can benefit from whole blood transfusions if compatible with their donors. During a mass casualty event at a military treatment facility (MTF), non-essential personnel should be considered whole blood donors. Donors should be screened periodically for infectious diseases to minimize risks with whole blood collection and transfusion.[25] During the process, appropriate training and rehearsals should be conducted to eliminate any administrative mistakes (i.e., donor-recipient mismatch, wrong blood type, mislabeling). Finally, anyone can be trained to collect blood so clinical personnel can focus on treating patients. INDOPACOM should consider implementing theater-wide exercises to practice this muscle movement as tensions continue to grow in the region. Further, China and the US are utilizing innovative technologies, such as delivering blood on the battlefield via drones.[26] The US must stay at the forefront of this pivot to ensure the safety of all its servicemembers. Sustainment/Class VIII From a medical emergency management standpoint, medical logistics capability faces both wins and challenges in the INDOPACOM region. First, the US Army maintains a robust posture of Army Prepositioned Stock (APS-4), where they routinely perform drills through tabletop or full-scale exercises.[27] In 2021, teams of U.S. Army medical logisticians performed an exercise to practice readiness to support regional contingency missions by aligning "health care assets to support the warfighter in forward-deployed environments,” including drawing from prepositioned stocks in Japan and setting up a 32-bed field hospital.[28] The 18th MEDCOM, which is staged in Hawaii, leads the medical contingency efforts in the region by coordinating health system support, including Class VIII assets, to enhance interoperability with allies and partner nations.[29] The 18th MEDCOM provides an active footprint on most, if not all, military exercises, from command-and-control to tactical operations, and serves as a consulting agency. Along with the USAF medics, their combined expertise and experience have exponentially evolved medical capability in the region. On the other hand, INDOPACOM’s vast maritime geography, lack of ground space, and volatile political atmosphere in neighboring nations can have compromising implications for medical logistics. Class VIII resupply will become the top challenge in a maritime-dominated conflict as US forces must overcome the region’s tyranny of distance. Next, prepositioning supplies is critical to reinforce medical treatment facilities and those who will be treating injured warfighters in the JOA (i.e., Roles 1 and 2 sites). This will require the Theater Lead Agent for Medical Materiel—Pacific (TLAMM-P) to streamline the supply chain from a staffing and resource lens.[30] Prepositioned supplies require security cooperation with partners and allies. However, complicating this relationship and the potential availability of supplies in a conflict rather than a natural disaster, some nations signal closer ties with the US but have not explicitly condemned the Chinese Communist Party (CCP). These nations include India, New Zealand, Singapore, and Vietnam.[31] Recommendations The US military must first focus on air and maritime superiority to ensure medical logistics advantage. If superiority cannot be established, pockets of superiority must be created and maintained to move supplies in and out of the JOA. The Defense Health Agency (DHA) should lead in reducing medical supply and equipment nuances to standardize processes and expedite treatment, especially in a contested environment. An enterprise standardization program where all medics, regardless of uniform, can work cohesively to generate seamless and safe care while organizing patient movement operations. DHA has partnered with Defense Logistics Agency (DLA) to streamline class VIII supply to the region to maintain effective readiness.[32] Continue to strengthen relationships with neighboring nations through global health engagements or other humanitarian missions can enhance security cooperation -- the US cannot win any war alone! The USAF’s effectiveness in these mission sets is intertwined with the broader success of the DoD. A collaborative approach, relying heavily on our sister services, allies, and partners, will be crucial. Regarding patient movement, embracing unregulated methods and using aircraft of opportunity will be pivotal, especially given the expected high casualty numbers expected in the theater. While the DoD blood program in INDOPACOM has a strong foundation, it requires proactive engagement at the tactical level. COVID has stifled the WBB program, and it is imperative for our senior leaders to place focused attention on it to ensure broad participation, its readiness and effectiveness. Finally, the sustainment of class VIII falls on the Army as it is their requirement to set and sustain the theater. DHA, DLA, and TLAMM-P will become the arteries and lifeblood to sustain the medical fight. As we navigate these challenges, continuous innovation and adaptability will be key to ensuring that we not only meet but exceed our operational goals, safeguarding the health and lives of those we are committed to protecting. This research was originally done as part of ACSC’s elective, Logistics and the Use of Military Force Author’s note: I want to thank Lt. Col. Rachel Jackson, Maj. Rafael Dy, Capt. JP Nance and MSgt Gerald Castilla for their time, insight, and feedback towards completing this article. Their help was instrumental in ensuring the direction of research and writing. Maj Jack Craven is a USAF MSC currently assigned to the 21 STUS, ACSC, Air University, Maxwell AFB. In addition to his current assignment, he has held a diverse range of assignments as a LAF and MSC officer at the Flight, Squadron, Group, Wing and Joint Staff levels in CONUS and OCONUS environments. [1] “Air Mobility Command Aeromedical Evacuation." [2] TRANSCOM Office of Public Affairs, “U.S. Transportation Command’s Patient Movement Requirements Center-East Administered Hundreds of Compassionate Care COVID-19 Aeromedical Evacuations across Three Continents,” 7 December 2020. [3] Air Force Medical Service Website, ”AFMS Capability: Critical Care Air Transport Team.” [4] ”Joint Publication 4-02, Joint Health Services,” 2018. [5] “NATO Logistics Handbook, Chapter 16: Medical Support,” October 1997, [6] James S. Nanney, ”Army Air Forces Medical Services in World War II,” Air Force History and Museums Program, 1998, pg. 10. [7] Martin et al, Front Line Surgery: A Practical Approach, Second Edition (Cham: Springer, 2017), pgs. 660-661. [8] Knowledge Exchange, ”En Route Care Training Department,” accessed with CAC. Also described here: https://afresearchlab.com/technology/en-route-care-training/ [9] Defense Health Agency (DHA), “Section 709 of the National Defense Authorization Act for Fiscal Year 2017 (Public Law 114-328),” 2017. [10] U.S. Government Accountability Office (US GAO), “Defense Health Care: Additional Assessments Needed to Determine Effects of Active-Duty Medical Personnel Reductions,” July 11 2023. [11] Defense Health Agency (DHA), “Section 709 of the National Defense Authorization Act for Fiscal Year 2017 (Public Law 114-328).” [12] C.T. Andicochea et al, ”An Assessment of Flight Surgeon Confidence to Perform En Route Care,” Military Medicine 184 (Mar 1 2019): 306-9. [13] Defense Security Cooperation Agency (DSCA), ”Security Cooperation Overview and Relationships." [14] 1st Lt. Iris Robare, ”U.S. Marines, Japanese Forces Conclude First Japan-Based Iron Fist Exercise,” U.S. Marines Official Website, 13 March 2023. [15] Capt. Lauren Woods, "Pacific Angel 22-2 Strengthens Ties with Indo-Pacific Allies and Partners,” DVIDS, August 19, 2022. [16] Whitney Wetsig,”Popular AFRL Invention Supports Joint Military Needs with Mobile Medical Documentation,” 3 September, 2023. [17] Department of Defense (DoD),”Military and Security Developments Involving the People’s Republic of China,” 2023. [18] Associated Press, "Solomon Islands Signs Policing Pact with China,” NPR, 11 July 2023. [19] Department of Defense (DoD),”Military and Security Developments Involving the People’s Republic of China,” 2023. [20] Kimberly Holland, ”How Much Blood Can You Lose without Severe Side Effects?” Healthline, 26 February 2022. [21] American Red Cross, “Blood Components. Donate Blood, Platelets or Plasma. Give Life.” [22] Mayo Clinic, “Blood Donation Frequently Asked Questions,” 2023. [23] Ministry of Foreign Affairs (MOFA) of Japan, “MOFA: Agreement Regarding the Status of United States Armed Forces in Japan. Ministry of Foreign Affairs of Japan,” [24] Armed Services Blood Bank Center (ASBBC), “Armed Services Blood Bank Center." [25] Col. Andrew Cap et al, "Joint Trauma System Clinical Practice Guideline: Whole Blood Transfusion,” CPG ID: 21, 2018. [26] J.P. Lawrence, “Army Tests Blood Deliver Drones, Applying Lesson from War in Afghanistan,” Stars and Stripes 24 November 2022. [27] Galen Putnam, “Leaders from South Korea, Japan Learn about APS-4’s Role during Contingency Operations,” 8 August 2022. [28] C.J. Lovelace, ”Army Medical Logisticians Modernize Units in Japan to Support Multiple Missions,” 26 July 2021. [29] 18th MEDCOM. [30] Kadena AB Public Affairs, “Kadena’s TLAMM-P Keeps USINDOPACOM Ready,” 19 October 2021. [31] Shannon Tiezzi, “Which Asian Countries Support China in the Taiwan Strait Crisis – and Which Don’t?” The Diplomat 13 August 2022. [32] Shaun Eagan, “DLA, DHA Agree on Joint Military Health Care Support,” DLA, August 15, 2019.