The Army Reserve's Medical Readiness and Training Command, based here, presented "Lessons Learned from Ukraine" in the Dec. 14 video and phone-in conference for military medical professionals, part of MRTC’s ongoing professional development program “MRTC Presents Operational Fluency.”

Col. Samuel L. Fricks, who traveled to Ukraine as a member of a Defense Department observation team, said the purpose of the brief was to make participants more aware of the different factors affecting patient movements in Large Scale Combat Operations, or LSCO, as opposed to the procedures establishing in the last two decades under the aegis of the Army’s counterinsurgency mission, or COIN.

"There is a hard turn-in that we have to make mentally and in a paradigm shift from COIN to LSCO," said the chief of the Medical Evacuation Concepts and Capabilities Directorate, Army Futures Command. “Most of our experiences have been defined by our experiences in COIN, and that's just not going to be the case for LSCO, and we're seeing that play out currently in Ukraine.”

The MRTC Commanding General Brig. Gen. Jeffrey B. McCarter said he was grateful for the presentation.

“I really appreciate this brief,” the general told Fricks. “As you’re going through this, I was thinking how can we apply this to the current training platform environment.”

McCarter said he was challenging everyone on the call to take Fricks’ observations for action. “A question for everybody on this call is whether you're going change your training individually or collectively.”

Major Gen. Joseph A. Marsiglia, the commanding general of the 3rd Medical Command (Deployment Support), said the presentation should spark more questions.

“There is a lot to think about, a lot to digest, but that's why I always talk about how we have to tax our critical and creative thinking skills,” the general said.

Marsiglia said the future threats will make Ukraine look like a walk in the garden. “We need to be prepared for that.”

The former medical battalion commander said he was not an expert, but the presentation was the culmination of his personal observation and his own engagements with others. “Observations are not universal for all of Ukraine. This brief is derived from many sources—of which I got most of their permission they use.”

The colonel, an aeromedical evacuations officer, also known by the military occupational specialty designator 67 Juliet, said senior leadership recognized that nearly a year ago, there was a gap in the military's understanding of the medical challenges on the Ukrainian battlefield.

“Back in February, there was an identified lack of medical observations from the Ukraine conflict,” he said. “We weren’t talking about it, and we weren't gathering them, and we weren't really using anything to inform our capability.”

Fricks said people must accept the Transparent Battlefield concept, which Army Secretary Christine E. Wormuth coined. The Transparent Battlefield is a combat zone where it is extremely difficult to remain undetected and untargeted because of contested airspace, advanced signal intelligence, and open topography.

"Anything that can be seen, anything that is stable for more than seven minutes on the ground, can be targeted, and it usually is," he said. “Deception is still effective through the use of deploys and camouflage, and being able to hide against drones in artillery strikes and the protection of the rear area is absolutely essential,” he said.

The colonel said when Ukrainians fire, the Russian counter-battery, both direct and indirect, creates high casualty rates, the loss of leaders, and the need for mass casualty evacuations and medical care.

Junior leaders must be able to assume leadership and be adaptable because there have been large numbers of senior leaders taken out on both sides, mainly the Russians, he said.

“If you look at the weapon systems and the casualties and the Ukraine conflict, most of the casualties are polytrauma, caused by explosive weapons,” he said. “The heavy losses are going to be shrapnel, broken bones, flesh wounds and lots and lots of amputations.”

The colonel said an example of the pervasiveness of hostile battlefield surveillance is the drones that follow the vehicles with the Red Cross on the side.

“When a drone saw a Red Cross-marked platform, they would follow it till it stopped, and then when they saw patients being unloaded into a building or going underground, then they knew that's where the treatment area was,” he said.

“Then, they start targeting it with artillery and rockets to destroy it,” he said.

He said another vulnerability for medical facilities is their electromagnetic interference signature, EMI. This EMI signature problem, which also applies to sites dedicated to command and control and operations, acts as a beacon for hostile fires.

“If you can see it, if it can be found, it doesn't have to be visually,” he said.

Fricks: Artillery is the King of Battle in Ukraine

The colonel said in the Ukrainian battlespace, it is difficult to maneuver.
"Artillery is once again the King of Battle and the center of gravity, and because of that, we've experienced high casualties and loss of leadership due to targeting extensive logistic expenditures and sustainment challenges," he said.

Artillery is a dominant weapon in Ukraine, and in the Transparent Battlefield, there is a premium on operation security and deception to protect the force, facilities, and assets, he said.

"The Russian, on average, has been using about 35,000 to 45,000 rounds a day, and you probably seen reports and so in the open source reports where they've had to kind of lower the rate of fire just because of ran out of ammo or they can't produce it as fast," he said.

Fricks said this must be viewed in the criticism from the Red Chinese that the Russians are not firing enough artillery.

One expert on the People's Liberation Army said the key to Chinese artillery strategy is depth, he said. "We can't talk about the actual number, but he describes it as obscene, meaning that you could expect a rate of about over 200,000 rounds a day, and they're able to sustain that for, for maybe even years at length."

This is not to suggest the Russians or the Chinese seek to target medical facilities and personnel, the colonel said. "Even though they may not deliberately target medical with that rate of fire, with that amount of destruction, medical would be at risk even through collateral damage."

Fricks: The Letterman System does not work in Ukraine

During the Civil War, Union Maj. Jonathan Letterman, a doctor serving with the Army of the Potomac, revolutionized American military medicine by championing innovations and reforms developed by Napoleon's chief surgeon, Baron Dominique Jean Larrey, such as the creation of an ambulance corps, manned by stretcher-bearers and wagon drivers to transport the wounded away from the fight, and the triage of injured.

Letterman also instituted the baron’s ideas regarding the stages of battlefield care, now called the Letterman System.

The Letterman System has three stages or roles: the casualty collection point or battle dressing station, the field hospital set off behind the lines, and the larger brick-and-mortar hospital safely in the rear areas.
This system has carried forth into the current day, with Army field hospitals must decide in 72 hours whether to return the Soldier to duty or send him to the brick-and-mortar facility.

Fricks said the Ukrainian battlespace, unlike the Army’s experience in COIN, makes it very difficult to stick to the Letterman System.

“For the Letterman System to have worked in the past, it was the rear areas had to be protected in and out of range,” he said. “That’s absolutely not the case now, and it's all fair game to include logistics, command post.”

The aeromedical evacuations officer said during the last two decades of COIN; it was routine to have aircraft positioned close to the fight, another change in the large-scale combat operations environment in Ukraine.

“The future of vertical lift cross-functional team is all about standoff,” he said.

He said that aircraft must now be positioned further to the rear to be out-of-range and preserved.

"There's a misunderstanding that we require air superiority to fight, which is ideal but not absolutely necessary, but air parity absolutely is," he said.

"It's kind of the minimum level of and the air domain that we need to be able to operate, but the lack of air superiority does impact all the warfighting functions, especially in our land evacuation, because we haven't ground evacuated at scale since Korea."

Fricks said that military capability has blended with civil capability due to the lack of military medical professionals close to the front.

"Imagine your state was invaded by a foreign power," he said. "You're going to use your local hospitals. You're going to use your local ambulances until they're destroyed, and then you're going to either figure out ways to do it through other means."

“We saw the void yet filled with between the civil response and the military response, with the NGO presence,” he said.

"The amount of NGO's volunteers that are operating in Ukraine, especially medically are kind of overwhelming," the colonel said. "They're doing most of the work that you would expect the military to do."

Fricks: Medical evacuation depends on maneuver; Maneuver depends on evacuation

The colonel said maneuver depends on medical evacuations to unshackle itself from its casualties, but in the Ukrainian battlespace, medical depends on maneuver to facilitate evacuations because medical cannot operate close to the lines, let alone execute prolonged field care.

“There’s no tolerance by maneuver to encumber their ability to maneuver by holding large amounts of casualties far forward,” Fricks said.

The colonel said the U.S. military medicine has not experienced anything close to LSCO since the Desert Shield and Desert Storm and the early days of the 2003 liberation of the Iraqi people.

"Not nearly the scale of which we would expect in LSCO--most all of our evacuations were done by air, simply because it's easier, it's quicker, it's safer, and we have an advanced capabilities on the aircraft that we don't have on the ground vehicles of primarily the critical care flight paramedic," he said.

Fricks said there is still debate about how to address the medical airlift challenge with existing airframes or drones. “We are looking and experimenting with autonomous systems.”

It does not matter if the airlift is piloted or a drone; the effect is the same; what is really at issue is the lack of air superiority, which takes away the air domain.

“It’s really eliminated the use of aircraft to which we've been heavily dependent upon for previous conflicts—so, this is really worrisome,” Fricks said.

“For folks like me, who have done helicopter evacuations away to the point of injury for decades, however, there's still going to be the requirement to evacuate, especially to the rear areas,” he said. “Of course, the distances are much larger, but there’s got to be aircraft used in those areas.”

He said there is still a debate about whether to go big or small. One option is the Bell-Textron V280 Valor tilt-rotor aircraft, he said.

“Valor gives us the range and speed that we need to be able to transverse to Indo-Pacific or any theater and gives us the standoff to survive,” he said.

“They took the lessons learned from the Osprey, and they applied it to the V280, so the whole engines don’t move,” he said.

“It's a smaller aircraft than the Osprey, but it's bigger than the Black Hawk on the cabin, so it gives us the speed and the range. It doesn't give us an increase in patient capacity, six litters, but what it does do is allow us to spread those patients out further to enable more room in between the patients to be able to do that critical care,” he said.

“I want to go big with the big Black Hawk; a lot of folks want to go small,” he said.

“We still need to invest in Blackhawk because they're gonna be around till 2060,” he said.

“There's probably needs to be a balance of both but to get into big weights, you lose range currently just because the technology is not there to haul heavy weights over long range just because of the demands of uplifting the payload with electric or hybrid type of power plants over,” said Fricks.

Aircraft medical facilities are also equipped with medic enhancement sets that enable advanced monitoring and interventions,” he said. “We have a disparity between that and our on our ground vehicles and on the air vehicles ISR encounter ISR is critical to fires.” ISR is shorthand for intelligence, surveillance and reconnaissance.

The colonel said another consideration learned from the war in Ukraine is that the standard Army ambulances are inadequate.

He said one example is a batch of 40 Army ambulances donated to Ukraine in 2018.

“All of them were destroyed the first week, and this is really what's informing our modernization efforts for the protective wheel ambulance,” he said. “It's unknown if this was a direct target or if this was collateral damage, but the result is the same.”

Fricks said Futures Command is developing a new protected-wheeled, armored and fast ambulance. This new ambulance would have to replace the M997A, the tactical High Mobility Multipurpose Wheeled Vehicle, or Humvee, ambulance. “We're still fielding the 997A3 which was a billion-dollar modernization effort for which we're not going to be able to use it during the LSCO.”

The colonel said for him, LSCO is an evacuation problem that must be solved, using the lessons from Ukraine, before the Army becomes engaged.

“If the front is as bad as it is in Ukraine as we expect it to be with China, treatment is going to be further to the rear,” Fricks said.

“How do we move those patients? How do we keep them alive en route through overextended distances?” he asked.

“I think a prolonged care is prolonged care in route over two to three-hour rides either in the ground vehicle or track or an aircraft,” Fricks said.

“Currently, China and Russia are completely different when it comes to this maneuver; survivability is dependent upon clearing the battlefield—this is something that we don't simulate very well in our warfighters.”

The U.S. military is maneuver-centric, the colonel said.

"We focus on maneuver, not necessarily sustainment and medical.”

The Medical Readiness and Training Command, Joint Base San Antonio Fort Sam Houston, Texas, executes mission command over three Medical Training Brigades, which are paired with three Regional Training Sites-Medical. These brigades and training sites train military medical professionals to execute duties across the full range of military operations.

The MRTC, a subordinate organization under the Army Reserve Medical Command, the Army Reserve's medical training institution, also sponsors the Global Medic Exercises and other collective and individual training events and courses.