Military medics train to keep casualties alive until evacuation. In the next war, that could take days, or even weeks.

Military medics and trauma teams are training for a potential battlefield where they must care for wounded teammates for weeks before they can be evacuated. Spc. Edgar Martinez/US Army

Military medics are training for a future war where fast casualty evacuation is no longer a reality.

Such a battlefield could see medics tending to stabilized casualties for days or weeks before accessing advanced care.

A senior military trauma leader warned that prolonged casualty care cannot solve all looming evacuation problems.

The corpsman strapped his patient onto the litter as the sound of swirling helicopter blades roared from a watchful instructor's hand-held speaker. Double-checking his IVs were secure, he and a stretcher team hoisted up their casualty and sprinted toward the landing zone amid flying debris from the helo's rotor wash — in this case, a leafblower.

On this makeshift battlefield in the parking lot of the Army's Joint Special Operations Medical Training Center, medics had already quelled enemy fire, stopped the bleeding, drawn two bags of blood from teammates for the wounded, and carried him half a football field to a protected position before the "helicopter" arrived to whisk the injured soldier off to a military hospital nearby.

Such a scene — a wounded US service member being swiftly evacuated to advanced lifesaving care — is familiar to veterans of the Global War on Terror and reflects the belief around which the American military has built its modern trauma system: medics triage the wounded, helicopters or Humvees arrive quickly to evacuate them to a higher-level care, and then surgeons take over.

That combat casualty care chain is expected to fracture in a future large-scale war.

During the post-9/11 wars, military medics routinely plugged gunshot wounds, stopped hemorrhage with tourniquets on limbs shredded by roadside improvised explosive devices, and cleared shattered teeth and debris from airways with their fingers.

Some lawmakers want Pentagon estimates of how many casualties US forces could suffer in a future large-scale war, according to draft versions of the annual defense policy bill. SFC Alexis Washburn/US Army

But the prospect of a large-scale war against a sophisticated foe — an adversary with advanced tech on par with the US military's, with millions of small attack drones potentially stocked and ready — means that they could face the daunting task of keeping casualties alive for longer, without reliable medical evacuation for days or weeks on end.

The military has quietly started preparing some medics to carry more of the burden when evacuation simply isn't possible. But while a single medic can buy time, they can't replace an entire medical logistics system disrupted by drones and electronic warfare , major problems in modern war.

In Ukraine, casualty evacuation within the " golden hour " for life-saving trauma care is effectively nonexistent. Surveillance drones and the threat of attack by explosive-laden drones make traversing the battlefield harder than ever, meaning evacuations are often impossible along the front lines.

Ukrainian troops say evacuating the wounded often means waiting for nightfall or for foggy or stormy weather conditions that disrupt drone operations. Soldiers are increasingly turning to  robotic systems  to evacuate wounded troops because of the danger to medical teams, though with varying degrees of success.

Facing the possibility that the US could one day find itself in a similar war in which medics are tasked with caring for the wounded for longer, some trauma specialists are preparing for that future now.

After decades of relying on rapid evacuation and robust surgical teams, the military is grappling with how much it might ask of combat medics in a major war. Spc Josefina Garcia/US Army

"Our emphasis on prolonged field care, and how we've changed the direction of the course, is sort of baked into what we're doing now," the special operations medical course chief said. "The amount of work that goes on after the point of injury for our medics is where we're shifting the emphasis, so that they can confidently take care of somebody."

For the instructors, that means exposing students early to skills like battlefield amputations and infection management, which previous generations usually only learned years into their careers and at higher ranks. The jam-packed training prioritizes the basics of trauma care , the chief noted, but instructors are introducing advanced skills earlier.

Tomorrow's medics, such as the young soldiers and sailors now in the course at Fort Bragg, could face a deluge of responsibilities after stabilizing casualties: feeding them, tracking intravenous fluids, and dealing with infections, a significant problem in Ukraine. Even the prospect of supporting battlefield dialysis in the event of kidney failure, a potential consequence of tourniquets being left on too long, is possible, medical experts say.

During the Global War on Terror, "missions were very often planned within the range of where you could get an aircraft within an hour," said Col. Ken Dwyer, the school's commander, which contributed to improved survival rates.

The idea that some evacuations in a future war could occur within an hour hasn't entirely vanished, Dwyer said. "But it is on life support with respect to what we think the future might hold, and what we've been told to prepare for."

With immediate casualty evacuation unlikely, medics suddenly become responsible for all of a patient's bodily functions, the course chief explained. One person might take on multiple roles normally seen in an ICU — cleaning patients' teeth, administering eye ointment for eyes dried out by sedatives, monitoring fluid intake, and managing bowel functions.

A select number of military medics have trained for years to provide care in austere environments. Now, more are training to keep patients alive for longer. Justin Moeller/US Army

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