“Emergency Care for America's Heroes”

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08/18/2025

Longer Times, More Drones: The Future of Army EM

CPT Matthew Turner, MD

Since the Secretary of Defense James Mattis published the 2018 National Defense Strategy, the Army has shifted from a focus on counterinsurgency operations to actions against near-peer forces.1 The full-scale Russian invasion of Ukraine in 2022 and ongoing tensions in various parts of the world have only corroborated this; more and more, Large Scale Combat Operations (LSCO) appear to be the inevitable future of warfare.2

The implications for military healthcare are immense. During the Global War on Terrorism, US forces sustained approximately 7,000 deaths and 50,000 non-lethal injuries over a period of 20 years,2 with case fatalities as low as 11-14%.1 The Russian invasion of Ukraine saw over 8,500 casualties in the first 7 days alone.1 Future LSCOs involving brigade and over-brigade sized elements could see even higher numbers of casualties at levels that the United States has not seen since the Second World War.2,3

Prolonged Field Care

The air superiority and excellent medical evacuation systems in place for US forces in Iraq and Afghanistan, where American forces were engaged in heavily asymmetrical warfare, will almost certainly not endure in future conflicts.1  A 2021 Joint Readiness Training Center simulation of a LSCO found that the majority of casualties sustained will likely be due to delays in evacuation.4 Even recovering casualties from the field will likely be incredibly difficult due to the nature of modern war. In Ukraine, a battalion may be distributed over several square kilometers, covering multiple firing positions, often making it extremely dangerous for medics to reach the wounded. Evacuation from the battlefield thus becomes heavily dependent upon weather, the use of obscurants such as smoke, and suppression of the enemy, meaning that in the worst cases, it may take days to evacuate the wounded from the battlefield.5 Medical facilities and workers are an extremely common target,6, and even positions in the rear are not safe, with up to 50% of casualties occurring in rear positions from drones, artillery, and glide bombs.5

In the modern Ukrainian combat environment, where the high saturation of drones “…means that even moving around on foot, let alone on a vehicle, makes one a target for a high-precision drone strike within a few minutes,”7 the impact on medical care is severe. When evacuation from the immediate battlefield takes days, even relatively minor wounds can become severe infections, and tourniquets lead to gangrenous limbs and a significantly increased number of amputees.7 Even further back from the frontlines, medical facilities must be both dispersed and hardened in LSCOs to protect against drone and artillery attack.5 Many Ukrainian Role 1 and Role 2 MTFs have been forced to move underground due to the proliferation of enemy drones.8

Russian and Chinese forces both excel in artillery and long-range capabilities that will almost certainly put any rear medical elements at risk of attack.2 Even in cases where medical facilities are not under imminent threat, it is likely that the Role 1 battalion aid station – often previously skipped over due to excellent medical evacuation – will play an outsized role in treatment of casualties due to delays in evacuation.2

Drones: Danger and Opportunity

Before 2022, the general consensus among scholars was that drones would have a limited impact on LSCOs. The Russo-Ukrainian War has ended this argument once and for all. On either side of the front line, both armies have employed thousands of cheap, commercially-built, hobbyist drones for reconnaissance, supply, bombings, and kamikaze attacks.9 The future of warfare will likely see further massive proliferation of drones. Small, cheap drones have already reshaped the battlefields in both Ukraine and Gaza, and have been identified by US General Frank Mckenzie of CENTCOM as “the single greatest threat to U.S. forces within my area of responsibility”.8 It appears that the genie is out of the bottle; a recent article from the Institute for the Study of War noted that a new Russian schoolbook is teaching 8th and 9th grade schoolchildren on how to operate drones.10 Even countries such as Lithuania have invested in mobile drone repair workshops – vehicles designed with 3D printing capabilities that may closely follow the front line and allow rapid repair and redeployment of drones.11

The danger that drones pose is not limited to just interfering with medical evacuation, challenging air superiority – it is their ability to “impose a persistent threat with no clear engagement boundaries,”8 creating a constant psychological stressor on medical personnel. Reports of a new form of PTSD related to this constant hypervigilance are already spreading, and will require more research in the future.8 

However, drones are a double-edged sword, and hold many promising opportunities for military EM in the future. They are especially promising for a rapid and decentralized means of providing medical supplies. Civilian programs such as the ‘Zipline’ drone service in Rwanda have already proven effective, delivering over 7,000 units of blood in 4,000 missions from 2016-2019. Similar programs have been effectively deployed in Haiti, the Dominican Republic, and New Guinea.12 One charity employing commercial drones has been able to deliver up to 16 kilograms of medical supplies up to 20 kilometers, dropping the payload a few feet above the ground for rapid deployment to isolated Ukrainian villages.13 Even in Ukrainian combat zones, platforms such as the Volya-E and ARK-1 have already been effectively used for limited medical resupply.8 In the battlefield conditions of future LSCOs, medics may be able to use a radio to talk a casualty through the necessary procedures for treatment, and send a drone to deliver medical supplies directly to their position, allowing for immediate treatment of medications and blood.5 In this way, drones will directly act as a force multiplier for the care of casualties.8

Conclusion

The lessons that we can extrapolate from the world’s current conflicts indicate that the LSCOs of the future will be grueling and difficult. Prolonged time in the field, difficulty with evacuation, and the transition of drones from operational assets to tactical and low-cost weapons8 will pose unique challenges to military EM care. However, this new development in warfare is not without opportunities: the potential for rapid deployment of blood supplies and medicines may further revolutionize the future of military medicine.

References

  1. Schauer SG, April MD. Large-scale combat operations and implications for the emergency medicine community. Annals of emergency medicine. 2022;80(5):456-9.
  2. Schauer SG, Long BJ, Rizzo JA, Walrath BD, Baker JB, Gillespie KR, et al. A conceptual framework for non-military investigators to understand the joint roles of medical care in the setting of future large scale combat operations. Prehospital Emergency Care. 2023;27(1):67-74.
  3. Remondelli MH, Remick KN, Shackelford SA, Gurney JM, Pamplin JC, Polk TM, et al. Casualty care implications of large-scale combat operations. Journal of Trauma and Acute Care Surgery. 2023;95(2S):S180-S4.
  4. April MD, Stednick PJ, Christian NB. A Descriptive Analysis of Notional Casualties Sustained at the Joint Readiness Training Center: Implications for Health Service Support during Large-Scale Combat Operations. Medical Journal, US Army Medical Center of Excellence (MEDCoE). 2021.
  5. Watling JR, Nick. Royal United Services Institute: Tactical Developments During the Third Year of the Russo–Ukrainian War 14 Feb 2025 [Available from: https://www.rusi.org/explore-our-research/publications/special-resources/tactical-developments-during-third-year-russo-ukrainian-war.
  6. Chauhan V, Secor-Jones S, Paladino L, Sardesai I, Ratnayake A, Stawicki SP, et al. Emergency departments: preparing for a new war. Journal of Emergencies, Trauma, and Shock. 2022;15(4):157-61.
  7. Farrell F. How medics of Ukraine’s 3rd Assault Brigade deal with horrors of drone warfare. Kyiv Independent. 06 May 2025. https://kyivindependent.com/a-night-with-the-medics-of-ukraines-3rd-assault-brigade-on-kharkiv-oblast-front/
  8. Nowadly CD, Maddry JK, Vargas CR, MacDonald AG, Maksimenko YM, Hewitt CW, et al. The Medical Implications of Emerging Unmanned Aircraft Systems in Military and Combat Environments: A Narrative Review. Military Medicine. 2025:usaf189.
  9. Chávez K, Swed O. Emulating underdogs: Tactical drones in the Russia-Ukraine war. Contemporary Security Policy. 2023;44(4):592-605.
  10. Trach T SK, Barros G, Olmstead J, Sobieski J. Russian Force Generation and Technological Adaptations Update May 30 2025. Institute for the Study of War [Internet]. 2025. Available from: https://www.understandingwar.org/backgrounder/russian-force-generation-and-technological-adaptations-update-may-30-2025.
  11. Rivero J. Innovating Under Fire: Lessons from Ukraine's Frontline Drone Workshops. Modern War Institute at West Point [Internet]. 2025. Available from: https://mwi.westpoint.edu/innovating-under-fire-lessons-from-ukraines-frontline-drone-workshops/.
  12. Ling G, Draghic N. Aerial drones for blood delivery. Transfusion. 2019;59(S2):1608-11.
  13. 13. Drones to Save, Not Take Life – Ukrainian Aerial Delivered Medical Services Expand. Kyiv Post. 2025.

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