Decisive Point Podcast – Ep 6-7 – Mahdi Al-Husseini, Samuel J. Diehl, and Samuel L. Fricks – On “Bridging Sky and Sea: Joint Strategies for Medical Evacuation in the Indo-Pacific”

This podcast contends that the US Army should coordinate agile and expeditious Joint medical evacuation operations in the Indo-Pacific and develop novel capabilities to do so effectively.

Keywords: medical evacuation, maritime operations, novel capability, World War II, Joint health service

Host (Stephanie Crider)

You are listening to Decisive Point. The views and opinions expressed in this podcast are those of the guests and are not necessarily those of the Department of the Army, the US Army War College, or any other agency of the US government.

I’m talking with Mahdi Al-Husseini, Samuel J. Diehl, and Samuel L. Fricks today, authors of “Bridging Sky and Sea: Joint Strategies for Medical Evacuation in the Indo-Pacific,” which was published in the Spring 2025 issue of Parameters.

Al-Husseini was previously the director of the Medical Evacuation Doctrine Course for the Department of Aviation Medicine. He’s now a PhD student at Stanford University in aeronautics and astronautics, with a follow-on as an experimental test pilot.

Diehl was the commander of the 3rd Battalion, 25th Aviation Regiment, and following the US Army War College, where he’s currently a student, he will be assigned as Medical Command G5.

Fricks serves as the chief of the Medical Evacuation Concepts and Capabilities Division and is responsible for air and ground evacuation modernization.

Welcome to Decisive Point, gentlemen.

Samuel L. Fricks

Thank you.

Samuel J. Diehl

Thanks. It’s great to be here.

Host

Why did you write this article, and why is now the time?

Fricks

The character of war is changing rapidly. Observations from the battlefield in Ukraine have shown that traditional ways of doing things don’t work, necessarily, when you’re under constant observation.

Why we wrote the article was, we have to change the way that we do medical evacuation, specifically—or especially—in the Indo-Pacific, in order to really have a chance.

Mahdi Al-Husseini

One of the ways we open up the article is by saying what is old is new again, and what is new changes everything, and I think that’s especially true in the context of medical evacuation in the Indo-Pacific. When we look back at World War II, which I would argue is one of the best case studies that we have, in terms of this particular problem set and this particular theater, a lot of what was true and relevant then continues to be true and relevant now. And, we see that on the tactical level. We see that on the strategic level. We see that across echelons and across mission sets.

And yet, despite that, I think so many things as, no doubt, Colonel Diehl and Colonel Fricks will allude to in a little bit, so many ways that our enemy operates has changed, right? And, those things need to be considered as well. And so, what we’re dealing with here is, I think, a very gnarly problem, and one that affects the lives of servicemembers. You know, I do think we’re at something of a junction point, and we need to be able to ensure we have the resources, the doctrine, the training necessary to ensure that when that next conflict comes, we are prepared for it. And, that’s another reason we really wanted to bring this article out to a larger community.

Samuel J. Diehl

And, I’ll give credit to Mahdi where it’s due that when I took command in May of 2023, he was already working towards a degree of experimentation and integration—both with joint partners, as well as with the Army Theater Sustainment Command—about how we tackle this problem, sort of at the micro/tactical level, more effectively from an integration standpoint, but then also how do we integrate and test new technologies?

As a career MEDEVAC [medical evacuation] pilot, I thought what he was doing was really exceptional, but I also understood institutionally, you know, where Colonel Fricks is coming from [in saying] that we have, you know, something of an obligation to get this information out there.

There’s a host of articles out now bemoaning the expectation that there is no more golden hour, that casualties will likely increase in a different conflict in the future, but we haven’t really taken many steps concretely to address that problem.

It’s known but then, also, there are elements, where I’ve discussed with Mahdi, where we evolved in World War II, but our organizations—our authorities, in some cases—haven’t necessarily evolved to catch up to some of the capabilities that we currently have.

So, capturing how do you exercise C2 [command and control] of these assets across joint and combined organizations is incredibly important. I think it’s important, probably, to just start with why is medical evacuation important?

We probably lose some degree of understanding—because we’ve taken it for granted in the last 25 years—that there are strategic implications for how we preserve our combat strength. And, we’ve done it historically very well, but it has implications for how we fight, right—how commanders can exercise audacity, how they can prevent culmination, and then how our individual soldiers see themselves on the battlefield. The risk that they’re willing to take reflects, right, their understanding and appreciation for how their medical system is going to take care of them.

Host

Tell me a little bit more about what you all are advocating for, not only in your article, but if there’s anything beyond that that you want to touch on, I’d love to hear it.

Al-Husseini

One of the luxuries I have here is having folks like Colonel Fricks and Colonel Diehl, who are, legitimately, I would argue, titans of the MEDEVAC enterprise.

So, I think all of us will have something of a different perspective. You know, I’ll kind of broach this from the tactical level—as somebody who was formerly, and very recently, a platoon leader and an operations officer in a MEDEVAC company—one of the challenges that we ask ourselves, we talk a lot about LSCO [large-scale combat operations], right, is to what extent do I have control, you know, in my foxhole and in my organization with the kind of impact that we want to have, given the challenges that we discuss in the article. When we talk about, you know, how do we enable medical evacuation to be effective over long distances, where the patient numbers are far beyond anything we’ve seen potentially, again, since World War II, where we have an enemy threat that is dynamic, that is evolving, whose weapon systems while, maybe known to us, we haven’t necessarily faced directly?

And those are tough, right? Especially, I’ll tell you, as a captain, as a platoon leader, as a section leader in a MEDEVAC company, I don’t have control over the acquisitions pipeline, right? So, I don’t have control over materiel, but what I do have an impact on is training.

And, one thing we try to advocate for in the article that is true for MEDEVAC, but also extends to other missions, is, you know, we can think critically about capability. And [that is] one of the things that the JCIDS [Joint Capabilities Integration and Development System] does very well. There’s a formal definition in there that kind of talks about capability in terms of integrating ways and means and means and ways. That’s something we also talk about in the article.

And, one of the things we advocate for is—even on the tactical level—to kind of think about, given, you know, the materiel that we do have, right, given the equipment that we have, given the force structure that we currently have, how can we think creatively about challenging problems and find ways to make a difference and to demonstrate potentially new capabilities given the things we already have?

So, to be a little bit more specific, you know, one of the things we talk about in the article, for example, is an exercise that we ran at the 25th Infantry Division, which we call MEDEVAC Projects Week. In that effort, what we effectively did was we demonstrated this concept of a maritime exchange point where we were able to use an Army watercraft to bridge the transport of a pace ship between two aircraft—hypothetically coming from different islands.

We had an existing setup in terms of what our force structure looks like. We know, you know, our aircraft have certain capabilities. We know we have a relationship with our watercraft teams—in this case down in Honolulu. How do we bring them together? How do we network, you know, all these various pieces of the puzzle effectively and in ways that can make a difference?

And so, one thing that we certainly want to bring to bear is this idea that even on the tactical level, there are ways to experiment and to consider how we use the things that sometimes we take for granted, but how do we use our existing units or our existing equipment to do new things in a way, in this case, in the case of MEDEVAC, impacts real-world patients in real-world conflicts?

Fricks

Yeah, just to build off what Mahdi indicated there, we also have to embrace, kind of, the new technologies, right, especially when it comes to autonomous systems. We’ve all seen the directives that are coming out, you know, unleashing drone dominance and such, and medical needs to be a part of that. The problem, though, is that we really lack the policy that addresses moving casualties on an autonomous system.

You know, there’s an ethical piece to it and there’s a policy piece. But, I think we would agree that we’d like to use it just like you would have used, you know, the helicopter in Korea. Remember, if you’ve ever seen MASH, they put the casualties on the outside of the aircraft, right, with no en route carrier. If we did that today, it would be considered wrong, but at the time, it was transformative and impactful—and that’s the way we really need to look at drones.

So, taking what Mahdi was talking about with what we have existed, we also need to look forward to how we can use evolving technologies to get after moving casualties in that really denied environment. And that’s where, you know, a lot of the observations from Ukraine, I think, really apply—the way that they’ve used ground robotics and remote systems to be able to evacuate in areas where we’ve traditionally sent a helicopter all the way to the point of injury to pick up a casualty. And that’s just simply not feasible in the future environment.

I think Colonel Diehl here will talk about, you know, how we command and control that economy of force to be able to task those things, but from my perspective, we really need to embrace that new technology to supplement—or complement—what we know works and what we already have in our inventory, like Mahdi alluded to.

Diehl

One thing Mahdi didn’t talk about, which we may be able to get to later, is how he’s working some automated decision-support tools, as well, to help apply algorithm solutions to some of these challenges.

My focus and specific interest is how do we see ourselves fighting? How have we fought as a military health service? And where do the gaps potentially exist?

The joint concept for health service support talks a lot about integration. It doesn’t talk an awful lot about command and control. And, I think commanders are essential at echelon—really even above the division level—in synchronizing these resources and how they fight. We know that it’s not prominent in the history. There were incredible challenges in historical conflicts in regulating patients, in prioritizing movement of resources and patients, in developing policies—or even best practices—as it pertained to medical care. And so, having senior commanders with a staff that’s capable, and provided the authorities to effectively exercise, that’s, I think, how we win.

War requires a tremendous amount of adaptation, and the medical community, just by virtue of supporting the war-fighting element, has to adapt in response to that adaptation. We have to think about how we expect to manage risk, and where are the leaders that are prepared to have very difficult conversations about how we employ very finite resources on the battlefield [and] where we accept risk for a patient or for a crew or employ an autonomous system at the end of the day, right, to preserve the health of the war fighter on the battlefield.

Host

Colonel Fricks, you brought up a really great point. If there’s no conflict, then likely MEDEVAC is not active. It’s kind of out of sight, out of mind, I guess, is what I’m getting at. What does our audience need to understand about MEDEVAC?

Fricks

It’s not out of sight, out of mind. It’s actually on the table for reductions because it’s not being used.

And that’s a battle that has gone back since the ’60s, when Charles Kelly, you know, one of the big names in MEDEVAC, kind of the father of MEDEVAC, was really fighting hard to protect his assets because they were out there on the ramp when everyone else was using their aircraft. The ones [aircraft] with the red crosses weren’t being used, so the commander wanted to take them and use them.

So, we are currently facing very similar challenges where we have this fleet of aircraft that are not necessarily engaged all the time, and those same questions are really being asked. Why do we have all these aircraft? And, there’s a cost that comes with maintaining them and a cost in training and folks for maintaining those aircraft. So, the risk is how do we maintain a large fleet that’s large enough to support the entire Joint Force, which the Army has been directed to do for air medical evacuation, at a time when we’re trying to save money and reduce spending when the demand’s really not there?

Now, we do have to keep some capability for homeland defense and some contingency operations—but the Army has actually already reduced MEDEVAC through Army transformation initiatives—because it takes a long time to build that up and to train everyone and be proficient. Because the MEDEVAC mission set is one of the most difficult missions to fly because we’re always flying in the worst weather, the darkest nights—because that’s when the casualties happen. It’s not an easily replicatable [replicable] capability to build from the ground up.

Host

We’re getting close to our time here, but I know you had some really good recommendations. I think there were six of them. Can we briefly go through them?

Diehl

I’ll lead off.

I’ll give credit where it’s due, to Mahdi, as the previous director of our MEDEVAC Doctrine Course. [One item] is updating our doctrine to make sure that we’re not comfortable with the status quo of how we’ve developed the system and that we challenge leaders. We institutionalize an understanding of how we can and should employ our assets in a littoral environment. I don’t think we’re there yet, though we’ve made some challenges, but that’s really, you know, institutionally how we communicate in a shared language, how we have to train. And so, if our doctrine doesn’t reflect that [it causes problems]. That’s step one is making sure that we have commanders who understand the imperative to operate in this environment and think through the challenges at the tactical level that need to be overcome, right, because that’s the best place to find out where they need top cover, where they need a better process, where they need to better understand risk, or there’s training that comes from the bottom up. So, that was number one.

And Mahdi, I’ll give you credit where it’s due or an opportunity to chime in on that.

Mahdi

Absolutely, sir. Doctrine is the foundation, right? So, every year, of course, we get a new crop of excellent “67 Juliets” [aeromedical evacuation officers], who come to us at the doctrine course to learn the fundamentals, which they then take out to their unit and can then start really meaningfully applying critical thinking to.

A lot has changed, actually, since we published the article, ATP 4-02.2, [Army Techniques Publication] Medical Evacuation, which is the, I would argue, preeminent piece of doctrine, on the techniques level, for all things medical evacuation in the Army. My understanding is a new one is shortly here to be published, but it really does include quite a bit on the maritime theater that, up until this point, has really not been the case.

And so, it’s really wonderful to see folks like Larry Smith and the MEDCoE [US Army Medical Center of Excellence] Doctrine Division pushing forward on the importance of the maritime theater and considerations for the maritime theater and how we do evacuation in that space in the foundations, right? That all 67 Js [Juliets], right, must understand—in many ways, in my opinion, from front to cover—before going out and doing this sort of critical thinking and unique demonstrations and extending capability that we talk about in this podcast.

That being said, I think there’s certainly a lot of work to be done there. There’s also, you know, how do we integrate with the other forces—or the other joint forces—in our doctrine through things like the Joint publications? And how do we think about how the Army fits into the larger puzzle with the use of our air ambulances in light of, you know, ships and the other capabilities that the other branches bring to bear? And, I would argue that’s still something of an open question that we’re still trying to figure out to this day, but it’s a start. And the doctrine is really where we start.

Diehl

The second recommendation, I think, just as ordered in the article, was about watercraft, right? And we certainly don’t have a lot of control over that. And the Army, arguably, is still at a deficit. I think between the Army and the Navy in World War II, we had upwards of 30 hospital ships in use. How and when we identify those, equip those, and man those is a discussion that’s far above my level.

But even at the tactical, low-operational level, understanding how we would interface with those and how they are integrated into a joint medical plan, I would argue we’re likely not there yet. And, that’s just informed by five years in Hawaii and a couple years in Korea. I haven’t seen a lot of concrete analysis that we’ve thought through that problem about how watercraft would be used. And, we understand contested logistics.

We understand TPFDD [Time-Phased Force Deployment Data] constraints and the incredible demand across 7,000 miles of ocean for [a] very finite number of resources to move people and resources. What we identify as a specific medical-lift capability and how many [are] questions, that I don’t have the answers to but, arguably, could use some refinement, I think, at this point.

Al-Husseini

One of the recommendations that we make is that we should continue to build on existing research agreements with our academic partners to develop and assess new evacuation capabilities at scale in some of these irregular theaters, where we have constraints like vast distances and kind of this distributed patient instantiation across islands, for example, and these enemy constraints. And, we’ve tried to do that. MEDEVAC Projects Week itself was kind of a joint effort, not just between the 25th Infantry Division and 8th TSC [Training Support Center], but also, actually, the Army Research Lab and Stanford University. And so, we brought all team members to the table to kind of figure out, hey, how do we introduce this capability in a way that, number one, operationally makes sense for the problem at hand? Number two—technically, on the backside—can be supported in a way that meets our requirements for things like continuity of care and also, of course, respects the employment of unique assets like HH-60 aircraft and the LSV [Logistics Support Vessel] aircraft that we were working with.

And so, it really does take kind of all parties to kind of come together to figure out some of these problem sets, and we want to kind of continue to be able to do that. And so, we currently have an existing research agreement for the next several years between the Army Research Lab in Berkeley, [California], and the Department of Aviation Medicine.

I’ve also kind of been privy to that and supported that effort to, kind of, continue exploring some additional capabilities in light of not just our current inventory but our future inventory. And then, the other part that we’re very interested in, and Colonel Diehl alluded to this, is the automated decision making, or how do we meaningfully employ data and historical trends in a way that allows our evacuation dispatchers in our control cells to make difficult decisions with regards to what platforms go where [and] in support of what patients and, again, what is oftentimes a very, very challenging and complex environment.

And so, you know, one thing we’re actively working on right now is a program we call MEDEVAC X, where we basically have this incredibly high-fidelity simulator for MEDEVAC operations, both in the European and the Pacific theater, and we’re able to employ a series of automated dispatching tools to evaluate not just, you know, how we might deal with these kind of very unique and extremely large casualty flows, but how we integrate, right, with medical planners and automation so we can really have the best dispatching, the best planning possible for any kind of given conflict. And so, we want to continue to kind of push the envelope on that, and we do think it’ll pay dividends down the road, but it is kind of early on in the research phase. But, we do advocate for more of this kind of exploration and bringing in bright minds, not just from within, you know, the Department of War, but beyond that to our academic institutions and even industry where it calls for it.

Fricks

So, to Mahdi’s point, there’s a lot of utility in applying AI solutions to some of these problems. One of the recommendations we make in the paper is applying those solutions in a denied, degraded, or disrupted environment, right?

Understanding that the fog of war is going to preclude a surgeon cell or a command team that owns those assets from having uninterrupted understanding of where those assets exist, where the casualties exist. There’s value in having some algorithmic input on how we allocate very finite resources. That also speaks to, you know, the larger challenge of who is making those decisions and who’s owning risks.

Ultimately, all of this conversation is about risk, assuming risk for the war fighter, assuming risk for a platform that’s in jeopardy. And so, how do we help commanders make better decisions is where Mahdi’s putting a lot of work. And, though his MEDEVAC X project is specific to MEDEVAC, I think one could argue that there’s a lot of potential utility in how that algorithm can drive point-of-need delivery or resupply, et cetera.

Al-Husseini

And, I’ll just say one more thing on that point. There is, of course, a lot of interest in AI and, oftentimes, I talk about decision-making support systems rather than calling them decision-making systems. And, that’s very intentional because having that human in the loop, especially when we talk about things like MEDEVAC, is critical, right? In general, I also just don’t think it’s a good idea to remove the human in the loop and allow a lot of these decisions to happen in an entirely decentralized way. There’s a lot of difficulties with that.

And so, one of the things I certainly advocate for when we think about AI implementation, especially in the MEDEVAC community, is safety and validation. What is the safety [mechanism] and how do we validate these tools so that when we are in an operational scenario, we have some level of guarantee? Because we’re not talking, of course, about moving bullets and beans, right? We’re talking about moving war fighters, folks who’ve been injured and who deserve, right, those sort of guarantees should these automated systems be used.

So, I know my team and I here at Stanford are certainly hard at work at that area. And, there’s a lot of others who are doing excellent work across the spectrum in support of the Army and the other branches doing the same thing, but those are some of the really difficult questions I think we have and we’ll continue to ask ourselves. And I think that is especially true for MEDEVAC.

Fricks

The military should pursue autonomous evacuation solutions and the policies that govern them. The big recommendation—and that’s kind of really tied into the complete autonomy one—is we have to have a policy that addresses the use of it because we’re not building drones specific for that [autonomous evacuation]. Even for CASAVAC, you know, which is casualty evacuation, not necessarily MEDEVAC, you can put a casualty on a drone and move it, but is it built to the standard or the airworthiness requirements to support human life? Can it recompute weight and balance? Does it know not to go above 14,000 feet with a human on board because of oxygen and the other human factors? So, a policy would help drive that, and then we can get into the materiel side of it and actually build capability that can support that. So, the world of autonomy is our oyster, right? But, we have to have the policies in place to govern its build and design. Between Sam and Mahdi, they can bring it home on the maritime evacuation concept, and I think they’ll have the last recommendation.

Diehl

I’ll add, autonomy absolutely has its place, but manned platforms also are not going away, not anytime soon, and there will be conversations about how far forward those can go. Future vertical lift capabilities, along with the HH-60s, are not going anywhere.

What we need to do, though, is understand that there have been proofs-of-concept—use cases—in Ukraine for unmanned capabilities in environments where putting a manned crew at risk could not happen, right, without almost their assured destruction. And so, what capabilities can we push farther forward, right? We want to get the best care as far forward as possible and get the patient to the rear as rapidly as possible. There’s always a risk conversation surrounding that. And so, if you have additional unmanned capabilities, that supports the conversation of developing it.

The last recommendation we make in the paper is really about a joint medical evacuation concept in littoral environments, and I would put a little bit of a finer point on it, understanding that there’s no boilerplate. You know, theater-nonspecific solution is about authorities, right? Who can integrate medical resources across joint forces in a specific geography to reduce risk to the war fighters, right? Who can do that in such a way that reduces the JFLCC [Joint Force Land Component Commander] or division or maneuver commander’s risk in a way that they don’t have to be concerned about culmination, right? Or about their soldiers lacking the care that they should have.

What the medical community can provide in a future conflict, you know, that standard may shift based on threat, but we have an obligation to plan against the very best standard of care. And so, that takes commanders. That takes commanders that are empowered to apply resources, integrate them across formations, across geographies, and that might be water. That might be land. But, there are battlefield frameworks that we don’t currently exercise. And I say this [based on] what I’ve seen in the Pacific, in Hawaii, and in Korea. We talk an awful lot about integration, but we don’t do very well in defining roles specifically for the theater medical command, right?

The Army has a theater-enabling command that is somewhat analogous to the TSC [Training Sustainment Command] but lacks some of the authorities and/or capacity to really fulfill the role, I think, for which they’re intended. And so, you know, whether or not there is a joint concept that’s published, forcing us to think about, right, where historically we have been very challenged, I think, is in placing the responsibility for medical advice and decisions on a surgeon or the surgeon’s staff instead of a commander, right? And medical command and control is foundational to this conversation—understanding how to integrate, how to anticipate, how to conform.

We’ve got to attack some of those challenges in the Indo-Pacific. And MEDEVAC, specifically, is one of 10 medical functions where, as a Joint Force, we need to understand better how we see to those assets.

Host

Listeners, you can read the genesis article at press.armywarcollege.edu/parameters. Look for volume 55, issue 1. For more Army War College podcasts, check out Conversations on Strategy, SSI Live, CLSC Dialogues, and A Better Peace.

Gentlemen, thank you very much for making time to speak with me today. Very interesting conversation.

Diehl

Thanks, Stephanie.

Al-Husseini

Thank you very much.

Fricks

Thanks for the opportunity.