In a near-peer conflict, Rotary Wing Aero Medical Evacuation (RWAME) may not always be available. Therefore, a PMV Combat Team (CT) risks preventable pre-hospital combat deaths by not possessing at least one PMV Ambulance (PMV-A) independent of the extant centralised admin company they may usually reside with.

The chances of survival diminish dramatically if a casualty cannot reach hospital care within “the golden hour.” The centralised method limits subordinate call signs to an orbital range of half an hour, when accounting for the travel time. But if a PMV-A is permanently attached with the CT Headquarters (HQ), the full one-hour range is achieved.

Within the CT HQ, this PMV-A will provide the greatest benefit to Army if it is fitted with an armament for self-protection, as is the case with the M113AS4 or ASLAV ambulance. Even greater value will be gained if the ambulance is able to carry ammunition to exchange for casualties, as is the practice in the British Army.

Always have a backup plan. Even in theatres such as Afghanistan, RWAME was not always guaranteed with 14 x UH-60 Black Hawks and 27 x CH-47 Chinooks lost by coalition forces between 2001 and 2020. The next conflict is likely to be characterised by more anti-air weapons with greater accuracy, leading to greater lethality and resulting in much less air freedom of action.

Under the current structure, if a soldier receives a life-threatening wound and RWAME is not available, the one or two centralised ambulances of the Battlefield Clearance team (BCT) will move forward. There are three CT per BG, so one or two ambulances for typically ~450 soldiers. These BCT PMV-A may be in a semi-permanent admin location or prepositioned some distance rear of the contact site for a deliberate advance to contact.

Getting that ambulance activated, moved forward, and married up is not always straight forward or quick. Time lost in error, delay, or simply covering the distance to the casualty can be dramatically reduced if the ambulance is part of the CT HQ already – it is in fact halved. Further, the risk of a fatality increases if the BCT is prepositioned on the other side of the BG’s area of operations when the enemy initiates the contact.

In either situation, confusion will often slow radio nets before there is movement. When ambulances are centralised, the area needs to be secured before the BG risks sending its high value assets. When the CT is self-sufficient with its own PMV-A, it need only send a notification that the causality is already loaded and on route via a pre-approved road space request, away from the contact. It is also worth noting that it could potentially provide its own self-protection.

Enhanced Independence via Mounted Weapon System. The PMV-A is not currently fitted with a mounted armament. The M113AS4 and ASLAV ambulances are fitted with a 12.7 mm heavy machine gun, so will the anticipated Land 400 Phase 3 Infantry Fighting Vehicle Ambulance.

For any vehicle to traverse the terrain of the modern battlespace, it needs to be able to protect itself, because the threat is not confined to established battle lines. Even the Army’s new fleet of trucks are now fitted with roof-mounted machine guns. Potentially every other vehicle the ADF deploys to a combat zone will have an armament except the PMV-A.

Having a mounted weapon system provides a critical self-defence capability. Being deficient in self-defence invites enemy attacks and makes any vehicle an easy target. Consider reporting from the Turkish Army and its efforts against ISIS in Syria where they documented that 80% and 5% of 676 recorded attacks against military vehicles were from rifle or machine fire and RPG respectively.

Typically, vehicles move in pairs as a minimum is such circumstances. Movement of PMV-A without an armament, forward to a contact site and rearwards with casualties, requires a third vehicle to provide the required protection. This is an unnecessary misuse of personnel and vehicles. In this regard, it seems that perhaps we have forgotten our history.

Ambulances in the Vietnam War. This idea is not new, an ambulance was part of the troop makeup in the Royal Australian Armoured Corps (RAAC) M113 Armoured Personal Carriers (APCs) Troops in Vietnam. There was even an ambulance in 3 Troop, 1 APC Squadron who participated in the Battle of Long Tan.

A post-Vietnam war troop construct shows an ambulance in their four car troop headquarters, in the figure below.[1] This ambulance was typically paired with the Troop Sergeant’s vehicle, evacuating casualties together, as soon as they occurred, typically to a Helicopter Landing Zone (HLZ) rearward. While both the Vietnam and Afghanistan conflicts were characterised by a near free employment of RW aviation, it speaks volumes that mounted units in Vietnam continued to maintain a degree of ground ambulance capability at the troop or CT level, noting that the casualty rate in Afghanistan conflict is estimated to be a third of that from Vietnam.[2]

Our assumption on RWAME is this capability will be best augmented by the inclusion of the additional medic with the ambulance to complement the CT medic, and the typical three or more Combat First Aider[3] (CFA’s) or one per platoon, who can all use the PMV-A as a supply and knowledge base. This increases awareness and aims to reduce injuries during casualty evacuation (CASEVAC).

The APC Troop Structure of The Forth Cavalry Regiment from Troop Training Notes 1978. Note the Ambulance, centre right.

“Reference my last: was SIMCAS, now No-Duff, more to follow. Wait-out.” The conduct of any military training comes with a level of risk the public do not usually understand. So too does the conduct of simulated casualty exercises or SIMCAS.

These help prepare soldiers for the real thing. One element of risk is the assembly of the stretcher loading ramps specific to the PMV-A. The quickly pinned together ramps and their braces allow soldiers to lift a heavy casualty two and a half meters from the ground into the vehicle. The problem, when not assembled correctly, is that these have been known to cause injuries by themselves. The solution: a greater focus on training with the PMV-A. This includes both training with the equipment within the vehicle and maintaining competency for the crews driving it.

An ambulance driver who has been able to traverse the area of operations with the CT they are a part of is one who more likely to get to where they need to be when it counts and less likely to become their own form of preventable casualty.

Applying the Combat Mindset to Medical Training. A greater focus on combat casualty care is not wasted. In the US Army, the ‘Ranger Model’ developed after Somalia took on an ethos of emphasising medical training, qualification, and specialisation across every member of the 75th Ranger Regiment.

In Afghanistan, they sustained 35% less fatalities compared to the rest of the US military, due to “substantial prehospital care” despite having higher casualty severity. Greater access to medics in the CT allows for more training more often with a medical focus.

Our doctrine identifies likely casualty rates for the range of tasks we are expected to achieve. Training for the mission means acknowledging this and training first aid and casualty evacuation into every opportunity. Having the PMV-A at the CT commander’s disposal means a lack of resources is no longer an issue. Having the PMV-A assist is not enough by itself, the interactions of all personnel involved needs to be rehearsed as often as possible or they can all too easily fumble in the heat of the moment. Separately, the British Army gain other efficiencies from a normally empty vehicle heading towards a contact.

To the CT sergeant major, the single most important thing the BCT has to offer during a contact is ammunition. Winning the fight is priority one, care and evacuation of casualties is second. Winning the fight and remaining ready for the next comes before casualties. In the British Army, some ambulances are used to carry ammunition to the fight, unloaded on a stretcher, to be replaced by a different stretcher with a casualty.

Conclusion

Including a PMV-A into the PMV CT HQ can reduce the risk of preventable pre-hospital combat deaths by expediting vehicle CASEVAC as well as reduce the risk of injuries during training, where a combat mindset is applied. It can double the mission range of a combat team by reducing the need for the PMV-A to travel to the casualty. It can also increase tactical combat efficiencies if the vehicle is able to carry ammunition forward to a CASEVAC site in-contact and is fitted with an armament to provide self-protection. It is supposed to be a protected mobility vehicle after all.