Optimizing aeromedical evacuation in combat: Balancing trauma system efficiency and patient outcomes.

BACKGROUND: The Israel Defense Forces Medical Corps (IDF-MC) operates an echelon-based system, evacuating combat casualties to civilian trauma centers. During multiarena conflicts, aeromedical evacuation of urgent casualties is directed to frontline-adjacent medical centers (FLAMCs) or to default medical centers (DMCs; Level I trauma centers) to prevent FLAMCs overwhelming. This study aims to assess the impact of casualty distribution on mortality outcomes.

METHODS: This is a retrospective cohort study of IDF combat casualties evacuated by helicopter during the "Swords of Iron" war, between October 27, 2023, and January 19, 2025. Prehospital data from the IDF Trauma Registry were linked with in-hospital records from the Israel National Trauma Registry. Urgent casualties (danger to life or limb) evacuated by air with signs of life on board were included. Primary outcomes were 24-hour and 30-day mortality. Multivariable logistic regression was applied to compare outcomes among FLAMCs versus DMCs in the severely injured casualties (ISS ≥16) and fatalities.

RESULTS: Of 5,649 casualties treated, 1,443 casualties met the inclusion criteria; 969 (67%) were routed to DMCs and 474 (33%) to FLAMCs. The predominant mechanism of injury was penetrating trauma (85%). Median evacuation time was 68 minutes (IQR: 54-93), 73 minutes (IQR: 59-97) to DMCs versus 60 minutes (IQR: 46-77) to FLAMCs ( p <0.001). Prehospital shock (31% vs. 9.1%; p <0.001) and en route blood product administration (32% vs. 14%; p <0.001) were more frequent among casualties evacuated to FLAMCs. Evacuation to DMCs was associated with lower 24-hour and 30-day mortality rates (OR: 0.27; 95% CI: 0.09-0.70 and OR: 0.40; 95% CI: 0.17-0.87, respectively).

CONCLUSIONS: In multiarena conflicts, aeromedical evacuation policy enables a well-balanced distribution of a high volume of casualties among medical centers while preventing overwhelming of frontline facilities, without worsening outcomes. ( J Trauma Acute Care Surg . 2026;101: S26-S35. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.).

LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.