Landstuhl Regional Medical Center provides outstanding care to patients evacuated from Iraq and Afghanistan. Patients receive further treatment while awaiting evacuation back to the United States. PROBLEM: Landstuhl, as capable as it is, reaches a threshold of effectiveness around a census of 100 medical/surgical patients. New capabilities and processes require development to optimize Landstuhl's effectiveness. METHODS: Statistical analysis showed the effects at Landstuhl of large numbers of casualties experienced downrange. Case studies of emergency direct aeromedical evacuation from the Middle East to the United States showed the feasibility of using this as a method to bypass Landstuhl when reaching the limits of its capabilities. Analysis of current aeromedical policies and procedures help to develop the communications and coordination required it initiate a bypass mission. FINDINGS: The USAF is tactically capable of direct Middle East to the United States aeromedical evacuation. However, its impact on global mobility would require judicious use of the method. CONCLUSIONS: Direct flights from the Middle East to the United States would help alleviate patient census at Landstuhl, given the casualties numbers from past battles in Iraq and Afghanistan. In the case of a concerted enemy effort to inflict harm on US military members in the Middle East, this method alone would not completely alleviate a bottleneck at Landstuhl and further means of increasing capabilities in Europe require more exploration.