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(e) The second paragraph of Article 19 imposes an obligation upon belligerents to
“ensure that the said medical establishments and units are, as far as possible, situated in such a manner that
attacks against military objectives cannot imperil their safety.” Hospitals should be sited alone, as far as
possible from military objectives. The unintentional bombardment of a medical establishment or unit due to
its presence among or in proximity to valid military objectives is not a violation of the GWS. Legal
protection is certainly valuable, but it is more valuable when accompanied by practical safeguards.
(2) The second protection provided by the GWS pertains to medical units, establishments,
materiel, and transports that fall into the hands of the enemy.
(a) Captured mobile medical unit materiel is to be used first to treat the patients in the
captured unit. If there are no patients in the captured unit, or when those who were there have been moved,
the materiel is to be used for the treatment of other wounded and sick persons.
(b) Generally, the buildings, materiel, and stores of fixed medical establishments will
continue to be used to treat wounded and sick. However, after provision is made to care for remaining
patients, tactical commanders may make other use of them. All distinctive markings must be removed if the
buildings are to be used for other than medical purposes.
(c) The materiel and stores of fixed establishments and mobile medical units are not to
be intentionally destroyed, even to prevent them from falling into enemy hands. In certain extreme cases,
buildings may have to be destroyed for tactical reasons.
(d) Medical transports that fall into enemy hands may be used for any purpose once
arrangement has been made for the medical care of the wounded and sick they contain. The distinctive
markings must be removed if they are to be used for nonmedical purposes.
(e) A medical aircraft is supposed to obey a summons to land for inspection. If it is
performing its medical mission, it is supposed to be released to continue its flight. If examination reveals
that an act “harmful to the enemy” (for example, if the aircraft is carrying munitions) has been committed,
it loses the protections of the Conventions and may be seized. If a medical aircraft makes an involuntary
landing, all aboard, except the medical personnel, will be POWs. A medical aircraft refusing a summons to
land is a fair target.
b. Identification. The GWS contains several provisions regarding the use of the red cross
emblem on medical units, establishments, and transports (the identification of medical personnel has been
previously discussed).
(1) Article 39 of the GWS reads as follows:
“Under the direction of the competent military
authority, the emblem shall be displayed on the flags, armlets, and on all equipment employed in the
Medical Service.”
(a) There is no obligation of a belligerent to mark his units with the emblem. Sometimes
a commander (generally no lower than a brigade commander for US forces) may order the camouflage of
his medical units in order to conceal the presence or real strength of his forces. The enemy must respect a
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medical unit if he knows of its presence, even one that is camouflaged or not marked. The absence of a
visible red cross emblem, however, coupled with a lack of knowledge on the part of the enemy as to the
unit’s protected status, may render that unit’s protection valueless. (Refer to paragraph 4-8b(3) below for
additional information.)
(b) The distinctive emblem is not a red cross alone; it is a red cross on a white
background. Should there be some good reason, however, why an object protected by the Convention can
only be marked with a red cross without a white background, belligerents may not make the fact that it is so
marked a pretext for refusing to respect it.
(c) Some countries use the red crescent on a white background in place of the red
cross. This emblem is recognized as an authorized exception under Article 38, GWS. Although not
specifically authorized as a symbol in lieu of the red cross, enemies of Israel in past wars have recognized
the red Star of David and have afforded it the same respect as the red cross. This showed compliance with
the general rule that the wounded and sick must be respected and protected when they are recognized as
such, even when not properly marked.
NOTE
The Geneva Conventions authorizes the use of the following distinctive
emblems on a white background: Red Cross; Red Crescent; and Red
Lion and Sun. In operations conducted in countries using an emblem
other than the Red Cross on a white background, US soldiers must be
made aware of the different official emblems. United States forces
are legally entitled to only display the Red Cross. However, com-
manders have authorized the display of both the Red Cross and the
Red Crescent to accommodate HN concerns and to ensure that
confusion of emblems would not occur. Such use of the Red Crescent
must be in a smaller size than the Red Cross.
(d) The initial phrase of Article
39 shows that it is the military commander who
controls the emblem and can give or withhold permission to use it. He is at all times responsible for the use
made of the emblem and must see that it is not improperly used by the troops or by individuals.
(2) Article 42 of the GWS specifically addresses the marking of medical units and establish-
ments.
(a)
“The distinctive flag of the Convention shall be hoisted only over such medical
units and establishments as are entitled to be respected under the Convention, and only with the consent of
the military authorities.”
(Paragraph 1, Article 42, GWS) Although the Convention does not define “the
distinctive flag of the Convention,” what is meant is a white flag with a red cross in its center. Also, the
word “flag” must be taken in its broadest sense. Hospitals are often marked by one or several red cross
emblems painted on the roof. Finally, the military authority must consent to the use of the flag (see the
above comments on Article 39) and must ensure that the flag is used only on buildings entitled to protection.
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(b)
“In mobile units, as in fixed establishments, [the distinctive flag] may be accom-
panied by the national flag of the Party to the conflict to which the unit or establishment belongs.”
(Paragraph 2, Article 42, GWS) This provision makes it optional to fly the national flag with the red cross
flag. It should be noted that on a battlefield, the national flag is a symbol of belligerency and is therefore
likely to provoke attack.
(3) In a NATO conflict, NATO STANAG 2931 provides for camouflage of the Geneva
emblem on medical facilities where the lack of camouflage might compromise tactical operations. Medical
facilities on land, supporting forces of other nations, will display or camouflage the Geneva emblem in
accordance with national regulations and procedures. When failure to camouflage would endanger or
compromise tactical operations, the camouflage of medical facilities may be ordered by a NATO commander
of at least brigade level or equivalent. Such an order is to be temporary and local in nature and
countermanded as soon as the circumstances permit. It is not envisaged that fixed, large, medical facilities
would be camouflaged. The STANAG defines “medical facilities” as “medical units, medical vehicles, and
medical aircraft on the ground.”
NOTE
There is no such thing as a “camouflaged” red cross. When camou-
flaging a medical unit or ambulance, either cover up the red cross or
take it down. A black cross on an olive drab or any other background
is not a symbol recognized under the Geneva Conventions.
4-7.
Loss of Protection of Medical Establishments and Units
Medical assets lose their protected status by committing acts “harmful to the enemy.”
(Article 21, GWS.)
A warning must be given to the offending unit and a reasonable amount of time allowed to cease such
activity.
a. Acts Harmful to the Enemy. The phrase “acts harmful to the enemy” is not defined in the
Convention, but should be considered to include acts the purpose or effect of which is to harm the enemy,
by facilitating or impeding military operations. Such harmful acts would include, for example, the use of a
hospital as a shelter for able-bodied combatants, as an arms or ammunition dump, or as a military observation
post. Another instance would be the deliberate siting of a medical unit in a position where it would impede
an enemy attack.
b. Warning and Time Limit. The enemy has to warn the unit to put an end to the harmful acts and
must fix a time limit on the conclusion of which he may open fire or attack if the warning has not been
complied with. The phrase “in all appropriate cases” recognizes that there might obviously be cases where
no time limit could be allowed. A body of troops approaching a hospital and met by heavy fire from every
window would return fire without delay.
c.
Use of Smoke and Obscurants. The use of smoke and obscurants during medical evacuation
operations for signaling or marking landing zones (LZs) does not constitute an act harmful to the enemy.
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However, employing such devices to obfuscate a medical element’s position or location is tantamount to
camouflaging; it would jeopardize its entitlement privilege status under the GWS. Refer to FM 8-10-6 for
additional information on the use of smoke and obscurants for HSS operations.
4-8.
Conditions not Depriving Medical Units and Establishments of Protection
a. Article 22 of the GWS reads as follows: “The following conditions shall not be considered as
depriving a medical unit or establishment of the protection guaranteed by Article 19, that the—
(1) Personnel of the unit or establishment are armed, and that they use the arms in their own
defense, or in that of the wounded and sick in their charge.
(2) Absence of armed orderlies, the unit or establishment is protected by a picket or by
sentries or by an escort.
(3) Small arms and ammunition taken from the wounded and sick and not yet handed to the
proper service, are found in the unit or establishment.
(4) Personnel and materiel of the veterinary service are found in the unit or establishment,
without forming an integral part thereof.
(5) Humanitarian activities of medical units and establishments or of their personnel extend
to the care of civilian wounded or sick.”
b. These five conditions are not to be regarded as acts harmful to the enemy. These are
particular cases where a medical unit retains its character and its right to immunity, in spite of certain
appearances which might lead to a contrary conclusion or, at least, created some doubt.
(1) Defense of medical units and self-defense by medical personnel. A medical unit is
granted a privileged status under the Law of Land Warfare. This status is based on the view that medical
personnel are not combatants and that their role in the combat area is exclusively a humanitarian one. In
recognition of the necessity of self-defense, however, medical personnel may be armed for their own
defense or for the protection of the wounded and sick under their charge. To retain this privileged status,
they must refrain from all aggressive action and may only employ their weapons if attacked in violation of
the Conventions. They may not employ arms against enemy forces acting in conformity with the Law of
Land Warfare and may not use force to prevent the capture of their unit by the enemy (it is, on the other
hand, perfectly legitimate for a medical unit to withdraw in the face of the enemy). Medical personnel who
use their arms in circumstances not justified by the Law of Land Warfare expose themselves to penalties for
violation of the Law of Land Warfare and, provided they have been given due warning to cease such acts,
may also forfeit the protection of the medical unit or establishment which they are protecting.
(a) Medical personnel may carry only small arms, such as rifles or pistols or authorized
substitutes. Army Regulation 350-41 (paragraph 10-2f[1]) supports this policy. It states “Army Medical
Department personnel and non-AMEDD personnel in medical units will train and qualify with individual
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small arms (pistols and rifles). These personnel are not required to train and qualify on crew-served
weapons. However, AMEDD personnel attending training at noncommissioned officer education system
courses will receive weapons instruction that is part of the curriculum. This will ensure that successful
completion of the course is not jeopardized by failure to attend the weapons training portion of the
curriculum (AR 351-1).”
(b) The presence of machine guns, grenade launchers, booby traps, hand grenades,
light antitank weapons, or mines (regardless of the method by which they are detonated) in or around a
medical unit or establishment would seriously jeopardize its entitlement privilege status under the GWS.
The deliberate arming of a medical unit with such items could constitute an act harmful to the enemy and
cause the medical unit to lose its protection, regardless of the location of the medical unit.
(2) Guarding medical units. As a rule, a medical unit is to be guarded by its own personnel.
However, it will not lose its protected status if the guard is performed by a number of armed soldiers. The
military guard attached to a medical unit may use its weapons, just as armed medical personnel may, to
ensure the protection of the unit. But, as in the case of medical personnel, the soldiers may only act in a
purely defensive manner and may not oppose the occupation or control of the unit by an enemy who is
respecting the unit’s privileged status. The status of such soldiers is that of ordinary members of the armed
forces. The mere fact of their presence with a medical unit will shelter them from attack. In case of
capture, they will be POWs.
(3) Arms and ammunition taken from the wounded. Wounded persons arriving in a medical
unit may still be in possession of small arms and ammunition, which will be taken from them and handed to
authorities outside the medical unit. Should a unit be captured by the enemy before it is able to get rid of
these arms, their presence is not of itself cause for denying the protection to be accorded the medical unit
under the GWS.
(4) Personnel and materiel of the Veterinary Corps. The presence of personnel and materiel
of the Veterinary Corps with a medical unit is authorized, even where they do not form an integral part of
such unit.
(5) Care of civilian wounded or sick. A medical unit or establishment protected by the GWS
may take in civilians as well as military wounded and sick without jeopardizing its privileged status. This
clause merely sanctions what is actually done in practice.
4-9.
The 1977 Protocols to the Geneva Conventions
Amendments to the Geneva Conventions have been ratified by some of our allies and potential adversaries.
The US representative to the diplomatic conference signed these amendments, but they have not been
officially ratified by our government.
4-10. Compliance with the Geneva Conventions
a. The US is a party to the 1949 Geneva Conventions. Two of these Conventions afford
protection for medical personnel, facilities, and evacuation platforms (to include aircraft on the ground).
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All HSS personnel should thoroughly understand the provisions of the Geneva Conventions that apply to
medical activities. Violation of these Conventions can result in the loss of the protection afforded by them.
Medical personnel should inform the tactical commander of the consequences of violating the provisions of
these Conventions. The consequences can include the following:
• Medical evacuation assets subjected to attack and destruction by the enemy.
• Health service support capability degraded.
• Captured medical personnel becoming POWs rather than retained persons. They may
not be permitted to treat fellow prisoners.
• Loss of protected status for medical unit, personnel, or evacuation platforms (to include
aircraft on the ground).
b. Because even the perception of impropriety can be detrimental to the mission and US interests,
HSS commanders must ensure that they do not give the impression of impropriety in the conduct of medical
operations. For example, if a medical evacuation battalion commander included in the tactical standing
operating procedure (TSOP) rules governing the use of automatic or crew-served weapons, it would give
the impression that the unit possessed and intended to use these types of weapons. Under the provisions of
the Geneva Conventions, medical units are only authorized individual small arms for use in the defense of
the patients under their care and for themselves. Even though the unit did not possess these types of
weapons, the entry in the TSOP could be misinterpreted and a case made that the commander intended to
use these weapons in violation of the Geneva Conventions.
4-11. Medical Care for Retained and Detained Personnel
a. Definitions.
(1) The term detainee refers to any person captured or otherwise detained by an armed force
(Joint Pub 1-02).
(2) The term retained personnel is defined as “Enemy personnel who come within any of the
categories below are eligible to be certified as retained personnel. a. Medical personnel exclusively
engaged in the (1) Search for, collection, transport, or treatment of the sick and wounded; (2) Prevention of
disease; and/or (3) Staff administration of medical units and establishments exclusively. b. Chaplains
attached to enemy armed forces. c. Staff of national Red Cross societies and other voluntary aid societies
duly recognized by their governments. The staffs of such societies must be subject to military laws and
regulations (Joint Pub 1-02).”
b. Provision of Medical Care. As the United States is a participatory nation to the Geneva
Conventions, personnel detained and/or retained personnel are protected under the provisions of the
Conventions. Personnel in US custody will receive medical care consistent with the standard of medical
care which applies for US military personnel.
c.
Additional Information. For additional information refer to DODD 2310.1, DODD 5100.77,
AR 190-8, FM 3-19.40, FM 4-02- and 8-10-series, and FM 27-10.
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CHAPTER 5
ARMY MEDICAL DEPARTMENT FUNCTIONAL AREAS
5-1.
Functional Areas
a. Force health protection in a global environment, executed by the HSS system, is comprised of
ten functional areas. To maximize the effectiveness and efficiency of the HSS system, all functional areas
must be considered in the planning process. The execution of the HSS mission and the implementation of
programs within the functional areas is essential in providing health care delivery on the battlefield. To
ensure the success of the HSS mission, thorough and comprehensive plans are required and, once developed,
should be exercised through rehearsals.
b. This chapter discusses each of the functional areas and provides references to functional-area
specific manuals which provide the doctrine and the tactics, techniques, and procedures (TTPs) necessary to
execute the HSS mission.
5-2.
Command, Control, Communications, Computers, and Intelligence
a. The medical C4I system provides a seamless state-of-the-art system across the operational
continuum. The medical C4I capability is flexible and versatile, and is capable of providing reliable HSS to
warfighters in current and future operations. It is strategically, operationally, and tactically responsive to a
broad range of worldwide requirements. The medical C4I capability integrates both vertically and
horizontally with the warfighters’ C4I battlefield operating system (BOS), and SU. It also has reliable
communications network interconnectivity with the global automated systems architectures to access clinical
and medical information to support force projection operations. The medical C4I system employs automation
and communications equipment to—
• Assist in conserving the fighting strength by integrating medical and OEH surveillance
data and other medical threat indicators. This assists in identifying disease and injury trends which
facilitates the prevention of performance deterioration and casualties due to DNBI.
• Provide seamless state-of-the-art medical information management across the operational
continuum.
• Ensure the capability of rapid strategic deployability in exercising the C4I first-in, last-
out principle.
• Enhance the capability to promptly clear the battlefield (locate, acquire, treat, and
evacuate battlefield casualties).
• Conduct split-base operations on a continuous basis.
• Provide HSS staff virtual presence at all command levels.
• Provide a lead element with deploying forces and coordinate the arrival of HSS assets
into an AO.
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• Support joint, allied, coalition, and HN medical forces, as directed, across the full
spectrum of operations.
• Interface with Army systems, other Services, and DOD-automated systems throughout
the operational continuum.
• Allow transfer of images and videos from numerous sensors and platforms, with image
compression and transmission technologies, enabling better HSS SU in the TO.
• Enable three-dimensional presentation of imagery and graphics with multimedia technol-
ogy to help commanders visualize their TO for more effective training, planning, rehearsal, and execution.
• Enable the conduct of telemedicine operations (telementoring and teleconsultation
activities).
b. For a more detailed discussion on the AMEDD C4I communications system and information
management, refer to FM 8-10-16.
5-3.
Medical Treatment
a. The medical treatment functional area encompasses Levels I and II medical treatment. These
levels of care are provided by organic assets or on an area support basis from supporting medical units/
elements. Within corps, this support is provided by divisional medical companies, medical companies/
troops of separate brigades or armored cavalry regiments, and the ASMC. In EAC, it is also provided by
the ASMC. The ASMC is assigned/attached to the medical battalion, area support (ASMB) which is a C2
headquarters for assigned and/or attached ASMCs, the medical detachment, area support (ASMD), and/or
other medical units/elements as assigned (such as COSC, PVNTMED, or veterinary detachments and/or
dental companies).
b. In operation, each medical company is assigned an AO to ensure all personnel receive adequate
medical care. Within each company sector, the treatment platoon with its treatment, dental, x-ray, labora-
tory, and patient-holding capability forms the core of the company’s support scheme. The treatment squads
are employed geographically to best support the troop population. Company ambulances are collocated
with HSS elements to provide a ground medical evacuation capability or to evacuate patients to the Level II
MTF established by the area support section of the medical company for further treatment or holding.
c.
For additional information on area medical support refer to FM 4-02.4, FM 4-02.6 and FM 4-
02.24.
5-4.
Medical Evacuation and Medical Regulating
a. Theater Evacuation Policy. The theater evacuation policy is established by the SECDEF, with
the advice of the Joint Chiefs of Staff (JCS) and upon the recommendation of the theater commander. The
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policy establishes, in number of days, the maximum period of noneffectiveness (hospitalization and
convalescence) that patients may be held within the theater for treatment. This policy does not mean that a
patient is held in the TO for the entire period of noneffectiveness. A patient who is not expected to be ready
for RTD within the number of days established in the theater evacuation policy is treated, stabilized, and
then evacuated out of theater. This is done providing that the treating physician determines that such
evacuation will not aggravate the patient’s disabilities or medical condition. For example, a theater
evacuation policy of 15 days does not mean that a patient is held in the theater for 14 days and then
evacuated. Instead, it means that a patient is evacuated as soon as possible after the determination is made
that he cannot be returned to duty within 15 days following admission to a Level III or above hospital.
This paragraph implements STANAGs 2087 and 3204.
b.
Evacuation Priorities. The initial decision of what level of treatment is required (Level I,
Level II, and so forth) is made by the treatment element. Soldiers are evacuated by the most expeditious
means of evacuation dependent on their medical condition, assigned evacuation precedence, and availability
of medical evacuation platforms. Patients may be evacuated from the point of injury or wounding to a
medical treatment facility in closest proximity to the point of injury/wounding to ensure they are
stabilized to withstand the rigors of evacuation over greater distances. The evacuation precedences are—
•
Priority I, URGENT is assigned to emergency cases that should be evacuated as soon
as possible and within a maximum of 1 hour to save life, limb, or eyesight and to prevent complications
of serious illness and to avoid permanent disability.
•
Priority IA, URGENT-SURG is assigned to patients who must receive far forward surgical
intervention to save life and stabilize for further evacuation.
•
Priority II, PRIORITY is assigned to sick and wounded personnel requiring prompt
medical care. This precedence is used when the individual should be evacuated within 4 hours or his
medical condition could deteriorate to such a degree that he will become an URGENT precedence, or
whose requirements for special treatment are not available locally, or who will suffer unnecessary pain or
disability.
•
Priority III, ROUTINE is assigned to sick and wounded personnel requiring evacuation
but whose condition is not expected to deteriorate significantly. The sick and wounded in this category
should be evacuated within 24 hours.
•
Priority IV, CONVENIENCE is assigned to patients for whom evacuation by medical
vehicle is a matter of medical convenience rather than necessity.
NOTE
The NATO STANAG 3204 has deleted the category of Priority IV,
CONVENIENCE; however, it will still be included in the US Army
evacuation priorities as there is a requirement for it on the battlefield.
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c.
Responsibilities for Medical Evacuation. At the tactical level, the Service Component
Commanders are responsible for executing the medical evacuation of their forces. Strategic aeromedical
evacuation is the responsibility of the United States Transportation Command (USTRANSCOM).
d.
Ship-to-Shore Medical Evacuation Mission. United States Army aeromedical evacuation
resources may provide, on an area support basis, medical evacuation from shore-to-ship for deployed USN
and USMC forces.
e.
Medical Regulating. Medical regulating is a patient management system designed to coordinate
the movement of patients from Level III and above hospitals through successive levels of medical care to an
MTF that can provide the appropriate medical care and treatment. A formal medical regulating system is
not available at Levels I and II. Prompt movement of patients to the required level of professional care is
necessary to avoid increased morbidity and mortality. The TPMRC is responsible for medical regulating
within and from Levels III and IV hospitals to the CONUS-support base (Level V). The Global Patient
Movement Requirements Center (GPMRC) is responsible for medical regulating within the CONUS-
support base.
f.
Additional Information. The primary references for medical evacuation are FMs 8-10-6 and
8-10-26. Additional information is contained in FM 4-02.4 and FM 4-02.6.
5-5.
Hospitalization
a.
Hospitalization is a part of the theater-wide HSS system for managing sick, injured, and
wounded personnel. The term hospitalization is used to embrace that portion of health care delivery
provided at hospitals on an inpatient basis for all classes of patients whose conditions cannot be managed on
an outpatient or holding status.
(1) An inpatient is a person admitted to and treated within a hospital and who cannot be
returned to duty within the same calendar day.
(2) An outpatient is a person receiving medical/dental examination and/or treatment from
medical personnel and in a status other than being admitted to a hospital. Included in this category are the
personnel who are treated and retained (held) in an MTF other than a hospital (such as a Level II MTF).
(3) A holding patient is a person who is treated at Level II and is expected to be able to RTD
within 72 hours or is being held for further evacuation to the rear.
b.
Under the Medical Force 2000 force structure, the theater hospitalization system included four
types of hospitals. In the corps, the combat support hospital (CSH) was the principle hospital to receive all
classes of patients. The mobile Army surgical hospital (MASH) could be deployed forward into the division
rear to provide far forward surgical intervention to stabilize nontransportable patients for further evacuation.
(The MASH was replaced by the FST.) In the communications zone (COMMZ), the field hospital (FH) and
general hospital (GH) provided definitive treatment to all classes of patients. Those patients anticipated to
RTD within the stated theater evacuation policy were transferred to a FH, while patients requiring evacuation
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from theater were transferred to the GH. For a discussion of the CSH, refer to FM 8-10-14. For a
discussion of the FH and GH, refer to FM 8-10-15. For a discussion of the FST, refer to FM 8-10-25.
c.
Under the MRI (Appendix G), the theater hospitalization system consists of one hospital—the
redesigned CSH. It has been redesigned to enable it to be used in force projection operations. Its modular
design allows it to be employed in different increments of operating beds. Refer to FM 4-02.10 for
additional information.
5-6.
Preventive Medicine Services
a. Preventive medicine services are essential in maintaining and sustaining the health of the force
in garrison and throughout the mobilization, predeployment, redeployment, and demobilization continuum.
The scope of PVNTMED services include—
• Providing assistance in the control of arthropod- and rodentborne diseases, including
technical consultation, entomological surveys/investigations, and reinforcement of the unit’s organic pest
management capabilities.
• Providing assistance in the control of waterborne diseases by monitoring the water
quality.
• Providing assistance in the control of foodborne diseases by monitoring food service
operations and providing guidance to commanders.
(The actual function of inspecting food for safety and
quality assurance is a veterinary function. Refer to paragraph 5-8 of this manual and FM 8-10-18 for
additional information on veterinary functions and support.)
• Providing policy guidance and monitoring compliance for immunization, chemopro-
phylaxis, antidotes, and pretreatment activities and barrier cream use.
• Providing assistance and subject matter expertise in the control of excessive OEH
exposures to such hazards as noise, TIMs, and climatic extremes.
• Providing assistance to command surgeons in evaluating the—
•
Elements of the medical threat.
•
Risk to the force associated with identified elements of the medical threat.
•
Integration of the medical threat into planning for and executing HSS operations.
• Establishing a medical and OEH surveillance system which encompasses predeployment
medical screening (developing a medical baseline), deployment and surveillance while in the operational
area, medical screening prior to redeployment, and follow-up medical assessments upon return to home
station.
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• Educating troops in DNBI prevention measures including those measures used to reduce
risks from NBC agents/weapons.
• Training unit field sanitation teams.
• Providing technical consultation on selecting and developing bivouac sites, cantonment
areas, refugee camps, and EPW compounds.
• Conducting a field water vulnerability assessment.
• Providing professional and technical advice to commanders at all levels on measures to
reduce noneffectiveness from DNBI.
• Reporting deployment health surveillance and readiness statistics and environmental
health data, as required.
• Surveying operational environments to detect and identify health hazards and to formulate
means for minimizing their effects.
• Investigating disease outbreaks and recommending control measures.
• Providing assistance in reducing noise hazard in rest and recuperation areas to nonstressful
levels.
b. A discussion of the medical threat is provided in paragraph 2-3. Medical intelligence
preparation of the battlefield is discussed in-depth in Appendix B and FM 8-10-8.
c.
For additional information on PVNTMED support, refer to AR 40-5, FM 4-02.17, FM 4-
02.33, FM 4-25.12, FM 8-42, FM 8-55, and FM 21-10. Policy and guidance on medical surveillance
activities is contained in Joint Staff Memorandum MCM 0006-02, DODD 6490.2, DODI 6490.3, and AR
40-66.
5-7.
Dental Services
a. The dental mission in a TO is to conserve the oral health of the soldier by—
• Preventing oral disease.
• Promoting dental health.
• Providing dental treatment to eliminate or reduce the effects of dental disease and injury.
• Providing early treatment of severe oral and maxillofacial injuries for casualties that
must be evacuated.
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b. There are two categories of dental care—operational care and comprehensive care.
(1) Operational care is provided in the TO and consists of two types of dental care.
(a) Emergency dental care is given for the relief of oral pain, elimination of acute
infection, control of life-threatening oral conditions (hemorrhage, cellulitis, or respiratory difficulty) and
treatment of trauma to teeth, jaws, and associated facial structures. It is the most austere type of care and is
available to soldiers engaged in tactical operations. Common examples of emergency treatments are simple
extractions, administration of antibiotics and pain medicines, and temporary fillings. At Level I there are
no dentists assigned, however, the physician or PA can provide limited emergency dental treatment (relief
of pain and administration of antibiotics until the patient can be seen by the dentist assigned to FSMC or
other Level II facility).
(b) Essential dental care includes dental treatment necessary to intercept potential
emergencies. This type of operational care is necessary for the prevention of lost duty time and preservation
of the fighting strength. It is also intended to maintain the overall oral fitness of soldiers at a level consistent
with combat readiness. Most dental disease is chronic and recurring. A soldier’s oral health status will
deteriorate from the day of deployment if essential dental care is not provided. The scope of services
includes minor oral surgery, definitive restorative, exodontic, periodontal, and prosthodontic procedures as
well as prophylaxis. This is the highest type of dental care provided within the TO.
(2) Comprehensive dental care is dental treatment to restore an individual to optimal oral
health, function, and esthetics and is normally provided in the CONUS-support base. If this capability is
deployed to the theater, it requires at least a Level III type facility.
c.
Refer to FM 4-02.19 for additional information on dental services.
5-8.
Veterinary Services
a. Veterinary service is an integral part of HSS within a TO. The US Army Veterinary Service
is designated as the DOD Executive Agent for veterinary services and as such, provides support as required
for the US Army, USN, USMC, US Coast Guard [USCG] and USAF. Veterinary support is also provided
upon request and subject to availability of resources for government-owned animals of other federal
agencies (such as the Drug Enforcement Agency [DEA] or US Border Patrol). In some instances, it is also
provided to allies, coalition partners, or HN agencies.
b. Veterinary support in the TO includes the—
• Inspection of subsistence (Class I).
• Inspection and approval of locally procured food, dairy products, and bottled water
plants in the TO.
• Examination of food animals and other food sources.
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• Control of zoonotic diseases.
• Treatment and hospitalization for government-owned animals and unit mascots.
NOTE
In operations where the anticipated duration of the operation is
sufficient to establish base camps of a semifixed nature, soldiers have
a tendency to adopt local domestic and/or wild animals (such as the
mongoose during the Vietnam War) as unofficial mascots. The
command should establish a policy and provide guidance on this issue
prior to deployment. The unofficial mascot has the potential to be a
significant medical threat in the transmission of zoonotic diseases to
US forces.
• Examination and wholesomeness determination of food and food-producing animals in
an NBC environment.
• Other veterinary PVNTMED activities as assigned.
c.
Normally, the staff veterinarian advises the commander on matters pertaining to—
• Food safety and quality assurance to include operations under NBC conditions.
• The health of government-owned and indigenous animals of the command.
d. For additional information on veterinary support activities, refer to AR 40-70, AR 40-656,
AR 40-657, AR 40-905, and FM 8-10-18.
5-9.
Combat Operational Stress Control
a. Advances in technology are continually changing the way warfare is conducted. The
operational tempo (OPTEMPO) has increased dramatically. On the modern battlefield, US forces will be
required to conduct continuous operations while executing the offense or defense. Leaders must, therefore,
ensure that troops rest and are resupplied on the run.
(See FM 21-10 and FM 6-22.5 for minimum sleep
requirements.) They must think faster, make decisions more rapidly, and act more quickly than the enemy.
Leaders must know the commander’s intent. They must be able to act spontaneously and synchronously,
even though the situation has changed and communications are disrupted. The demands on CSS units will
be equally extreme. If NBC weapons are employed, the stressors on the integrated battlefield will be
incalculably greater. Exhausted and attrited units must be reconstituted and returned quickly to the battle.
In stability operations and support operations, the terrorist or guerrilla also counts on causing stress to the
enemy as his principal weapon and objective. Although the stressors of terrorism and/or guerrilla tactics
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are less overwhelming than those of full spectrum warfare, they are deliberately designed to cause the
breakdown of professionalism and discipline.
b. It is the responsibility of leadership to control stress. Army Medical Department personnel in
unit MH sections and in specialized CSC units assist the command in—
• Preventing battle fatigue (BF) and misconduct stress behaviors.
• Treating patients suffering from BF or neuropsychiatric (NP) disorders.
• Returning soldiers to duty or determining their disposition.
• Evaluating soldiers who display misconduct stress behaviors.
• Evacuating patients with NP disorders who cannot RTD.
c.
Refer to FM 6-22.5, FM 8-51, and FM 22-51 for additional information on COSC operations.
5-10. Health Service Logistics
a. The HSL system encompasses the planning and execution of medical supply operations, med-
ical equipment maintenance and repair, optical fabrication and repair, contracting services, regulated
medical or hazardous waste management and disposal, and production and distribution of medical gases.
The HSL system also involves the management of blood and blood products, to include blood-banking ser-
vices for the Army and the other Services, and when authorized allied, coalition, and HN forces under the
technical guidance of the appropriate command surgeon. The HSL system is modular in design and pro-
vides tailorable support across the operational continuum. The modular design of HSL units facilitates task
organization to support varied missions and enables the successful accomplishment of split-base operations.
b. In joint operations, the combatant commander may designate one Service as the SIMLM for
all Services operating within the AO. The SIMLM functions encompasses the provision of medical
supplies, medical equipment maintenance and repair, blood management, and optical fabrication to all joint
forces within the TO including, on an emergency basis, USN ships for common-use items. By exercising
directive authority over the HSL arena for the accomplishment of assigned missions, the combatant
commander can centralize control, reduce duplication of services, and provide the support in a more
economical and efficient manner.
c.
For additional information on HSL and blood management, refer to Joint Pub 4-02, Joint Pub
4-02.1, FM 4-02.1, FM 4-02.70, FM 8-10-9, TM 8-227-3, TM 8-227-11, and TM 8-227-12.
5-11. Medical Laboratory Services
a. Medical laboratory services in a TO are designed to enhance diagnostic capabilities and to
identify suspect BW and CW agents.
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b. The function of a medical laboratory in support of an MTF is to analyze body fluids and
tissues, or to identify microorganisms as an adjunct in the diagnosis and treatment of patients and in the
prevention of disease. Additionally, the management of blood and blood components are critical tasks
requiring medical laboratory and HSL assets.
c.
The primary mission of the area medical laboratory (AML) focuses on the identification and
evaluation of OEH hazards in the AO through accurate field confirmatory laboratory testing of suspect BW
and CW agents, endemic disease, zoonotic disease and occupational and environmental agents.
d. For additional information on medical laboratory capabilities refer to FM 4-02.6, FM 4-02.7,
FM 4-02.24, FM 8-10-14, FM 8-10-15, FM 8-42, FM 8-43, and FM 8-55.
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CHAPTER 6
FORCE HEALTH PROTECTION IN GLOBAL OPERATIONS
6-1.
The Continuum
a. Modern warfare will combine elements of traditional combat formations, task-organized
elements, and newly designed units. The force projection units and comprehensive OPLANs must be
flexible and have the capability to adapt to changing battlefield conditions. Additionally, units and plans
must be capable of transitioning from one peacetime/wartime scenario to another or participating in different
types of operations simultaneously (such as performing humanitarian assistance operations while conducting
tactical operations).
b. For an in-depth discussion of TTPs for the medical platoon of maneuver units refer to FM 4-
02.4 and for division and nondivisional medical companies refer to FM 4-02.6.
6-2.
Offensive Operations
a. Support to the Offensive Operations.
(1) The offense is the decisive form of war, the commander’s only means of attaining a
positive goal or of completely destroying an enemy force. The offense is characterized by rapid movement,
deep penetrations, aggressive action, and the ability to sustain momentum regardless of counterfires and
countermeasures.
(2) When considering the HSS plans to support an offensive action, the HSS planner must
consider many factors (FM 8-55). The forms of maneuver, as well as the enemy’s capabilities, influence
the character of the patient workload and its time and space distribution. The analysis of this workload
determines the allocation of HSS resources and the location or relocation of MTFs.
(3) Global force health protection of offensive operations must be responsive to several
essential characteristics. As operations achieve success, the areas of casualty density move away from the
supporting facilities. This causes the routes of medical evacuation to lengthen. Heaviest patient workloads
occur during disruption of enemy main defenses, at terrain or tactical barriers, during the assault on final
objectives, and during enemy counterattacks. The accurate prediction of these workload points by the HSS
planner is essential if HSS operations are to be successful.
(4) In traditional combat operations, the major casualty area of the division is normally the
zone of the main attack. As the main attack accomplishes the primary objective of the division, it receives
first priority in the allocation of combat power. The allocation of combat forces dictates roughly the areas
which are likely to have the greatest casualty density. As a general rule, all division MTFs are located
initially as far forward as combat operations permit. This allows the maximum use of these facilities before
lengthening evacuation lines force their displacement forward.
(5) In operations that feature deep battles with NBC weapons targeted at supporting logistical
bases, mass casualty operations may be conducted in rear areas.
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(6) As advancing combat formations extend control of the battle area forward, supporting
HSS elements overtake patients. This facilitates the acquisition of the battle wounded and reduces the vital
time elapsed between wounding and treatment. In offensive operations, two basic problems confront the
supporting HSS units. First, contact with the supported unit must be maintained. Responsibility for the
contact follows the normal HSS pattern—rear to front. The contact is maintained by forward deployed air
and ground evacuation resources. Secondly, the mobility of the MTFs supporting the combat formations
must be maintained. Periodically, division medical companies, FSTs, and CSHs are cleared so that they
may move forward. This requirement for prompt evacuation of patients from forward MTFs requires
available ambulances to be echeloned well forward from the outset. The requirement for periodic movement
of large numbers of patients from divisional and corps facilities further stresses the evacuation system.
(7) Types of operations in the offense include—
(a) Movement to contact. Health service support in movement to contact is keyed to
the tactical plan. Prior deployment of evacuation resources and comprehensive rehearsals with parent and
supported units permits uninterrupted and effective evacuation support.
(b) Exploitation. Exploitation is a type of offensive operation that rapidly follows a
successful attack and is designed to disorganize the enemy in depth. Medical evacuation support of
exploitation and pursuit operations resembles those discussed for the envelopment (paragraph 6-2b(1)(b)
below). Since exploitation and pursuit operations can rarely be planned in detail, medical evacuation
operations must adhere to TSOPs and innovative C2. These actions are often characterized by—
• Decentralized operations.
• Unsecured ground evacuation routes.
• Exceptionally long distances for evacuation.
• Increased reliance on convoys and air ambulances.
(c) Pursuit. The pursuit is designed to catch or cut off a hostile force attempting to
escape with the aim of destroying it.
b. Health Service Support for Choices of Maneuver and Enabling Operations.
(1) Choices of Maneuver.
(a) Penetration. In this tactic, the attack passes through the enemy’s principal defensive
position, ruptures it, and neutralizes or destroys the enemy forces. Of all forms of offensive maneuver, the
penetration of main enemy defenses normally produces the heaviest medical evacuation workload. Patient
acquisition starts slowly, but becomes more rapid as the attack progresses. The evacuation routes lengthen
as the operation progresses. The penetration maneuver is often preceded by heavy preparatory fires which
may evoke heavy return fire. These enemy fires may modify the decision to place medical evacuation assets
as far forward as possible. Medical evacuation may be slow and difficult due to damage to roads or the
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inaccessibility of patients. Medical evacuation support problems multiply when some combat units remain
near the point of original penetration. This is done to hold or widen the gap in enemy defenses while the
bulk of the division forces exploit or pursue the enemy. Treatment elements are placed near each shoulder
of the penetration; ground evacuation cannot take place across an avenue of heavy combat traffic. Besides
the heavy traffic, the area of the penetration is normally a target for both conventional and NBC weapons.
(b) Envelopment. In the envelopment, the main or enveloping attack passes around or
over the enemy’s principal defensive positions. The purpose is to seize objectives which cut his escape
routes and subject him to destruction in place from flank to rear. Since the envelopment maneuver involves
no direct breach of the enemy’s principal defensive positions, the medical evacuation system is not confronted
with a heavy workload in the opening phase. Ambulances are echeloned well forward in all levels of care to
quickly evacuate the patients generated by suddenly occurring contact. Medical treatment facilities moving
with their respective formations overtake patients during evacuation and reduce delays in treatment. After
triage and treatment, the patients are evacuated to corps-level facilities by accompanying corps assets.
When the isolated nature of the envelopment maneuver precludes prompt evacuation, the patients are
carried forward with the treatment element. Again, nonmedical vehicles may be pressed into emergency
use for this purpose. When nonmedical vehicles are used to move patients, augmentation with medical
personnel or CLSs should be considered and when tactically feasible, implemented. When patients must be
carried forward with the enveloping forces, HSS commanders use halts at assembly areas and phase lines to
arrange combat protection for ground ambulance convoys to effect evacuation through unsecured areas.
Further, the commander may take advantage of friendly fires and suppression of enemy air defenses to call
for prearranged air ambulance support missions, or emergency use of medium-lift helicopter backhaul
capabilities.
(c) Infiltration.
1.
Infiltration is a choice of maneuver used during offensive operations. The
division can attack after infiltration or use it as a means of obtaining intelligence and harassing the enemy.
Though it is not restricted to small units or dismounted actions, the division employs these techniques with a
portion of its units, in conjunction with offensive operations conducted by the remainder of its units.
2.
Health service support of infiltration is restricted by the amount of medical
equipment, supplies, and transportation assets that can be introduced into the attack area. No deployment of
division-level medical units without their organic transportation should be attempted. Elements of unit-level
HSS should be accompanied by their organic vehicles, and ambulances should receive priority for
deployment. It may be necessary to man-carry enough BAS equipment into the attack area to provide EMT
and ATM; however, this results in degrading mobility. When the element is committed without its
ambulances, patients are evacuated to the BAS by litter bearer teams. This requires reinforcement of the
medical platoon by division or corps medical personnel or improvisation of litter teams using combat troops
(if available and approved by the tactical commander). Medical evacuation from the BAS and medical
resupply of the force may be provided by litter bearers, depending upon distances and degree of secrecy
required.
3.
When airborne and air assault forces are used, infiltrating elements may land
at various points within the enemy’s rear area and proceed on foot to designated attack positions. As in
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surface movement, the amount of medical equipment taken may be limited. In airborne operations, the
evacuation of patients will be by litter bearers or ground ambulances to CCPs or the BAS and then by
division-level ambulances to the Level II MTF. In air assault operations, the evacuation is by litter bearers
to CCPs or to the BAS and then by air ambulances to a Level II MTF. Once the combat element begins the
assault on the objective, secrecy is no longer important and its isolated location requires HSS characteristic
to airborne and air assault operations until ground linkup.
(d) Turning movement. The turning movement is a variant to the envelopment in which
the attacker attempts to avoid the defense entirely; rather, the attacker seeks to secure key terrain deep in the
enemy’s rear and along his LOCs. Faced with a major threat to his rear, the enemy is thus turned out of his
defensive positions and forced to attack rearward at a disadvantage.
• General MacArthur’s invasion at Inchon during the Korean War is an example
of a classic turning movement. Casualties were initially light as the main defenses were avoided; however,
as the invasion developed, resistance stiffened and higher casualty rates were experienced. Further, as
fighting occurred in a populated area (Seoul), significant civilian casualties resulted. The lack of Korean
health care providers caused many of these civilians to seek medical aid from US field medical units.
• Medical evacuation support to the turning movement is provided basically in
the same manner as to the envelopment. As the operation is conducted in the enemy’s rear area, LOCs and
evacuation routes may be unsecured resulting in delays in resupply and evacuation. In the Inchon example,
a hospital ship was located off the coast to accept patients evacuated from the fighting. However, due to the
precarious tides, evacuation and resupply were often delayed for hours and sometimes days since the harbor
could not be navigated by small vessels. It was not until Kimpo Airfield fell that timely evacuation could
occur. The deployed HSS units must be able to quickly clear the battlefield of patients, evacuate them from
the forward areas, and sustain the patients in rear areas until evacuation routes are established. Augmentation
of medical treatment personnel may be required if patients are to be held and sustained for an extended
period in the rear area pending medical evacuation. This possibility should be included as a consideration
during course of action (COA) development.
(2) Enabling Operations.
(a) Passage of lines. This situation presents a challenge for the HSS planner. There
will be a number of medical evacuation units using the same air and road networks. Coordination and
synchronization are essential if confusion and overevacuation are to be avoided. The information required
to operate in the division AO includes—
• Radio frequencies and call signs.
• Operations plans and TSOPs.
• Location of MTFs.
• Location of CCPs and ambulance exchange points (AXPs).
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• Main supply route, forward arming and refueling points (FARP), and Army
air space command and control (A2C2) data.
(b) Security operations. The covering forces are dependent upon organic resources
found in the maneuver battalion medical platoon for initial support. The level of command for the covering
force (division or corps) determines the responsibility for the subsequent evacuation plan. In a corps
covering force, for example, the corps HSS structure has the responsibility for establishing and operating
the medical evacuation system to support the forward deployed corps forces. This is done to prevent the
divisions following the covering forces from becoming overloaded with patients prior to the hand off and
passage of lines. The use of CCPs, AXPs, and nonmedical transportation assets (casualty evacuation
[CASEVAC]) to move the wounded is essential. The covering force battle may be extremely violent.
Patient loads will be high and the distance to MTFs may be much longer than usual. The effectiveness of
the medical evacuation system depends upon the forward positioning of a number of ground ambulances and
the effective integration of corps air ambulances into the medical evacuation plan.
(c) Advance, flank and rear guards. These forces normally receive medical evacuation
support through the attachment of evacuation teams. The teams evacuate patients to predesignated CCPs
along a main axis of advance or to the nearest treatment element providing area support. Employment of air
ambulances provides a measure of agility and flexibility.
(d) River crossing operations. The river barrier itself exerts decisive influence on the
use of divisional medical units. Attack across a river line creates a HSS delivery problem comparable to
that of the amphibious assault. Health service support elements cross as soon as combat operations permit.
Early crossing of treatment elements reduces turnaround time for all crossing equipment that is used to load
patients on the far shore. Maximum use of air ambulance assets is made to prevent excessive patient
buildup in far shore treatment facilities. Near shore MTFs are placed as far forward as assault operations
and protective considerations permit to reduce ambulance shuttle distances from off-loading points. For
detailed information on river crossing operations, refer to FM 90-13.
(e) Reconnaissance operations. The reconnaissance in force is an attack to discover
and test the enemy’s position and strength or to develop other intelligence. The division usually probes with
multiple combat units of limited size, retaining sufficient reserves to quickly exploit known enemy
weaknesses. Health service support techniques follow those discussed for a movement to contact (paragraph
6-2a[7]). Ambulances are positioned well forward at both unit and division levels (Levels I and II).
Ambulances are moved at night to enhance secrecy. The echeloning of ambulances is an indication to the
enemy that an attack is imminent due to the forward placement of these resources. Level II MTFs are not
established until a significant patient workload develops. Patients received at BASs of reconnoitering units
are evacuated to Level II MTFs as early as practical, or are carried forward with the force until a suitable
opportunity for evacuation presents itself. Maximum possible use of air ambulance assets is made to cover
extended distances and to overcome potentially unsecured ground evacuation routes.
(f)
Unified action. The majority of operations occurring at the present time are joint,
interagency, or multinational operations. The HSS planner must determine in the initial planning stages of
these operations whose responsibility it is to provide HSS to the force. The HSS planner must also ensure
that duplications in support do not exist, guidelines are established as to eligible beneficiaries and when
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FM 4-02
individuals are to be returned to their own nation’s health care delivery system, and what mechanisms exist
for reimbursement of services. For additional information, refer to FM 8-42.
6-3.
Defensive Operations
There are three forms of the defense: area defense, mobile defense, and retrograde. The area defense
concentrates on denying enemy access to designated terrain for a specific period of time, rather than on the
outright destruction of the enemy. The mobile defense focuses on denying the enemy force by allowing him
to advance to a point where he is exposed to a decisive counterattack by the striking force. The primary
defeat mechanism, the counterattack, is supplemented by the fires of the fixing force. The third form of
defense is the retrograde. The retrograde is an organized movement to the rear and away from the enemy.
The enemy may force these operations or a commander may execute them voluntarily. Within the retrograde
operation there are three forms: delay, withdrawal, and retirement.
a. The provision of timely and effective HSS presents challenges to the medical planner in
defensive operations. The patient load reflects lower casualty rates, but forward area patient acquisition is
complicated by enemy actions and the maneuver of combat forces. Medical personnel are permitted much
less time to reach the patient, complete vital EMT, and remove him from the point of injury. Increased
casualties among exposed medical personnel further reduce the medical treatment and evacuation capabilities.
Heaviest patient workloads, including those produced by enemy artillery and NBC weapons, may be
expected during the preparation or initial phase of the enemy attack and in the counterattack phase. The
enemy attack may disrupt ground and air routes and delay evacuation of patients to and from treatment
elements. The depth and dispersion of the defense create significant time and distance problems for
evacuation assets. Combat elements may be forced to withdraw while carrying their remaining patients to
the rear. The enemy exercises the initiative early in the operation which may preclude accurate prediction
of initial areas of casualty density. This makes the effective integration of air assets into the evacuation plan
essential. The use of air ambulances must not only be integrated into the HSS annex to the OPORD, but
also into the A2C2 system.
b. The support requirements for retrogrades may vary widely depending upon the tactical plan,
the enemy reaction, and the METT-TC factors. Firm rules that apply equally to all types of retrograde
operations are not feasible, but considerations include—
• Requirement for maximum security and secrecy in movement.
• Influence of refugee movement that may impede medical evacuation missions conducted
in friendly territory.
• Integration of evacuation routes and obstacle plans should be accomplished.
• Difficulties in controlling and coordinating movements of the force which may produce
lucrative targets for the enemy.
• Movements at night or during periods of limited visibility.
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• Time and means available to remove patients from the battlefield. In stable situations
and in the advance, time is important only as it affects the physical well-being of the wounded. In
retrograde operations, time is more important. As available time decreases, HSS managers at all levels
closely evaluate the capability to collect, treat, and evacuate all patients.
• Medical evacuation routes will also be required for the movement of troops and materiel.
This causes patient evacuation in retrograde movements to be more difficult than in any other type of
operation. Command, control, and communications may be disrupted by the enemy. Successful medical
evacuation requires including ambulances on the priority list for movement; providing for the transportation
of the slightly wounded in cargo vehicles (CASEVAC); and providing guidance to subordinate commanders
defining their responsibilities in collecting and evacuating patients. Special emphasis must be placed on the
triage of patients and consideration given to the type of transportation assets available for evacuation.
• When the patient load exceeds the means to move them, the tactical commander must
make the decision as to whether patients are to be left behind. The medical staff officer keeps the tactical
commander informed in order that he may make a timely decision. Medical personnel and supplies must be
left with patients who cannot be evacuated.
6-4.
Stability Operations
a. Stability operations apply military power to influence the political environment, facilitate
diplomacy, and interrupt specified illegal activities. They include both developmental and coercive actions.
Developmental actions enhance a government’s willingness and ability to care for its people. Coercive
actions apply carefully prescribed limited force and the threat of force to achieve objectives. The types of
activities conducted in stability operations include—
• Peace operations (to include peacekeeping operations, peace enforcement operations,
and operations in support of diplomatic efforts).
• Foreign internal defense (categories of operations include indirect support, DS [not
involving combat operations], and combat operations).
• Combatting terrorism operations (which includes counterterrorism and antiterrorism
[Appendix H]).
• Support to counterdrug operations.
• Security assistance.
• Noncombatant evacuation operations (NEO).
• Humanitarian and civic assistance (HCA).
• Arms control.
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• Support to insurgencies.
• Shows of force.
b. Health service support to forces deployed in stability operations is dependent upon the specific
type of operation, anticipated duration of the operation, medical threat, number of forces deployed, theater
evacuation policy, medical troop ceiling, and anticipated level of violence. In most situations, HSS follows
the traditional support provided to combat forces. If there is a shortened theater evacuation policy, a limited
medical troop ceiling, and limited hospitalization assets within the AO, organic and DS ambulance support
is provided from the point of injury to the supporting Levels I or II MTF and, once the patient is stabilized
for further evacuation, from the treatment element to an airfield for evacuation out of the theater. Preventive
medicine resources should be included early on in the operational planning process to reduce the effect of
the medical threat on deploying forces.
(1) During NEO, those persons who are injured, wounded, or ill are treated and stabilized
by the medical element accompanying the NEO force. Once stabilized, they are evacuated by the NEO
force. In NEO conducted in a permissive environment (no apparent physical threat to the evacuees), sick,
injured, or wounded persons should be evacuated on dedicated medical evacuation platforms, if at all
possible. In an uncertain or hostile environment, the transportation assets used to insert and extract the
NEO force are normally used to evacuate the patients. The medical personnel accompanying the force
provide en route medical care until the NEO force reaches an ISB or safe haven. Those evacuees requiring
medical care are provided the required care or are stabilized for further evacuation to MTFs capable of
providing the required care.
(2) During combatting terrorism operations, planning considerations for HSS include—
• Using medical and nonmedical transportation assets to evacuate casualties in mass
casualty situations. If nonmedical assets are used, planning should include augmenting these assets with
medical personnel to provide en route medical care. Refer to STANAG 2068, FM 4-02.6, and FM 8-42 for
a discussion of mass casualty operations.
• Applying techniques for acquiring, treating, and evacuating patients under hostile
fire or on adverse terrain (from rubble or from above or below ground level).
• Ensuring security measures (such as establishing checkpoints, screening personnel
and vehicles, and limiting access to the MTF area) are implemented.
(3) For additional information, refer to FM 8-42.
6-5.
Support Operations
Support operations provide essential supplies and services to assist designated groups. They are conducted
mainly to relieve suffering and help civil authorities respond to crises. In most cases, Army forces achieve
success by overcoming conditions created by man-made or natural disasters. The ultimate goal of support
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operations is to meet the immediate needs of designated groups and transfer responsibility quickly and
efficiently to appropriate civilian authorities. There are two types of support operations which are DSO and
foreign humanitarian assistance (FHA).
a. Army support to DSO supplements efforts and resources of state and local governments and
organizations. A Presidential Declaration of a major disaster or emergency usually proceeds a DSO.
Domestic support operations require extensive coordination and liaison among many organizations such as
joint, interagency, and state and local governments. The Federal Response Plan (FRP) provides a national-
level architecture to coordinate actions of all supporting federal agencies. The forms of support in DSO
encompass—
• Relief operations. These operations are in response to man-made or natural disasters.
The Army assists the state and local governments to restore or recreate essential infrastructure (such as
power generation, water supply, sanitation systems, and medical care facilities and services). Humanitarian
relief focuses on the well-being of supported populations. These activities normally occur simultaneously.
• Support to domestic chemical, biological, radiological, nuclear, and high-yield explosive
(CBRNE) consequence management. Incidents involving CBRNE may be deliberate or unintentionally
initiated. The result, regardless of what initiated the incident, produces catastrophic loss of life or property.
When directed by DOD, Army forces assist civil authorities in protecting US territory, population, and
infrastructure before an attack by supporting domestic preparedness and protecting critical assets.
(Refer to
FM 3-11.21 for NBC aspects of consequence management.)
•
Domestic preparedness efforts of local, state, or federal personnel/organizations is
enhanced with training from US Army sources and cooperative efforts of the AMEDD to provide courses
on the medical management of NBC casualties.
•
Terrorists or hostile forces may attack facilities essential to society, the government,
and the military, such as the destruction of the World Trade Center in New York on September 11, 2001
and the attack on the Pentagon in Washington, D.C. Department of Defense Directive 5160.54 identifies
specific civil infrastructure assets necessary to conduct military operations. In conjunction with civil law
enforcement, Army forces may protect these assets or temporarily restore lost capability.
•
When a CBRNE incident occurs, local authorities will be the first to respond to
the incident. If federal assistance is required, other government agencies (rather than the military) have
primary responsibility for responding to domestic CBRNE incidents. However, Army forces have a key
supporting role and can quickly respond when authorized. Additionally the President and SECDEF can
authorize Army assets to assist a foreign government after a CBRNE incident. Such assistance may be
linked to concurrent relief operations. In CBRNE response to domestic support operations, the US Army
Medical Command (USAMEDCOM) can provide large-scale medical care and support.
(Refer to
Appendix I for information on requesting support.) Its experienced clinicians, planners, and support
staffs can furnish assessment, consultation, triage, medical treatment and trauma care, hospitalization, and
follow-up care for chemical and biological casualties. The Army can deploy and establish a hospital
in a field environment or it can medically evacuate victims to a USAMEDCOM fixed facility. Further,
the USAMEDCOM has special medical augmentation response teams (SMARTs) that can rapidly deploy to
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an incident site to provide consultation and assistance on medical issues.
(For additional information on the
types of SMARTs that are maintained, refer to Appendix I of this manual and FM 8-42.)
• Support to civil law enforcement. Army support is provided, when authorized and
governed by the Posse Comitatus Act, during counterterrorism activities, counterdrug operations, military
assistance during civil disturbances, and general support. Army National Guard units in a state status can
be a particularly useful military resource. They may be able to provide assistance to civil authorities when
federal units cannot due to the Posse Comitatus Act.
• Community assistance. This is a broad range of activities that provide support and
maintain a strong connection between the military and the civilian community. An example of an AMEDD
community assistance mission is the Military Assistance to Safety and Traffic (MAST) program, where an
air ambulance unit provides evacuation support to the nearby civilian community.
(For additional
information, refer to AR 500-4, FM 8-10-6, and FM 8-10-26.)
b. Army forces usually conduct FHA operations to relieve or reduce the results of natural or
man-made disasters. They also relieve conditions (such as pain, hunger, or disease) that present a serious
threat to life or loss of property. Foreign humanitarian assistance is limited in scope and duration. It
focuses on prompt aid to resolve an immediate crisis. In FHA, the most frequently conducted form of
support is relief operations, however, FHA may also involve support to incidents involving CBRNE and
community assistance.
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CHAPTER 7
HEALTH SERVICE SUPPORT IN INTERAGENCY AND
MULTINATIONAL OPERATIONS
7-1.
Interagency and Multinational Environments
a. Army operations conducted in today’s global environment will normally not be unilateral in
nature. The Army HSS planner must be prepared to support a wider community of eligible beneficiaries, as
determined by the—
• Type of operation (such as FHA, disaster relief, or peacekeeping).
• Anticipated duration of the operation.
(The longer the operation continues the more
resources are required and a larger theater CSS footprint is established.)
• Types of forces to be supported.
(This includes sister Services, HN, allies, coalition
partners, DOD contractors, DOD civilian employees, civilian employees from other Federal agencies,
international organizations [such as the UN], NGOs, and HN or third country civilians.)
• Law of Land Warfare (Chapter 4), treaties, agreements, regulations, and policies.
• Civilian considerations.
b. Prior to initiation of an operation, a determination of eligible beneficiaries is required to
ensure that adequate HSS resources are planned for and deployed to manage the anticipated medical work
load. The eligible beneficiary determination is also required to ensure that those receiving treatment and
other medical support are legally entitled to the care/treatment and that appropriate fund sources are used.
(Refer to Appendix G for a discussion on eligibility for care determinations.)
7-2.
Interagency Operations
a. Interagency operations facilitate the implementation of all elements of national power.
Interagency operations are critical to achieving the strategic end state, especially in stability operations and
support operations. The Army often operates in an interagency environment alongside other agencies/
organizations of the US Government. This occurs when the military is the prime strategic option, as it is in
war, but also when other instruments of national power are the preferred option and the military assists with
accomplishment of the mission.
b. Interagency operations facilitate unity and consistency of effort, maximize the use of national
resources, and reinforce the primacy of diplomatic elements. The DOD and the CJCS coordinate interagency
operations at the strategic level. This coordination establishes the framework for coordination by
commanders at the operational and tactical levels.
c.
The lead agency is determined by the type of operation and the agencies involved. In domestic
support operations, specifically disaster relief, the Federal Emergency Management Agency (FEMA) is the
lead agent in coordinating the relief activities.
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d. The requirements for the use of HSS assets and/or resources will vary on the type and duration
of the operation and the availability of medical resources. For example, as the Army is the DOD Executive
Agent for Veterinary Services, a requirement for animal care of government-owned animals used in
interagency operations
(drug enforcement, disaster relief, or patrolling operations) may become the
responsibility of the AMEDD.
7-3.
Multinational Operations
a. The types of multinational force structures are alliances and coalitions. These forces must
create a structure that meets the needs, diplomatic realities, constraints, and objectives of the participating
nations.
(Multinational operations however may also be conducted under the auspices of an international
organization, such as the UN. Forces participating in these sponsored operations do so under the direction/
structure prescribed.)
(1) Alliances. Alliances are long-standing agreements between or among nations for the
attainment of broad, long-term objectives. An example of an alliance is NATO.
(2) Coalitions. Coalitions, on the other hand, are ad hoc agreements between two or more
nations for a common action (the attainment of a short-term objective).
b. The C2 of multinational operations differs with the type of multinational force.
(1) Alliances.
(a) Alliances are characterized by years of cooperation among nations. In alliances—
• Agreed-upon objectives exist.
• Standard operating procedures have been established.
• Appropriate plans have been developed and exercised among the participants.
• A developed TO exists, some equipment interoperability exists, and command
relationships have been firmly established.
(b) Alliances are normally organized under an integrated command structure that
provides unity of command in a multinational setting. The key ingredients in an integrated alliance
command are that a single commander will be designated, that his staff will be composed of representatives
from all member nations, and that subordinate commands and staffs will be integrated to the lowest echelon
necessary to accomplish the mission.
(c) Another form of alliance is the lead nation command structure. This structure may
exist in a developing alliance when all member nations place their forces under the control of one nation.
This means that the lead nation’s procedures and doctrine form the basis for planning and coordinating the
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conduct of operations. Although this type of arrangement is unusual in a formal alliance, such a command
structure may have advantages under certain treaty circumstances. A lead nation command in an alliance
may be characterized by a staff that is integrated to the degree necessary to ensure cooperation among
multinational or national subordinate army formations.
(2) Coalitions. Coalitions are normally formed as a rapid response to an unforeseen crises
and, as stated above, are ad hoc arrangements between two or more nations for a common action.
(a) During the early stages of such a contingency, nations rely upon their military
command systems to control the activities of their forces. Therefore, the initial coalition arrangement will
most likely involve a parallel command structure. (Under a parallel command, no single multinational army
commander is designated.) Usually member nations retain control of their national forces. Coalition
decisions are made through a coordinated effort among the participants. A coalition coordination,
communications, and integration center (C3IC) can be established to—
• Facilitate exchange of intelligence and operational information.
• Ensure coordination of operations among coalition forces.
• Provide a forum for resolving routine issues among staff sections.
(b) As a coalition matures, the members may choose to centralize their efforts through
establishing a lead nation command structure. A lead nation command is one of the less common command
structures in an ad hoc coalition. A coalition of this makeup sees all coalition members subordinating their
forces to a single partner, usually the nation providing the preponderance of forces and resources. Still,
subordinate national commands maintain national integrity. The lead nation command establishes integrated
staff sections, with the composition determined by the coalition leadership.
7-4.
Planning Considerations
a. Planning for interagency and multinational operations follow the fundamental principles of the
military decision-making process (MDMP) including HSS estimate and plan. Planning checklists for
missions conducted in a joint or multinational environment are provided in Appendix G.
b. Refer to Joint Pubs 4-02, 4-02.1, and 4-02.2, and FMs 8-42, 8-55, for additional information
on planning.
7-5.
Rationalization, Standardization, and Interoperability in Multinational Operations
One of the most difficult aspects of multinational operations concerns the RSI of equipment, supplies, and
procedures. This task is compounded by differences in terminology, language, and doctrine.
a. Communications. To ensure mission success, it is imperative that communications are quickly
established with all participating Services, agencies, or nations.
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(1) Initial communications can be facilitated by exchanging liaison teams who will have
direct interface with the operation’s participants. When possible, liaison personnel should be deployed
early in the planning/organization phase of the operation.
(2) Compatible communications equipment may pose a severe problem for a multinational
force. Even within joint and interagency operations, the US experiences interoperability problems with
communications equipment; these difficulties are magnified when US forces are engaged in multinational
operations. Depending upon the size of the multinational force, one nation may be required to provide
communications equipment to all elements for C2 purposes. Depending upon the topography in the AO and
dispersion of forces, the planning for and effective use of messengers and wire communications may also
assist in alleviating this situation.
This paragraph is in consonance with NATO STANAG 2131.
(3) A glossary of standardized operational and medical terminology and their definitions
must be compiled. Due to differences in language, translation, and usage, the operational and medical
terminology of one nation may not be understood by one or more of the coalition partners. By providing a
reference guide of operational terms, misinterpretation can be minimized and can aid in the synchronization
of military efforts. North Atlantic Treaty Organization STANAG 2131 (DA Pamphlet 40-3) provides a
multilingual medical phrase book which contains basic medical questions in some of the languages of the
NATO nations. If the languages addressed in this phrase book do not include the phrases in all the
languages of the multinational force, it should be supplemented with the appropriate information.
b. Standardization. Within alliances, standardization can be accomplished in many areas. The
specifications and requirements for equipment, treatment protocols, and procedures can be developed by
working groups and adopted for use by each nation. An example of this is the NATO standard litter which
can be interchangeably used in all ambulances employed by the member nations. In coalitions there is not
sufficient time permitted to reach standardization agreements of this nature. Due to the short duration and
limited purpose of these arrangements, there is usually only sufficient time to standardize principles and
time-sensitive procedures, such as report formats or radio frequencies to be used, rather than materiel
development issues. Whenever possible, international standardization agreements (ISAs) (such as NATO
STANAGs and ABCA Armies QSTAGs) should be used as a starting point for coalition standardization. As
mentioned earlier, those agreements pertaining to policy, procedures, and treatment protocols are more
easily adapted to the coalition operation.
c.
Command and Control. As coalitions are ad hoc agreements of countries sharing a common
interest, it may not be possible to establish C2 over all participants, as each nation may have its own specific
requirements which limit the authority it will permit international or national commanders to exercise over
its forces. Thus, command in the formal sense may not exist, and a system of cooperation may be required
in its place. Hasty agreements must be made to formulate workable methods. These are always specific to
the situation and must be decided by commanders and staffs, taking into consideration the mission,
requirements, and capabilities of the participating forces. Regardless of the type organization and/or
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agreements made by the coalition forces, specific guidance must be provided to the various national
contingents as to how the coalition will operate.
d. Rationalization. Rationalization consists of those actions that increase the effectiveness of
coalition forces through more efficient or effective use of defense resources committed to the coalition.
Rationalization applies to both weapons and materiel resources and nonweapons military measures. As the
US is a signatory of the Geneva Conventions, the provisions of these conventions must be adhered to by US
forces. Specific information on the protected status of medical personnel, self-defense and the defense of
patients in their care, and the protected status of medical facilities, vehicles, aircraft, and medical materiel is
provided in Chapter 4.
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CHAPTER 8
DOMESTIC SUPPORT OPERATIONS
8-1.
Support Operations
Support operations use Army forces to assist civil authorities, foreign and domestic, as they prepare to
respond to crises and relieve suffering. In support operations, Army forces provide essential support,
services, assets, or specialized resources to help civil authorities deal with situations beyond their capabilities.
The purpose of support operations is to meet the immediate needs of designated groups for a limited time,
until civil authorities can do so without Army assistance. Support operations conducted in the United
States, its territories and possessions are referred to as DSO. For additional information on support
operations refer to FM 3-0 and FM 100-19.
8-2.
Domestic Support Operations
a. Army support to DSO supplements the efforts and resources of state and local governments
and organizations. A presidential declaration of a major disaster or emergency usually precedes DSO.
Domestic support operations require extensive coordination and liaison among many organizations—
interagency, joint, active duty, reserve, and National Guard units—as well as with state and local
governments. The FRP provides a national-level architecture to coordinate the actions of all supporting
federal agencies.
b. Although the Constitution permits the use of Army forces to protect the states against invasion
and, upon request of a state, to provide the nation with critical capabilities, such as missile defense,
necessary to secure and defend the homeland. It is the responsibility of civil authorities to preserve public
order and carry out governmental operations within their jurisdiction. Restrictions on the use of Army
forces providing assistance to civil authorities are contained in the Posse Comitatus Act, as amended, and
the Stafford Act. The primary reference for military assistance to civil authorities is DODD 3025.15. It is
wide-ranging, addressing such actions as civil disturbance control, counterdrug activities, combatting
terrorism and law enforcement. In DSO, Army forces always support civil authorities—local, state, and
federal.
8-3.
Domestic Support Operations Missions
During DSO, Army forces perform relief operations, support to CBRNE consequence management, support
to civil law enforcement, and community assistance.
a. Relief Operations. Relief operations may be required in response to natural or man-made
disasters. Civil authorities are responsible for restoring essential services in the wake of the incident. To
assist the civil authorities in accomplishing this action, the President can deploy Army forces.
(1) Disaster relief. Disaster relief involves the restoration of critical infrastructure such as
hospitals and other health care facilities, water and sewage systems, electricity, and communications
capabilities. It includes establishing and maintaining the minimum safe working conditions necessary to
protect relief workers and the affected population.
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(2) Humanitarian relief. This focuses on those lifesaving measures that alleviate the
immediate needs of the population in crisis. Civilian relief organizations (governmental or nongovernmental)
are best suited to provide this type of relief. Army forces conducting humanitarian relief usually facilitate
civil relief efforts. Activities within these types of operations include the provision of medical care and
medications, food, water, clothing, blankets, and shelter.
b. Support to Domestic CBRNE Consequence Management. Support to CBRNE incidents may
be required due to the deliberate or unintentional events involving a release or use of CBRNE agents that
produce catastrophic loss of life and property.
(1) Domestic preparedness. This encompasses all activities that prepare the nation to rapidly
respond to natural or man-made disasters and to terrorist or weapons of mass destruction (WMD) incidents.
The pillars of domestic preparedness include training, exercises, expert assistance, and response.
(2) Protection of critical assets. Hostile forces (including terrorists) may attack facilities
essential to society, the government, and the military. These assaults can disrupt civilian commerce,
government operations, and military capabilities. Department of Defense Directive 5160.54 identifies
specific civil infrastructure assets necessary to conduct military operations. In order for the Army to
conduct full spectrum operations, this infrastructure must be protected. In conjunction with civil law
enforcement, Army forces may protect these assets and temporarily restore lost capability.
(3) Response to CBRNE incidents. The FRP is the key plan that affects the use of Army
forces in CBRNE incidents. The resources required to deal with CBRNE incidents differ from those needed
during conventional disasters. Mass casualties may require decontamination and a surge of medical
resources (to include health service logistics, such as antidotes, vaccines, and antibiotics). The sudden onset
of a large number of casualties may pose public health threats related to food, vectors, water, waste, and
mental health. Damage to chemical and industrial plants and secondary hazards such as fires may cause
toxic environmental hazards. Mass evacuation may be necessary. The Army possesses capabilities suited
to respond to CBRNE incidents. The USAMEDCOM has the capability, through its experienced clinicians,
planners, and support staffs to accomplish assessments, triage, medical treatment (for conventional and
NBC casualties), hospitalization, and follow-up care, and provide consultation and advice.
c.
Support to Civil Law Enforcement. Support to domestic civil law enforcement involves
activities related to counterterrorism, counterdrug operations, military assistance to civil disturbances, and
general support. Although the AMEDD does not directly participate in these operations, they do provide
HSS to those forces participating. Further, veterinary personnel may also be required to support
government-owned animals engaged in these operations.
d. Community Assistance. Community assistance is a broad range of activities that provide
support and maintain a strong connection between the military and civilian communities. Community
assistance activities provide effective means of projecting a positive military image, providing training
opportunities, and enhancing the relationship between the Army and American public. They should fulfill
community needs that would not otherwise be met. In addition to providing educational/training
opportunities for domestic preparedness, programs such as MAST have enabled communities without
aeromedical resources to evacuate critically injured civilians from the incident site (automobile accident or
job site) by air to the local area hospital.
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8-4.
Army Medical Department Activities in Domestic Support Operations
a. The AMEDD may have numerous support roles in DSO. Some of the major AMEDD areas
of participation are:
(1) In coordination with federal, state, and local health organizations, annually teaches
courses in the medical management of NBC casualties.
(2) Currently, there are 43 SMARTs (Appendix I) in ten functional areas that can
respond within 12 hours and provide short duration, medical augmentation to federal and defense agencies
responding to a disaster, WMD, humanitarian and/or emergency incidents.
(3) Selected MTFs have been trained and equipped to provided limited patient
decontamination as a contingency to a CBRNE event.
(4) Each Army MTF develops and supports their installation with emergency medical
management plans in coordination with the installation commander.
(5) The USACHPPM in coordination with other federal agencies, such as the US
Environmental Protection Agency, develops appropriate products (reports, protocols, and enhanced
monitoring) to enhance security of the Army’s critical infrastructure and to develop appropriate guidance to
counter acts of bioterrorism. Further, the USACHPPM is a reach-back center for medical information on
chemical, biological, radiological, and nuclear incidents and is capable of providing specialists in the
medical arena, if required.
(6) Army Medical Department resources can assist in conducting vulnerability assess-
ments of drinking water systems.
b. For additional information on AMEDD support to DSO refer to FM 4-02.7 and FM 8-42.
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APPENDIX A
CLINICAL POLICY AND GUIDELINES
A-1. Joint Readiness Clinical Advisory Board
a. The JRCAB, formerly designated as the Defense Medical Standardization Board (DMSB),
was established by DODI 6430.2.
b. Department of Defense Directive 6000.12 establishes that the JRCAB, a joint DOD activity,
will provide policy and standardization guidance relative to the development of DEPMEDS and medical
materiel used for the delivery of health care in the MHS. In executing this duty, the JRCAB has developed
a DEPMEDS database (task, time, treater files) and clinical guidelines for patient care (patient condition
codes [PCs] and clinical pathways [treatment briefs] [paragraph A-15]). It provides standardization for field
facilities, MESs and medical materiel sets (MMSs), consumables, and treatment protocols. Further, it
provides standardization across the Services for health care needs for modeling and simulations.
c.
The PCs and their accompanying treatment briefs are updated on a quarterly basis by the
JRCAB. For the most up-to-date information on PCs and specific treatment briefs, refer to the JRCAB
A-2. Assumptions
This paragraph provides a discussion of the existing assumptions used by the JRCAB in developing the
DEPMEDS Administrative Procedures, Clinical and Support Guidelines, and Patient Treatment Briefs.
Additionally, it discusses proposed AMEDD changes to these assumptions.
a. Current Assumptions.
(1) Essential care versus definitive care. As with the change in focus of JHSS Vision, the
subject matter expert (SME) panels developed the treatment briefs under the assumption that only essential
care will be provided in the theater versus the previous principle of definitive care being provided. This
assumption results in a smaller HSS footprint and increases the reliance on timely aeromedical evacuation
(AE) of patients from the theater. In keeping with the focus of only essential care being provided in theater,
a theater evacuation policy of 7 days within the CZ and 15 days within EAC is assumed. In any given real-
time scenario, the theater evacuation policy is established by the SECDEF with the advice of the JCS and
may differ given the specific scenario (refer to paragraph 5-4).
(2) Stabilized versus stable patient. With the shift in the paradigm from definitive care to
essential care, the patient condition status required for medical evacuation also shifts from the stable patient
to the stabilized patient. This allows the patient to be more rapidly evacuated with the provision of en route
medical care than before.
• Stabilized patient: (1) Patient whose condition may require emergency interventions
within the next 24 hours. The patient’s condition is characterized by a minimum of a secured airway,
control or absence of hemorrhage, treated shock, and immobilized fractures. Stabilization is a necessary
precondition for further evacuation.
(2) A patient whose airway is secured, hemorrhage is controlled, is
treated for shock, and fractures are immobilized.
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• Stable patient:
(1) A patient whose condition is not predicted to change within the
next 24-hour period.
(2) A patient for whom no in-flight medical intervention is expected but the potential
for medical intervention exists.
(3) Core capabilities. Although differences exist in each Services health care capabilities
and at what level they become available, the panels developed the treatment briefs based on core capabilities.
For frame of reference, the requirements for first responder equates with Level I care and the trauma
specialist is the first medically-trained individual the soldier encounters. The forward resuscitative surgery/
care is equivalent to Level II care, but is best defined as the first place that an ill or injured soldier could be
held overnight in a medical environment and where forward resuscitative surgery (lifesaving) would take
place, if the Level II facility is augmented with an FST. The theater hospital is equivalent to Level III (and
sometimes Level IV), but is the first place that full hospital services would be available in theater from
which patients would enter the theater AE system. The primary mission of each level is to preserve life,
limb, and sight and to stabilize the nonreturn-to-duty patient for evacuation to the next level of care. Those
patients who can RTD are treated and promptly returned to duty as far forward as possible.
(4) Minimum capabilities. The treatment briefs do not limit a Service from providing more
advanced care forward, but rather they establish a baseline for the minimum care feasible on the battlefield
and as envisioned in the JHSS Vision.
(5) Mobility. Units forward of the theater hospital must be mobile and able to carry their
own supplies. Mobility considerations place limits on the types of equipment and procedures which can be
accomplished far forward. These can include sterilization, refrigeration, laboratory, and radiology
technologies. These constraints were considered in planning for blood, some pharmaceuticals, x-rays, and
the like. Some forward units may have an increased capability in these areas above the minimum required.
(6) Expected time between levels (from when a patient is ready for evacuation to when they
arrive at the next level).
(a) Level IA (trauma specialist) to Level IB (BAS) by ground ambulance will take from
as little as 5 minutes to as much as 45 minutes. If an air ambulance at Level IA picks up patients, it will
overfly Level IB (BAS) directly to Level II and the FST (Level 2.5). The expected time is between 15 and
70 minutes.
(b) Level IB (BAS) to Level II/2.5 by ground ambulance will take between 10 minutes
and 100 minutes. By air ambulance the expected time is between 10 minutes and 45 minutes.
(c) Level II/2.5 to Level III by ground will take between 50 minutes and 9 hours (8
hours in NATO and ABCA assumptions). By air ambulance the expected time is between 50 minutes and
2.5 hours.
(d) Intratheater evacuation from Level III to Level IV may take up to 12 to 24 hours for
the bed-to-bed move.
(e) Intertheater evacuation from Level III or IV may take up to 24 to 48 hours for the
bed-to-bed move.
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(7) Aeromedical evacuation resources. Sufficient aircraft and en route care teams will be
available within 48 hours in an immature theater to evacuate stabilized patients from either Levels II, III, or
IV to out of theater. Success in future conflicts will be even more dependent upon support from other
Services, with joint operations being the norm. Health service support forces will establish sister-Service
liaisons and test communications before they are needed. This will be accomplished at all levels of medical
care.
(8) Mass casualty. In a mature theater, during maximum estimated casualty flows, there
may not be sufficient en route care teams available within 24 hours to evacuate all projected stabilized
patients from Level III. A Level IV capability or an increase in Level III holding will be required to support
the theater commander’s major theater war (MTW) plan and specialty augmentation teams may be required
in both immature and mature theaters.
(9) Clinical decision criteria. There are different clinical decision criteria for (1) prehospital
evacuation, (2) interhospital evacuations for required increase in care capability, and (3) elective interhospital
evacuations.
(10) Location. Levels III or IV may be deployed in theater, may be out of theater, or there
may not be a Level III or Level IV deployed. Level IV may be a fixed facility, such as Landstuhl Regional
Medical Center (RMC) in Germany.
(11) Treatment Briefs. Treatment briefs will define the postoperative period for stabilization
required to survive evacuation to each subsequent point of care, as well as en route care personnel,
equipment, and transport times. In an ideal trauma system, equipment and appropriately capable personnel
will be placed where they are needed in time, regardless of distance.
(12) Population at risk. The population at risk must be identified. United States service
members located in or near the theater would be cared for by theater HSS assets. However, in virtually all
situations, local nationals seek care and an eligibility for care determination must be made. Enemy
prisoners of war, detained and retained personnel, allied and coalition partners, US government employees
(DOD and interagency), and contractors on the battlefield may be provided care depending upon appropriate
authorization (such as, memorandum of understanding or agreement, US and international law, and US
policies and regulations). The treatment of local nationals and/or authorized dependents may include the
requirement to provide pediatric, obstetric, or geriatric care.
b. Proposed Assumptions.
(1) Within the primary mission and field operational constraints (METT-TC), every soldier
will be provided the best possible care. Given the primary HSS mission, optimal care is rendered within an
environment which may delay immediate access to the patient, inhibit immediate evacuation, result in
extended evacuations to appropriate facilities, and may be overwhelmed at particular parts in the system.
This system resembles rural trauma care in the US in that trauma usually occurs at a distance from definitive
care capability; however, forces deployed for combat expect far higher casualty densities.
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(2) Evacuation is the means to clear the battlefield and to get casualties to treatment
capabilities that are needed for recovery and/or survival. Evacuation of less-than-stable casualties may be
accomplished safely and help decrease the treatment capability required in theater.
(3) Evacuating patients to a higher level of care necessary for saving life, limb, or eyesight
may require URGENT (URGENT-SURG) evacuation of stabilized and unstable patients. This includes the
requirement to move a patient from a Level III hospital to either a Level IV with specialty augmentation
teams or possibly another Level III hospital that has specialty augmentation teams (such as neurosurgery,
ophthalmology, and head and neck surgery). Levels III and IV hospitals may be augmented with specialty
augmentation teams in either a mature or immature theater (potentially making them the equivalent of a
American College of Surgeons Committee on Trauma Surgery [ACOS COTS] Trauma Level II facility).
(4) Patients undergoing surgery at a FST, who are doctrinally capable of being held for up to
6 hours, should be held longer if the tactical situation permits. Patients evacuated by Army rotary-wing
aircraft from FSTs to Level III (or IV) within 6 hours of surgery will be evacuated with personnel capable
of providing care, to include airway and ventilation management.
(5) The requirement to transport a patient on medical lift (ground, air, or sea) is initiated
by the originating attending medical officer, who is responsible for assessing the stability of the patient
and the urgency of evacuation in light of the current theater evacuation policy. In conjunction with the
theater medical regulating authority, the decision is made of who, when, how, and where patients will be
evacuated.
(6) A stabilized patient is one who, in the best clinical judgment of the originating physician,
can withstand a bed-to-bed evacuation of 12- to 24-hours duration. Patients will be stabilized within the
limitations of the originating medical facility’s (OMF) capability. It is understood that patients moved from
Level I or Level II to Level III may not be clinically stable due to the patient’s condition and the limited
medical resources and time available. Prior to moving patients, an airway must be ensured, fractures
splinted, hemorrhage controlled, and shock treated. Patients being moved from Level III to Level IV
should be stable enough to tolerate a 12 hour bed-to-bed move. Patients being moved from Level IV to
CONUS should be stable enough to tolerate a 24 hour bed-to-bed move.
(7) Unless constrained by operational considerations, the attending physician at the origina-
ting MTF will determine when a patient is sufficiently stable to be evacuated. After the attending physician
determines that the patient can be considered for evacuation, USAF physicians will make the final
determination of whether a patient may be evacuated by AE lift.
(8) Postoperative length of stay will be kept to a minimum consistent with good outcome and
the requirement for bed space for anticipated incoming patients.
(9) Only in the event that the USAF is unable to provide their function for care in the air,
Army medical personnel will be prepared to augment or do this mission of accompanying unstable or
stabilized patients to provide en route medical care in the USAF AE system. The USAF has primary
responsibility to provide en route care personnel on other than lifts of opportunity.
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(10) The AMEDD will establish policies, guidelines, and assumptions for determining when and
who will request movement. The guidelines will identify what type of en route care to provide, if required.
(a) Patients evacuated while on a ventilator will be accompanied by medical personnel
trained in ventilator management.
(b) Patients will receive the same level of care en route that they required in the OMF.
Thus an intensive care unit (ICU) patient will receive ICU care, unless clearly ready for transfer from the
ICU to a lower level of care.
(c) Patients with a high likelihood of requiring care beyond that available en route will
not be evacuated if that care is available at the patient’s current location, within the limits imposed by the
tactical situation.
(11) Joint Pub 4-02.2 indicates that “...psychiatric or terminal cases with a very short life
expectancy are therefore not considered URGENT (USAF) for evacuation...”.
(12) Casualties will be triaged in accordance with accepted standards outlined in the latest
edition of the NATO Emergency War Surgery Handbook.
(13) The AMEDD will adopt ACOS COTS concepts regarding documentation and collection
of data leading to a trauma registry for military patients.
A-3. Deployable Medical Systems and Logistical Considerations
a. Department of Defense Instructions 6430.2, dated 21 June 1984, provided the original DOD
policy on the development of DEPMEDS. In part it stated “In order to ensure maximum standardization,
increase efficiency, and minimize costs, DOD components shall acquire only those field DEPMEDS
approved by the Assistant Secretary of Defense (Health Affairs) (ASD[HA])”. The design of the components
of DEPMEDS must ensure that the facility will be—
• Capable of providing current quality care.
• Affordable, maintainable, and relocatable.
• Constructed in a modular format for ease of incorporation of a variety of Service-specific
configurations.
• Useable by all four Services.
• Capable of being strategically airlifted.
b. The initial MMS developed for use with DEPMEDS facilities were in response to the threat
environment focusing on Soviet threat in Europe and around the world. As the threat has changed to
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emphasize less intense conflicts and humanitarian assistance and disaster relief, the Services are developing
smaller, lighter deployable systems and augmentation. During Desert Shield/Desert Storm, the concept of a
SIMLM was introduced. The Service designated as the SIMLM provides medical logistical support to all
Services participating in the operation/AO. Therefore, it became paramount that medical materiel be
standardized across the Services which would result in limiting the number of items which needed to be
available in the logistics supply/resupply chain.
(Refer to Joint Pub 4-02.1 and FM 4-02.1 for additional
information on the SIMLM.)
(1) The basic modules of MMSs consist of the equipment, durables, and high use consum-
ables required to support early operational capabilities.
• Medical materiel sets are divided into two components: one including equipment
and long shelf-life durables and a second detailing related dated and deteriorative (D&D) items and short
shelf-life durables.
• While D&D and short shelf-life durables appear as components of an MMS, these
items are held either in the pharmacy, OR, central material supply (CMS), or resupply MMS, and are
pushed to or drawn by the MTF departments after the facility has been established.
• Medical materiel sets normally are not built or stored with D&D and short shelf-life
items included to avoid loss due to expiration.
(2) The quantities of supplies and equipment contained in MMS are based on patient load
data, a 30-day combined scenario, a 7-day (CZ) and a 15-day (EAC) evacuation policy, and a 7/15 day
Level III to Level IV bed stay alternative.
(3) The Services use basic MMSs plus select augmentation MMSs to design their MTFs
based upon general subjective guidelines including a 2-table OR, a 12-bed ICU, and 20-bed wards.
(4) Resupply MMSs are built based on Service-specific MTFs and workload projections.
(5) Augmentation and special augmentation modules provide increased or enhanced capability
by supplementing a basic module with specialty items of equipment, durables, or consumable supplies.
Specialty augmentation sets are developed using the following guidelines:
• Use a foundation set to treat a select number of patients.
• Resupply to a select number of patients not tied to days of supply (DOS).
• Requirement for capability increases as the theater evacuation policy lengthens.
• Services provide any supplemental manpower requirements.
(6) Resupply modules provide adequate materiel to replenish patient driven consumables and
durable supplies which have been consumed in use with basic and augmentation modules. Resupply modules
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are tailored to a specific Service’s projected patient workload data and required DOS. For Army resupply
sets the DOS is 7 days or more.
c.
The D-Day Significant Items List is a comprehensive list of medical and dental consumable
items essential to medical forces operating in the field. This list is designed to encompass those supplies
available to the military Services from day 1 through day 60 of any conflict for Levels I through IV. The
purpose of the listing is to—
• Identify those medical and dental items that are essential for accomplishing the wartime
medical missions of the Services at all levels of care. These items would then be available through the
SIMLM.
• Alert the medical and dental materiel manufacturing industry to our war surge and
sustainment requirements.
• Act as an adjunct to the DEPMEDS database in aiding Service management and
development of medical sets, allowance lists, and equipment tables.
• Identify alternate and substitute medical items to satisfy wartime and contingency
requirements.
• Encourage the use of D-Day listed items in peacetime medical practice to familiarize care
givers with what they will use in wartime.
d. In the requirements determination process for DEPMEDS MMS modules there are two
categories: patient-driven items and functionally-driven items.
• Patient-driven items are those medical material items consumed during direct patient care
(such as pharmaceuticals and bandages). These items are tied into the DEPMEDS database to specific PCs
(paragraph A-13), treatment procedures, and material quantities identified by SMEs.
• Functionally-driven (bulked) items are those major equipment, durables, and selected
consumables with levels established by panels of SMEs for each DEPMEDS module.
A-4. Patient Estimates
a. Health service support planners must consider numerous factors when planning for an
operation. The HSS planner must determine the medical workload based upon the casualty estimate devised
by the S1/G1. In addition, he must consider time and distance factors, distribution of patients on the
battlefield and areas of patient density, scenario specific constraints/limitations, and many other factors. An
in-depth discussion of medical planning factors is contained in FM 8-42 and FM 8-55.
(1) For standardization purposes, the two simultaneous MTW casualty estimation process
from the Total Army Analysis (TAA) process is used in determining the quantities of items placed in basic
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