FM 8-42 COMBAT HEALTH SUPPORT IN STABILITY OPERATIONS AND SUPPORT OPERATIONS (October 1997) - page 1

 

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FM 8-42 COMBAT HEALTH SUPPORT IN STABILITY OPERATIONS AND SUPPORT OPERATIONS (October 1997) - page 1

 

 

FM 8-42
COMBAT HEALTH SUPPORT
IN
STABILITY OPERATIONS
AND
SUPPORT OPERATIONS
HEADQUARTERS, DEPARTMENT OF THE ARMY
DISTRIBUTION RESTRICTION: Approved for public release; distribution is unlimited.
*FM 8-42
FIELD MANUAL
HEADQUARTERS
No. 8-42
DEPARTMENT OF THE ARMY
Washington, DC, 27 October 1997
COMBAT HEALTH SUPPORT
IN STABILITY OPERATIONS AND SUPPORT OPERATIONS
TABLE OF CONTENTS
Page
PREFACE
vii
CHAPTER
1.
COMBAT HEALTH SUPPORT PERSPECTIVE
1-1
1-1.
General
1-1
1-2.
Stability and Support Operations
1-1
1-3.
Principles
1-2
1-4.
Logistics Preparation of the Theater
1-4
1-5.
Medical Threat Assessment
1-4
1-6.
Foundations for Combat Health Support Programs
1-7
1-7.
Command Surgeon
1-8
1-8.
Command Surgeon’s Role
1-10
1-9.
Army Medical Department Battlefield Rules
1-12
1-10.
The Law of Land Warfare
1-12
CHAPTER
2.
COMBAT HEALTH SUPPORT OPERATIONS
2-1
2-1.
General
2-1
2-2.
Planning and Preparing for Contingency Operations
2-1
2-3.
Task Organization of Elements
2-2
2-4.
Medical Evacuation Support
2-3
2-5.
Patient Treatment, Stabilization, and Holding
2-4
2-6.
Preventive Medicine
2-5
2-7.
Combat Health Logistics
2-5
2-8.
Veterinary Support
2-5
2-9.
Combat Stress Control
2-6
CHAPTER
3.
COMBAT HEALTH SUPPORT TO STABILITY OPERATIONS
AND SUPPORT OPERATIONS
3-1
3-1.
General
3-1
3-2.
Noncombatant Evacuation Operations
3-1
3-3.
Domestic Support Operations
3-2
DISTRIBUTION RESTRICTION: Approved for public release; distribution unlimited.
*This publication supersedes FM 8-42, 4 December 1990.
i
FM 8-42
Page
3-4.
Foreign Humanitarian Assistance
3-5
3-5.
Security Assistance
3-7
3-6.
Nation Assistance
3-7
3-7.
Support to Counterdrug Operations
3-11
3-8.
Combatting Terrorism
3-11
3-9.
Peace Support Operations
3-14
3-10.
Show of Force
3-17
3-11.
Support for Insurgencies and Counterinsurgencies
3-17
3-12.
Attacks and Raids
3-23
CHAPTER
4.
SPECIFIC FUNCTIONAL AREA CONSIDERATIONS IN
STABILITY OPERATIONS AND SUPPORT OPERATIONS
4-1
Section
I.
Command, Control, Communications, Computers, and
Intelligence
4-1
4-1.
General
4-1
4-2.
Considerations
4-1
Section
II.
Patient Evacuation and Medical Regulating
4-2
4-3.
General
4-2
4-4.
Patient Evacuation and Medical Regulating Support to Stability
and Support Operations
4-2
Section
III.
Hospitalization and Treatment
4-4
4-5.
General
4-4
4-6.
Nonphysician Health Care Practitioners
4-4
4-7.
Hospitalization and Medical Treatment in Support of Stability
and Support Operations
4-6
Section
IV.
Preventive Medicine
4-9
4-8.
General
4-9
4-9.
Medical Threat
4-10
4-10.
Preventive Medicine Support to Stability and Support Operations
4-12
Section
V.
Veterinary Support
4-16
4-11.
General
4-16
4-12.
Veterinary Support to Stability and Support Operations
4-17
Section
VI.
Dental Support
4-22
4-13.
General
4-22
4-14.
Dental Assessment
4-22
4-15.
Dental Support to Stability and Support Operations
4-23
Section
VII.
Combat Stress Control and Mental Health Services
4-24
4-16.
General
4-24
4-17.
Combat Stress Control Support to Stability and Support Operations
4-25
Section
VIII.
Combat Health Logistics
4-27
4-18.
General
4-27
4-19.
Combat Health Logistics Support to Stability and Support
Operations
4-27
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FM 8-42
Page
Section
IX.
Medical Laboratory Support
4-30
4-20.
General
4-30
4-21.
Medical Laboratory Support to Stability and Support Operations
4-31
APPENDIX
A.
ANTITERRORISM AND FORCE PROTECTION
A-1
A-1.
General
A-1
A-2.
Terrorism Considerations
A-1
A-3.
Estimate of the Situation for a Security Assessment
A-1
A-4.
Force Protection and Security Measures
A-3
APPENDIX
B.
INTERAGENCY OPERATIONS
B-1
B-1.
General
B-1
B-2.
Unity of Effort
B-1
B-3.
Operations Within the United States
B-1
B-4.
Operations Outside the United States
B-3
B-5.
Military Effort
B-4
B-6.
Combat Health Support Implications in Interagency Operations
B-5
APPENDIX
C.
RISK ASSESSMENT
C-1
C-1.
General
C-1
C-2.
Risk Assessment
C-1
C-3.
Rules of Risk Assessment
C-1
C-4.
Three-Tier Approach
C-2
C-5.
Levels of Risk
C-3
C-6.
Factors to Consider in Risk Assessment
C-4
APPENDIX
D.
MULTINATIONAL OPERATIONS
D-1
D-1.
General
D-1
D-2.
Alliances and Coalitions
D-1
D-3.
Command Structure of Multinational Forces
D-1
D-4.
Rationalization, Standardization, and Interoperability
D-3
D-5.
Combat Health Support Issues
D-5
D-6.
Combat Health Support Considerations
D-6
APPENDIX
E.
COMBAT HEALTH SUPPORT ASSESSMENT CHECKLIST
E-1
E-1.
General
E-1
E-2.
Sample Medical Assessment Checklist
E-1
APPENDIX
F.
COMBAT HEALTH SUPPORT ASSESSMENT PLANNING
FOR STABILITY OPERATIONS AND SUPPORT
OPERATIONS
F-1
Section
I.
Combat Health Support Estimate
F-1
F-1.
General
F-1
iii
FM 8-42
Page
F-2.
Sample Format for the Combat Health Support Estimate
F-2
F-3.
Sample Format for the Veterinary Estimate
F-11
F-4.
Sample Format for the Preventive Medicine Estimate
F-17
F-5.
Sample Format for the Dental Estimate
F-26
F-6.
Sample Format for the Combat Stress Control Estimate
F-31
F-7.
Sample Format for the Combat Health Logistics Estimate
F-37
Section
II.
Combat Health Support Plan
F-44
F-8.
General
F-44
F-9.
Sample Format for the Combat Health Support Plan
F-44
F-10.
Sample Format for the Veterinary Service Portion of the
Combat Health Support Plan
F-50
F-11.
Sample Format for the Preventive Medicine Portion of the
Combat Health Support Plan
F-51
F-12.
Sample Format for the Dental Service Portion of the Combat
Health Support Plan
F-53
F-13.
Sample Format for the Combat Stress Control Portion of the
Combat Health Support Plan
F-54
F-14.
Sample Format for the Combat Health Logistics Portion of the
Combat Health Support Plan
F-55
APPENDIX G.
NUCLEAR, BIOLOGICAL, AND CHEMICAL
CONSIDERATIONS
G-1
G-1.
Threat
G-1
G-2.
Biological Warfare Agents
G-1
G-3.
Chemical Warfare Agents
G-2
G-4.
Nuclear Weaponry
G-4
G-5.
Operations Under Nuclear, Biological, and Chemical Conditions
G-4
G-6.
Civilian Disasters
G-4
APPENDIX H.
SAMPLE CHECKLIST FOR DEPLOYMENT FOR COMBAT
HEALTH SUPPORT OPERATIONS
H-1
H-1.
General
H-1
H-2.
Sample Predeployment Checklist
H-1
APPENDIX
I.
SPECIALTY RESPONSE TEAMS
I-1
I-1.
General
I-1
I-2.
Responsibilities
I-1
I-3.
Requests for Assistance
I-1
I-4.
Team Composition and Specialty-Specific Equipment
I-2
I-5.
Deployability and Continuous Operations
I-2
I-6.
Administrative Support and Requirements
I-3
I-7.
Equipment
I-4
I-8.
Training
I-4
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FM 8-42
Page
I-9.
Trauma/Critical Care Specialty Response Team
I-5
I-10.
Burn Specialty Response Team
I-5
I-11.
Preventive Medicine Threat Assessment Specialty Response Team
I-6
I-12.
Chemical/Biological Specialty Response Team
I-7
I-13.
Stress Management Specialty Response Team
I-8
I-14.
Telemedicine Specialty Response Team
I-10
I-15.
Food Safety, Veterinary Preventive Medicine, and Animal Health
Care Specialty Response Team
I-11
APPENDIX
J.
MASS CASUALTY SITUATIONS
J-1
J-1.
General
J-1
J-2.
Mass Casualty Management
J-1
J-3.
Triage Categories
J-2
J-4.
Control Element
J-4
J-5.
Establishing Triage, Treatment, and Holding Areas
J-5
J-6.
Medical Evacuation
J-6
J-7.
Disposition of Remains
J-8
APPENDIX K.
UNITED STATES DISASTER ASSISTANCE OPERATIONS
K-1
K-1.
General
K-1
K-2.
Administrative Support
K-1
K-3.
Priorities of Support
K-2
K-4.
Disaster Relief Task List and Status Board
K-2
APPENDIX
L.
SELECTED SECTIONS OF TITLE 10, UNITED STATES CODE,
PERTAINING TO HUMANITARIAN ASSISTANCE
L-1
L-1.
Humanitarian Assistance under Title 10, United States Code,
Section 401
L-1
L-2.
Transportation for Humanitarian Relief Supplies under Title 10,
United States Code, Section 402
L-2
L-3.
Foreign Disaster Assistance under Title 10, United States Code,
Section 404
L-3
L-4.
Excess Nonlethal Supplies for Humanitarian Relief under Title 10,
United States Code, Section 2547
L-3
L-5.
Humanitarian Assistance under Title 10, United States Code,
Section 2551
L-4
APPENDIX M.
MEDICAL MISSION RECONNAISSANCE CHECKLIST
M-1
M-1.
General
M-1
M-2.
Sample Medical Mission Reconnaissance Checklist
M-1
APPENDIX
N.
COMBAT HEALTH SUPPORT OF SPECIAL OPERATIONS
FORCES
N-1
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FM 8-42
Page
N-1.
Special Operations
N-1
N-2.
Department of the Army Special Operations Forces
N-1
N-3.
The Threat to Special Operations Forces
N-1
N-4.
Special Operations Forces Missions
N-2
N-5.
Command and Control
N-3
N-6.
Army Special Operations
N-3
N-7.
Organic Combat Health Support Capability
N-4
N-8.
Planning for Combat Health Support of Special Operations Forces
N-6
N-9.
Patient Evacuation and Medical Regulating
N-6
N-10.
Hospitalization
N-7
N-11.
Combat Stress Control
N-7
N-12.
Preventive Medicine
N-7
N-13.
Medical Intelligence
N-7
N-14.
Veterinary Services
N-8
N-15.
Medical Laboratory Services
N-8
N-16.
Combat Health Logistics and Blood Management
N-8
N-17.
Dental Services
N-8
N-18.
Interrelated Missions
N-9
N-19.
Unconventional Warfare
N-9
N-20.
Foreign Internal Defense
N-9
N-21.
Counterterrorism
N-10
N-22.
Direct Action
N-11
N-23.
Special Reconnaissance
N-11
APPENDIX
O.
COMBAT STRESS CONTROL ACTIVITIES BY PHASE
OF THE OPERATION
O-1
APPENDIX P.
DEVELOPMENT OF MEDICAL ELEMENT TACTICAL
STANDING OPERATING PROCEDURES
P-1
P-1.
General
P-1
P-2.
Purpose of the Tactical Standing Operating Procedure
P-1
P-3.
Format for the Tactical Standing Operating Procedure
P-2
P-4.
Orientation of Newly Assigned Personnel
P-3
P-5.
Tactical Standing Operating Procedure (Sections)
P-4
P-6.
Tactical Standing Operating Procedure (Annexes)
P-5
GLOSSARY
Glossary-1
REFERENCES
References-1
INDEX
Index-1
vi
FM 8-42
PREFACE
This field manual (FM) establishes the combat health support (CHS) doctrine and provides the
principles for providing CHS in stability operations and support operations. It is designed for use by
personnel involved in CHS planning for stability operations and support operations and command surgeons (at
all levels of command) and their staffs.
The proponent of this publication is the United States (US) Army Medical Department Center and
School (AMEDDC&S). Send comments and recommendations on Department of the Army (DA) Form
2028 directly to the Commander, AMEDDC&S, ATTN: MCCS-FCD-L, 1400 East Grayson Street,
Fort Sam Houston, Texas 78234-6175.
Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively to
men.
Use of trade or brand names in this publication is for illustrative purposes only and does not imply
endorsement by the Department of Defense (DOD).
vii
FM 8-42
CHAPTER 1
COMBAT HEALTH SUPPORT PERSPECTIVE
1-1.
General
Although the Army’s primary focus is to fight and win our nation’s wars, it is often employed in stability
and support operations. In stability and support operations, the Army executes missions in both peace and
conflict: what combat does occur is limited to the minimum necessary to support the political objectives.
The primary recipients of combat service support (CSS) in stability and support operations are likely to be
civilians (US or foreign), rather than US combat forces as in war. The CHS planner must be capable of
adapting traditional methods of health care delivery, leveraging technology, and establishing new procedures
to meet the challenges presented.
1-2.
Stability and Support Operations
a. Stability and support operations are conducted in the political-military environments of peace
and conflict. In both, the role of the Armed Forces is to aid in the protection and promotion of national
objectives without resort to war. Conflict is distinguished from peace by the introduction of organized
political violence. Yet, it is a situation that remains amenable to solution by political means with military
support. In peacetime, the Army prepares for war and effects deterrence by its demonstrated capabilities.
In addition, military resources are used in peacetime as a matter of economy in government. Stability and
support operations can include—
• Noncombatant evacuation operations (NEO).
• Foreign humanitarian assistance and disaster relief.
• Combatting terrorism (counterterrorism and antiterrorism [Appendix A]).
• Nation assistance.
• Security assistance.
• Support to counterdrug operations.
• Support to counterinsurgencies.
• Arms control and disarmament.
• Domestic support operations, to include domestic humanitarian assistance and emergency
services.
• Peace operations.
• Support to insurgencies.
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FM 8-42
• Shows of force and demonstrations.
• Strikes and raids.
b. In stability and support operations, the provision of CHS and health education plays a more
direct role in countering both the medical and general threats. Combat health support in stability and
support operations can be defined as those actions encompassing all military health-related activities taken
or programs established to further US national goals, objectives, and missions. These actions and programs
may differ to some degree from the traditional CHS role (delivery of quality health care) of the Army
Medical Department (AMEDD) in war. For example, these CHS operations can play a significant and
proactive role in nation assistance by—
• Assisting with the development and refinement of the host-nation
(HN) medical
infrastructure.
• Providing and maintaining the basic necessities of life for the general population through
HN civilian medical programs.
• Providing assistance in establishing, repairing, or improving basic health and sanitation
services.
1-3.
Principles
a. The principles of war apply in stability and support operations, although they may require
adaptation to meet the challenges presented (refer to FM 100-5 for an in-depth discussion of these principles).
A number of principles that guide actions within the stability and support operations arena are also well
established. These principles are—
(1) Objective. The CHS commander directs every CHS operation towards a clearly defined,
decisive, and attainable objective. The military effort must be integrated with the total effort in achieving
the strategic aims and culminating in the desired end state. The CHS commander must—
• Understand the strategic, operational, and tactical aims.
• Set appropriate objectives.
• Execute the CHS mission.
(2) Unity of effort. The CHS commander must seek unity of effort toward every objective.
In stability and support operations, the problems requiring military action are so complex and of such
magnitude that no single agency can overcome them. Further, it is important that the participating agencies
(Appendix B) work toward the same purposes. The unified efforts of all participants are required. Planning
must address the military contribution to stability and support operational initiatives that are political,
economical, psychological, and military in nature. The other participants may include—
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FM 8-42
• Other Services.
• United States governmental agencies.
• Allies.
• Coalition partners.
• Host nation.
• Nongovernmental organizations (NGOs).
• Private volunteer organizations (PVOs).
• Religious groups.
(3) Legitimacy.
(a) Legitimacy involves sustaining the people’s willingness to accept the right of the
government to govern or of a group or agency to make and carry out decisions.
(For example, in
counterinsurgency operations, CHS programs and initiatives must not undermine the confidence people
have in their nation’s government. Combat health support operations must compliment, not detract from,
the legitimate authority of a HN government.)
(b) United States military forces are also concerned with the legitimacy issue when
involved with foreign intervention. Combat health support, due to its acceptance by the civilian population,
can assist in mitigating the adverse impact that other US military interventions may cause in the region.
(4) Perseverance. In stability and support operations, strategic goals may be accomplished
by long-term involvement, plans, and programs. Short-duration operations will occur, but these operations
must also be viewed as to their impact on the long-term strategic goals. Therefore, the CHS planner must
prepare for the measured, protracted application of the military CHS capability to support the strategic
goals and work toward the desired end state.
(5) Restraint. Stability and support operations place constraints on the potential actions that
can be accomplished and the rules of engagement (ROE) governing these actions. Imprudent action outside
the ROE may, in fact, have a detrimental effect on the attainment of strategic goals and objectives. All
forces participating in stability and support operations, therefore, must incorporate restraint and adherence
to established laws, regulations, policies, and norms to ensure the furtherance of the military objectives.
(6) Security. The security of US forces abroad is paramount. Commanders and planners
must be aware of the ever-present danger that can exist from various groups, factions, or other governments.
Commanders must continually perform risk assessments to ensure the safety of all operations (Appendix C).
Even in a peacetime environment, US military forces can be targeted for terrorist activities. The commander
must ensure that his forces remain vigilant, implement active and passive security measures, and can
1-3
FM 8-42
transition from a peacetime operation to a combat response, if required.
(For example, CHS planners must
ensure the capability exists to transition from humanitarian activities to the traditional support of conventional
forces engaged in combat.) Further, CHS personnel must be prepared to defend themselves and their
patients should the need arise.
b. Especially in stability and support operations, the political arena within which missions are to
be accomplished is of considerable importance. As in all military operations, political objectives drive
decisions at the strategic level. While the individual operator need not be driven by political motives,
it is important for the leadership to recognize the importance of political objectives in planning and
executing the mission.
1-4.
Logistics Preparation of the Theater
a. Logistics preparation of the theater is a systematic approach for planning for the logistics
(force structure, resources, and strategic lift) needed to support the commander’s plan. This process
focuses on identifying the resources currently available in the theater of operations (TO) for use by friendly
forces and ensuring access to them. These planning actions include—
• Identifying and preparing bases of operations.
• Selecting and improving lines of communications (LOC).
• Projecting and preparing forward logistics bases.
• Forecasting and building operational stock assets forward and afloat (FM 100-17-1).
b. This process is essential to ensure that sufficient CHS resources are allocated and correctly
distributed within the TO. In stability and support operations, where brigade-sized or smaller
organizations may enter the TO first, the only logistics available to them may be what they bring with
them. In the CHS arena, contracting for HN support may not be possible as quality assurance standards
are stringently enforced. Further, our medical equipment and repair parts may be beyond the technology
available in the HN.
c.
Stability and support operational missions will be joint or multinational (Appendix D) in
nature. The CHS planner must include the availability of resources of the other Services, the HN, and other
participating nations, agencies, and organizations within the TO. This ensures that the employment of the
resources available are maximized and that a duplication of services does not occur.
1-5.
Medical Threat Assessment
a. A critical element of the CHS assessment is a thorough appraisal of the medical threat. This
assessment includes the medical threat to the deploying forces and to the residents in the area of operations
(AO). The US soldier is placed at more risk in stability and support operational scenarios as the incidence
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FM 8-42
and exposure to infectious diseases and environmental hazards are greater in man-made or natural disaster
areas and in developing nations. The medical threat is derived through established intelligence channels and
from a variety of informational sources outside the military.
b. The ability to obtain, interpret, and use medical intelligence is critical to the success of the
CHS mission. Regardless of whether the operation is conducted within the US or abroad, man-made and
natural disasters can cause a resurgence of diseases once thought to be at low epidemiological levels and
may also result in environmental contamination. A combination of factors can result in the spread of
communicable diseases in epidemic proportions and increased opportunity for exposure to nuclear, biological
or chemical (NBC) hazards. These factors are—
• Disruption of sanitation services (such as garbage disposal or sewer systems).
• Contamination of food and water.
• Development of new breeding grounds for rodents and arthropods (such as in rubble or
in stagnant pools of water).
• Disruption of industrial operations.
• Dispersion of biological or radiological waste by improper handling or terrorist activity.
(1) Medical intelligence is the product resulting from the collection, evaluation, analysis,
integration, and interpretation of all available general health and bioscientific information. Medical
intelligence is concerned with one or more of the medical aspects of foreign nations or the AO and which is
significant to CHS (Appendix E) or general military planning. Until medical information is processed, it is
not considered to be medical intelligence. Medical information pertaining to foreign nations is processed by
the Armed Forces Medical Intelligence Center (AFMIC). Medical threat information in AOs within the US
can be obtained from—
• The United States Army Medical Command (USAMEDCOM).
• United States Army Medical Department medical centers (MEDCENs) and medical
department activities (MEDDACs) within the immediate area.
• The United States Civil Affairs (CA) and Psychological Operations Command.
• Local public health officials.
• The American Public Health Association (FM 8-33).
• The Centers for Disease Control.
(2) The special training of preventive medicine (PVNTMED) personnel, as well as other
medical professionals, is used to provide a clear assessment of the medical threat. Preventive medicine
personnel are specifically trained and equipped to collect, analyze, and interpret health information. When
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FM 8-42
the assessment includes oral, dental, or maxillofacial considerations, the dental public health officer has
similar specialized training in his field. The veterinary PVNTMED officer can provide expertise in the
public health ramifications of zoonotic diseases and biological warfare (BW) and chemical warfare (CW)
agents. These personnel can make recommendations for types of activities to be accomplished and their
priority for support. Using these skills maximizes the efficient use of limited CHS resources. For
consultation purposes during the assessment, the medical personnel conducting the assessment should have
free access to all medical professionals within the CHS force and the local medical community.
c.
Combat health support planners must acquaint themselves with the currently existing
intelligence products. These products include national-level intelligence products such as the Medical
Capabilities Studies and Disease Occurrence Worldwide. These reports are specifically produced to support
US military CHS operations conducted outside the continental United States (OCONUS). These reports can
be obtained through operational and medical intelligence channels
(such as the medical brigade S2
[Intelligence Officer, US Army] or the corps surgeon’s office).
(Refer to FM 8-10-8 for specific information.)
d. As CHS plans (Appendix F) and operations progress, the requirements for additional medical
intelligence will occur. All such requirements should be requested through intelligence channels as soon as
they are validated; when required, coordination should be effected with local agencies.
e.
In OCONUS operations, the CHS planner must make himself aware of the medical threat
posed by the disaster (such as continued flooding, earthquakes and aftershocks, or further explosions) and
groups, factions, opponents, terrorists, or enemy forces operating within the AO. This threat also includes
the potential use and capabilities of weapons systems and munitions, such as NBC (Appendix G), directed-
energy (DE) weapons or devices, or conventional armaments, and the potential for terrorist attacks or
incidents, including the use of CW and BW agents without weapons delivery systems. Combat health
support planning and force survivability necessitate that CHS units remain abreast of the complete
intelligence picture.
f.
The medical threat includes the stress threat. The stress threat encompasses all stressors in the
environment that are likely to threaten the mission and the soldier’s current and future well-being. The
stress threat can result in—
• Misconduct stress behaviors.
• Post-traumatic stress disorder.
• Battle (conflict) fatigue (BF).
• Neuropsychiatric (NP) disorders, including organic mental disorders.
g. Should CHS personnel gain information of potential medical intelligence value while in
the performance of their duties, they are required to report it to their supporting intelligence element
(FM 8-10-8).
h. For additional information on infectious diseases and their prevalence, refer to FM 8-33.
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FM 8-42
i.
For additional information on the medical threat and intelligence preparation of the battlefield,
refer to FM 8-10-8 and FM 8-55.
1-6.
Foundations for Combat Health Support Programs
a. The cornerstones of CHS in stability and support operations are determined by the specific
mission but can include—
• Planning for and providing direct health services to US, allied, coalition, and HN military
forces and, when authorized, US government employees, civilian contractors, and United Nations (UN)
personnel.
• Planning for and providing PVNTMED and veterinary services to HN and civilian
populations.
• Providing humanitarian care and assistance to disaster victims.
• Enhancing readiness by real-time, hands-on training.
(This training is conducted in an
unfamiliar venue, involving diseases not normally widespread in the US or which are normally at low
epidemiological levels. These missions are conducted in varying public health conditions.)
• Promoting and enhancing the growth potential of a HN medical infrastructure.
• Planning for and developing programs which provide direct patient care support for both
HN military and civilian populations.
• Planning for and providing health education and CHS training for HN or US-backed
military or paramilitary forces.
• Providing traditional CHS to conventional and unconventional forces to ensure the rapid
return to duty (RTD) of trained manpower.
b. The CHS commanders and planners must exercise flexibility and initiative to enhance the
potential for success of the CHS mission and to further national strategies.
c.
Although the missions assigned to medical units may be classified under general activities
(such as disaster relief, support for counterinsurgency operations, or support to counterdrug operations),
each will be unique to its specific situation. The unique setting for each stability and support operational
mission is dependent upon—
• Type of operation.
• Level of hostilities.
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• Duration of the operation.
• Rules of engagement.
• Political climate.
• Economic status.
• Cultural influences and biases.
• Religious preferences.
• Other socioeconomic considerations.
Combat health support commanders and planners must recognize these influences, determine their
significance, and incorporate them into the planning and decision-making process.
1-7.
Command Surgeon
a. The command surgeon is instrumental in planning, developing, and implementing CHS
programs. Due to the necessity to task organize the forces employed in stability and support operations and
established troop ceilings for operations, the number of medical personnel employed may be limited. In
many cases, the CHS commander is dual-hatted as the command surgeon.
b. The duties and responsibilities of the command surgeon include—
• Determining requirements and providing oversight for—
•
Requisition, procurement, storage, maintenance, distribution management, and
documentation of combat health logistics (CHL), to include blood management.
•
Combat health support personnel.
•
Financial management of resources allocated and expended.
• Planning and coordinating transportation requirements in excess of organic capability.
• Planning and coordinating with the CHS commanders, task force (TF) commanders, or
other elements, units, or agencies for continuous CHS.
• Submitting to higher headquarters those recommendations on professional medical
problems that require research and development.
(In developing nations, this responsibility takes on added
significance as unfamiliar diseases may be encountered.)
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• Recommending uses of captured (or abandoned) Class VIII or locally available medical
supplies in support of detainees, enemy prisoners of war (EPW), HN personnel, and other recipients.
• Advising on the—
•
Health of the command.
•
Combat health support resources available within the AO.
•
Medical effects of the environment and of NBC or DE weapons systems and
devices on personnel, Class VIII materiel, rations, and water.
•
Medical intelligence requirements.
• Planning and coordinating (internally and externally) the following CHS operations:
•
Medical evacuation by US Air Force (USAF) or US Navy (USN) resources or
resources from the civilian community, HN, allies, or coalition partners.
•
Medical treatment to include hospitalization in medical treatment facilities (MTFs)
established by the other Services, allies, coalition forces, or HN.
(This includes MTFs afloat.)
•
Dental services.
(The senior dental officer assigned serves as the command dental
surgeon for the purpose of coordinating dental activities for the command surgeon.)
•
Veterinary food inspection, animal care, veterinary PVNTMED activities of the
command, and civic assistance programs within the local community.
•
Preventive medicine services.
•
Nursing services.
•
Medical laboratory services.
•
Humanitarian assistance and disaster relief programs.
•
Mental health (MH) and combat stress control (CSC) programs.
•
Rehabilitation support.
•
Nutrition care services.
•
Combat health support aspects of rear area protection.
•
Recommendations on the assignment and/or attachment of medical units and/or
personnel.
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•
Combat health support assessments, estimates, and plans.
1-8.
Command Surgeon’s Role
The command surgeon’s role includes the duties and responsibilities specified in paragraph 1-7. The
elements of assessing, problem solving, planning, and coordinating programs takes on an added significance
in stability and support operations.
a. Assessing.
(1) Combat health support assessments must be carefully and comprehensively completed.
They need to include such areas as—
• Health status of population groups (such as disaster victims or HN’s military).
• Potential medical threat under various operational scenarios.
• Availability of CHS resources from all sources.
(2) In operations conducted OCONUS, US assistance should only be provided when all
resources of the requesting state are exhausted or overwhelmed.
(3) Current and timely medical intelligence and information (paragraph 1-5) is an important
aspect in preparing a comprehensive CHS assessment (Appendix E).
(4) Updated assessments should be maintained on each specific country or geographical area
within the commander’s AO.
b. Problem Solving. Due to the uniqueness of the stability and support operational missions,
planning for potential scenarios requires initiative, flexibility, versatility, and improvisation to successfully
complete established missions. As CHS planners, command surgeons must not become inflexible in their
thinking or rely solely on the traditional methods of CHS delivery. Combat health support planners must
explore all potential alternative courses of action
(COAs). They must also be prepared to deal with
unanticipated occurrences. As CHS resources are scarce, the CHS planner must maximize their effective
use to ensure adequate health care regardless of the scenario.
c.
Planning.
(1) Involvement early in the planning process and inclusion on the advance party assists in
ensuring that—
• Adequate CHS assets are available.
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• Requirements that cannot be met by the available CHS resources are identified and
action is taken to correct the deficiencies noted.
• An accurate assessment of the medical threat is made and measures to counter this
threat are implemented.
(2) Stability and support operations require coordinated actions with other US and foreign
military forces and both private and public civilian agencies.
d. Coordinating.
(1) The conduct of CHS in stability and support operations requires thorough coordination
prior to implementation. This coordination ensures that—
• Duplication of services and/or missions does not occur.
• The mission is executed properly.
• Interoperability exists between the Services and other participating agencies/nations
in areas such as communications.
• Adequate CSS resources are allocated for the mission. This includes all classes of
supply and the means to resupply the operation.
• Scarce resources are used effectively and efficiently.
• Operations security (OPSEC) is not compromised.
(2) In stability and support operations, coordination is not limited only to the military forces
operating within the AO, but extends to all other participants.
(3) Thorough coordination during the planning process ensures that the final plan—
• Contributes to the accomplishment of the desired end state.
• Satisfies the requirements of the civil authorities or the HN.
• Can be accomplished with the resources available.
• Provides a favorable climate for the acceptance of the government program by the
targeted population.
• Does not bypass or discourage the full application of all local or HN resources to
the situation.
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1-9.
Army Medical Department Battlefield Rules
a. The AMEDD Battlefield Rules define the focus of the CHS system in both war and stability
and support operations. These Battlefield Rules in order of precedence are to—
• Maintain a presence with the soldier (being there).
• Maintain the health of the command.
• Save lives.
• Clear the battlefield.
• Provide state-of-the-art care.
• Ensure the early RTD of sick, injured, or wounded soldiers.
b. In stability and support operations, PVNTMED plays an important role in the focus of health
care delivery, as the major cause of soldier noneffectiveness in this environment is disease and nonbattle
injuries (DNBI). In many situations, CHS personnel will arrive in the AO before combat and combat
support (CS) troops. Effective measures to counter the medical threat will reduce the number of soldiers
who become ill from endemic diseases (morbidity and mortality rates) and will enhance the ability to rapidly
return soldiers to duty once stricken by disease. Combat stress control will also reduce DNBI and stress
casualties and promote mission effectiveness. During conflicts and contingency operations, wounded
soldiers are quickly evacuated from the battlefield to established MTFs within the AO, or provided
evacuation to the continental United States (CONUS) or another designated support base. During Operation
Just Cause, wounded soldiers were stabilized at MTFs established at the airfield and immediately evacuated
to Brooke Army Medical Center and Wilford Hall Medical Center in San Antonio, Texas, for definitive and
restorative care. The care provided our forces is as sophisticated as possible in the immediate AO with
comprehensive and definitive care available in the support base. Rapid medical evacuation with the
provision of en route medical care enables the patient to be cared for during evacuation to the destination
MTF.
1-10. The Law of Land Warfare
a. The conduct of armed hostilities on land is regulated by the Law of Land Warfare. This body
of law is inspired by the desire to diminish the evils of war by—
• Protecting both combatants and noncombatants from unnecessary suffering.
• Safeguarding certain fundamental human rights of persons who fall into the hands of the
enemy, particularly prisoners of war, the wounded and sick, and civilians.
• Facilitating the restoration of peace.
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b. The law of war is derived from two principal sources—
(1) Treaties (or conventions) such as the Hague and Geneva Conventions.
(2) Customs which are practices that by common consent and long-established uniform
adherence have taken on the force of law.
c.
Under the US Constitution, treaties constitute part of the Supreme Law of the Land, and thus
must be observed by both military and civilian personnel. The unwritten or customary law of war is also
part of the law of the US. It is binding upon the US, citizens of the US, and other persons serving this
country.
d. Combat health support commanders must ensure that they operate within the confines of the
Law of Land Warfare. Additionally, in stability and support operations, questions concerning eligibility of
beneficiaries, sources of funding, ROE, and other legal issues will be encountered. Combat health support
commanders must ensure that they receive adequate and timely legal advice prior to implementing programs
or executing missions. Due to the increased visibility to the news media that these operations attract, CHS
commanders must also ensure their actions do not provide an impression of impropriety in the execution of
their duties.
e.
For additional information on the Law of Land Warfare, refer to FM 27-10.
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CHAPTER 2
COMBAT HEALTH SUPPORT OPERATIONS
2-1.
General
a. Combat health support provides the capability to prevent DNBI and to collect, triage, treat,
and evacuate or RTD sick, injured, or wounded soldiers. The AMEDD objective of conserving the fighting
strength faces one of its greatest challenges in stability and support operations. This chapter discusses many
of the aspects of providing traditional CHS and the factors that influence its delivery in stability and support
operational scenarios.
b. Each stability and support operational mission is unique to the geographical area, the mix of
forces, and the objectives of the operation. Due to this fact, the CHS planner must—
• Be included early in the mission planning process.
• Remain flexible to accommodate last minute requirements.
• Remain receptive to new and innovative methods of providing the required support.
• Ensure that thorough coordination is accomplished on all aspects of the operation.
2-2.
Planning and Preparing for Contingency Operations
a. In stability and support operations, many of the missions assigned to US Army forces will be
received as short-notice deployments. The advance preparation time will be limited. Further, due to the
sensitivity or the OPSEC level of the operation, the number of individuals engaged in the planning process
may also be restricted. It is, therefore, necessary for the CHS commander to ensure that his unit is admin-
istratively ready for a short-notice deployment (Appendix H). He can accomplish this by ensuring that—
• Unit personnel have all required immunizations; that the dental status of the command is
monitored; and that any personnel actions stemming from medical conditions (such as military occupation
specialty [MOS] reclassification based on physical profile) are expeditiously processed.
• Based on operation plans (OPLANs) and contingency plans, special clothing, equipment,
or supplies required for the AO are on hand and in a serviceable condition. For example, if the potential
AO is in mountainous terrain, equipment such as pitons, piton hammers, and extra ropes may be required.
Depending upon the climate, additional heavy clothing (winter parkas) may be needed to operate at high
altitudes. Other supplies and equipment that might be required include sunscreen and sunglasses to combat
the effects of bright sunlight. On the other hand, operations in tropical jungles require items such as
lightweight jungle fatigues, arthropod netting, insect repellent, and aerosol insecticides, as well as sunscreen
and sunglasses.
• Updated medical intelligence on the medical threat in the proposed AO is maintained.
This information is vital to ensure that the appropriate immunizations are provided; that any
chemoprophylaxis that may be required (such as for malaria) is on hand or obtainable on short notice; and
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that effective PVNTMED measures (PMM) are planned for and implemented to counter the specific
medical threat. For example, in Operation Urgent Fury, US forces were not familiar with the vegetation
indigenous to the area. Some troops began to present with large blisters on their bodies after conducting
sweeps of jungle areas and underbrush. This condition initially led to speculation that a CW agent which
burned and blistered the skin and damaged the respiratory system might be in use in the AO. The cause of
the blistering was determined to be, however, the sap of the manchineel tree. Had the troops been
forewarned of the effect of the sap, they would have been better able to protect themselves against injury.
• Soldier stress related to family issues can be reduced by integrating unit families into an
active family support group network and by briefing families on the unit mission if OPSEC permits. To
enhance readiness, family care plans should be kept up to date.
• Since operations in stability and support operations will normally be joint or combined in
nature, it is important that CHS personnel be familiar with the other Services’ equipment and procedures.
Early and continuous coordination among command surgeons will facilitate this process. For example, if
the USAF is providing all of the medical evacuation support or if the USN is providing Echelon III
hospitalization afloat, the US Army personnel participating should know how to load and unload patients on
the other Services aircraft and ships. During Operation Urgent Fury, problems were experienced with
communications between US Army air ambulances and a USN hospital ship. Also, many medical evacuation
pilots did not have the appropriate deck-landing certification required to land on a ship. These situations
presented difficulties which could easily have been avoided with the proper coordination and familiarization
training.
b. To enhance mission success, planning must be thorough, and the plan must be rehearsed. A
rehearsal is the process of practicing a plan before its actual execution. Rehearsing key actions allows
participants to become familiar with the operation and to visualize the plan. Rehearsals take on an added
importance in stability and support operations to ensure synchronization and interoperability among the
various participants.
c.
A rapid response capability is often needed to mobilize assets to assess what support is
required in the event of a disaster or other serious incident. The USAMEDCOM has developed specialty
response teams (SRTs) within their table of distribution and allowances (TDA) organization. Refer to
Appendix I for further information.
2-3.
Task Organization of Elements
a. Forces used for providing CHS to contingency operations will often be task-organized to
accomplish the mission. In a mature theater, there are four echelons of medical care. Each echelon of care
incorporates the capabilities of the lower echelon plus enhancing and expanding on that care. Echelon I
care is provided by the combat medic (assisted by the administration of first aid by nonmedical soldiers
[self-aid, buddy aid, and combat lifesaver]) and the battalion aid station (BAS). The care provided consists
of emergency medical treatment (EMT), advanced trauma management (ATM), and those procedures
necessary to stabilize a patient for further evacuation
(to include early surgical intervention for
nontransportable patients) or to return the soldier to duty. Echelon II care is provided by the forward
support medical company (FSMC), the main support medical company (MSMC), the area support medical
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company (ASMC), and the medical companies/troops of separate brigades and armored cavalry regiments.
This echelon of care has a 72-hour holding capability for those patients who can RTD within that time.
Echelon II can be augmented by the forward surgical team (FST) to provide surgical intervention within the
division area. The theater hospitalization system (Medical Force 2000) is encompassed by Echelon III
(combat support hospital [CSH]) and Echelon IV (field hospital [FH] and general hospital [GH]). Under the
medical reengineering initiative (MRI) there will be only one hospital in corps and echelons above corps.
(For an in-depth discussion of the echelons of medical care, refer to FM 8-10.)
b. In stability and support operations, this full array of medical units may not be in place to
provide the required care and to perform the administrative support needed to coordinate patient evacuation,
care, and treatment.
c.
There is no specific table of organization and equipment (TOE) medical unit which is designed
to solely operate in stability and support operations. Rather, during the planning process, it is determined
what CHS assets will be required to support the operation. This support is then task-organized from
existing units designated to provide CHS for the operation. This type of tailoring of the CHS package for
the support of the mission necessitates the early involvement of the CHS planner. If the CHS planner is not
included early in the process, the required support may not be tailored to maximize the effective use of
limited CHS resources.
2-4.
Medical Evacuation Support
a. Evacuation Policy. With a force projection Army the evacuation policy for the AO may only
be a matter of hours or days. Soldiers who are wounded, injured, or ill and who cannot be rapidly returned
to duty are evacuated to MTFs in a support base outside of the AO or to CONUS. The CHS planners
should determine what the evacuation policy will be, and in cases where it is compressed, build the
necessary evacuation platforms into the plan. An adequate treatment capability must also be included in the
plan to ensure that patients are sufficiently stabilized to withstand the evacuation. The evacuation policy in
stability and support operations may be governed by such factors as the—
• Short duration of the operation.
• Inadvisability of building a large military base structure in the AO where the US presence
is intended to display a low profile.
• Troop ceiling established for the operation.
• Anticipated patient work load.
• Anticipated level of hostilities.
• Availability of HN support.
b. Coordination. In the mature theater, medical evacuation support is provided by the echelon of
care to which the patient is being evacuated. In stability and support operations, medical evacuation support
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may not follow the traditional patient flow means (FM 8-10-6). It may also require a longer lead time for
coordination of issues, such as—
• Using civilian controlled air space.
• Crossing national borders.
• Obtaining route approval.
c.
United States Air Force Support. A task-organized Echelon II medical unit may be required to
coordinate for medical evacuation and medical regulating support directly with the USAF.
(In the mature
theater, this is normally accomplished by Echelons III and IV MTFs, and the medical brigade, or command
medical regulating offices [MROs], Theater Patient Movement Requirements Center [TPMRC], and USAF
liaison elements.) The administrative burden for preparation of the required forms for entering the patient
into the USAF patient evacuation system is the responsibility of the originating medical facility (OMF)
which, in this case, is the Echelon II MTF. The preparation of Department of Defense (DD) Form 600,
Patient Baggage Tag, DD Form 601, Patient Evacuation Manifest, and DD Form 602, Patient Evacuation
Tag, is normally not done at this echelon, nor does the unit routinely stock these forms. It is, therefore,
important for the CHS commander to anticipate this requirement. The unit should have the necessary forms
on hand and should have conducted training on their preparation, if required.
(For information on the
completion of these forms, refer to FM 8-10-6.)
d. United States Navy Support. The USN may also provide medical evacuation, treatment, and
hospitalization support during the operation. The CHS commander must ensure that coordination on
communications requirements and capabilities and the availability of services is accomplished. Without
affecting the required coordination, it may not be possible for US Army elements to communicate effectively
with the USN element providing the support.
e.
Evacuation Responsibility. Depending on the scenario and resources available, the doctrinal
method of the higher echelon of care evacuating patients from the lower echelon may not be possible. The
CHS planner must ensure that the medical evacuation support planned is sufficiently flexible to adapt to the
realities of the situation. For example, depending upon the CHS resources deployed, air ambulance assets
may have to be attached to an Echelon II MTF. To ensure adequate support can be obtained and to sustain
the air ambulances, coordination for fuel, aviation maintenance (both unit and intermediate), and Army
airspace command and control (A2C2) must be accomplished. Additionally, the CHS commander will need
to familiarize himself with requirements for crew endurance, aircrew training programs, aircraft capabilities,
and flight surgeon support. The stated evacuation policy for the operation will influence the task organization
for the mission. It will also dictate the number of evacuation platforms required to perform the mission
efficiently. A short evacuation policy requires that the number of air and ground ambulances, as well as
USAF aeromedical evacuation resources, be increased for the mission.
2-5.
Patient Treatment, Stabilization, and Holding
During the initial phase of the operation, medical evacuation support may not be available. The CHS
commander must include in his planning the possibility that he may be required to hold seriously injured or
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wounded patients for a number of hours or perhaps even days. Faced with this requirement, the CHS
commander may have to include a task-organized surgical capability to stabilize these patients sufficiently to
withstand the delay in evacuation or he may be required to increase his capability to hold, treat, and care for
patients. During this period, the only evacuation means may be by vehicles/aircraft of opportunity. If this
situation is planned for, the CHS commander may be able to provide en route medical care for the most
seriously injured on these backhaul missions.
2-6.
Preventive Medicine
Disease and nonbattle injuries have in past wars exceeded the number of soldiers who were wounded in
action (WIA). This is especially true in stability and support operations. The combined effects of endemic
and epidemic diseases, soldiers not acclimatized to the environmental conditions, poor sanitation, increased
exposure to disease vectors and environmental contamination, and foodborne and waterborne diseases may
have a catastrophic effect on mission accomplishment. All commanders must be prepared to counter the
medical threat through command emphasis on water discipline programs, physical training, immunization/
chemoprophylaxis, personal hygiene, and field sanitation. Field sanitation teams are the eyes of the
commander; therefore, they must maintain close coordination and must accurately report on any potential
medical threats. The CHS commander must not only be concerned with these activities for his own unit
but also for the command as a whole. He must ensure that he has an aggressive pest management
program and that dining facilities are inspected. He must also ensure that all supported company-sized or
larger units have on hand all authorized unit-level PVNTMED equipment and supplies. For additional
information on PVNTMED issues, refer to Chapter 4 of this manual, Army Regulation (AR) 40-5,
FM 21-10, and FM 21-10-1.
2-7.
Combat Health Logistics
a. In stability and support operations, a medical logistics battalion (forward or rear) may not be
available within the AO. Coordination for Class VIII supply/resupply, medical equipment maintenance,
eyewear fabrication, and blood management takes on an added importance in stability and support operations.
Prior to the operation, the number of days of supply which the in-country CHS organizations will require is
determined. A critical items list of supplies which will be in high demand is also prepared. Pre-configured
push packages must be developed to maintain appropriate stockage levels in-country until CHL elements
enter the theater, become operational, and line order requisitioning procedures can be instituted.
b. When deployed in joint operations, the medical logistics battalion may be designated as the
single integrated medical logistics manager (SIMLM) for the mission.
c.
For additional information on CHL, refer to Chapter 4 of this manual and FM 8-10-9.
2-8.
Veterinary Support
a. Department of Defense Veterinary Support. Department of Defense (DOD) veterinary support
in stability and support operations entails the equitable distribution of veterinary support in the areas of food
safety surveillance and animal health care to all military services.
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FM 8-42
b. Planning Factors. The CHS planner must determine the feeding policy, extent of local food
procurement, type of available food storage facilities, zoonotic disease threat to US forces, and required
health care support for deployed military working dogs (MWD), other government-owned animals, and
military mascots.
c.
Veterinary Support Packages. Veterinary support packages can be tailored to respond to
either food safety surveillance or animal health care missions in the planning process. For additional
information, refer to Chapter 4 of this manual and FM 8-55.
2-9.
Combat Stress Control
Predeployment training on stress identification and control and command emphasis on stress-related issues
will assist in maintaining positive mission focus and in reducing the number of stress casualties and stress-
induced misconduct during an operation. The environments in which many stability and support operations
occur can induce stress through feelings of loneliness, boredom, and alienation due to cultural and language
differences. Some stability and support operations expose soldiers to personal danger, to the injury of other
unit personnel, or to injustices, suffering, or death of innocent people. Changing mission objectives and
ambiguous ROE can add greatly to the stress of the situation. Command emphasis should be placed on
ensuring control measures are implemented by unit commanders and their troop leaders. Where feasible
and within the limits of the troop ceiling, the CHS plan should provide a 1- to 3-day medical holding
capability for acute stress casualties. This facility can be austere. For additional information, refer to
Chapter 4, and to FM 8-51 and FM 22-51.
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FM 8-42
CHAPTER 3
COMBAT HEALTH SUPPORT TO
STABILITY OPERATIONS AND SUPPORT OPERATIONS
3-1.
General
Commanders are used to thinking about changes in the direction and depth of the battle and adjusting battle
plans to achieve objectives. Stability and support operations require attention to factors which may be
absent in war. The political dimension lies at the core of stability and support operations. The objective of
these operations is to support a political resolution of problems affecting US national interests.
3-2.
Noncombatant Evacuation Operations
a. Noncombatant evacuation operations are conducted to evacuate civilian noncombatants and
nonessential military personnel from locations in a foreign (host) nation during time of endangerment to a
designated safe haven. These operations are normally conducted to evacuate US citizens whose lives are in
danger from a hostile environment or natural disaster. They may also include the evacuation of US military
personnel and dependents, selected citizens of a HN, or third country nationals. These operations are of
short duration and consist of rapidly inserting a force, occupying an objective, and withdrawing as planned.
The amount of force used is normally limited to that required for self-defense and the defense of the
operation. The level of hostilities encountered varies with each specific mission. The key factor in
planning for this type of operation is the correct appraisal of the politico-military environment in which the
operation is to be conducted.
b. Combat health support to NEO is tailored to the size of the military force and the anticipated
health needs of the evacuees. Every effort is made to use the existing medical skills of the evacuees.
c.
The CHS planner must be included in the mission planning as medical considerations and
factors may influence the success of the mission. For example, seriously ill or injured evacuees may not be
transportable until medically stabilized. Combat health support planning factors include—
• Assessment of the medical threat.
• Anticipated duration of the operation.
• Size of the force.
• Anticipated number of evacuees.
• Anticipated level of hostilities to be encountered.
• Medical requirements for both the force and the evacuees (including the location for
hospitalization, stress control support, medical equipment and supplies, and the rapid medical evacuation of
those seriously injured or ill).
• Potential for transferring diseases back to the US.
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• Evacuation or disposition of privately owned pets and government-owned animals.
• Potential sources of food supplies and water.
• Security provisions for patients and medical personnel.
3-3.
Domestic Support Operations
Traditionally, the US Army has been called upon to assist federal, state, and local governments in times of
need. There are four basic categories of domestic support activities (or support to domestic civil authorities)
which may be provided. These are disaster assistance, community assistance, environmental assistance,
and law enforcement support.
(For additional information on domestic support operations, refer to FM
100-19 and the Federal Response Plan [FRP] for Public Law [PL] 93-288, as amended.)
a. Disaster Assistance. The Federal Emergency Management Agency (FEMA) is the federal
government’s executive agent for implementing federal assistance during disaster relief operations.
(1) Disaster assistance includes those humanitarian and civil defense activities, functions,
and missions in which the Army has legal authority to act. The Army provides disaster assistance to states,
the District of Columbia, territories, and possessions. Assistance is based upon requests from civil authorities
and usually as a result of natural or man-made disasters such as hurricanes, typhoons, earthquakes, or
massive explosions. The US Army is the lead agency for urban search and rescue under the provisions of
PL 93-288. The Emergency Support Function (ESF) #8 is the Health and Medical Services Annex of the
FRP. The purpose of this function is to provide US government assistance to supplement state and local
resources in response to public health and medical care needs following a significant natural disaster or
man-made event. Assistance provided under ESF #8 is directed by the Department of Health and Human
Services (DHHS) through its executive agent, the Assistant Secretary for Health, who heads the US Public
Health Service (USPHS). Resources will be furnished when state and local capabilities are overwhelmed
and medical and/or public assistance is requested from the federal government. Emergency Support
Function #8 will be implemented upon the appropriate state-level request for assistance following the
occurrence of a significant natural disaster or man-made event and a determination has been made that a
federal response is warranted.
(2) At the onset of the operation, criteria for eligibility of care (such as disaster victims,
civilian rescue workers, military retirees and families, and/or other individuals in the disaster area) must be
established and disseminated to all supporting units. A determination must also be made as to when this
eligibility ends and the patients once again become the responsibility of the local medical infrastructure.
Further, a determination must be made of what supplies and services are reimbursable and what
governmental agency or organization is responsible for this reimbursement.
(3) Once tasked to provide the support, an assessment of the operational area is required.
This is used to determine the correct mix of CHS resources to be employed and the level of support
required.
(Depending upon the specific situation, this could entail small selected specialty teams or
complete organizations such as a CSH.) For command, control, and coordination, it is important for the
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military headquarters to be established in a location that will facilitate coordination/liaison. Ideally, the
military headquarters can be collocated with the civilian agency in charge of the disaster relief operations.
• The CHS planner must include in his assessment the—
•
Endemic diseases prevalent in the AO (even those considered to be at a low
epidemiological level).
•
State of the public works and services (sanitation [including sewer systems],
water sources, and garbage pickup).
•
Availability of local medical facilities, personnel, and resources and services
being provided by other non-DOD and nongovernment agencies.
•
Numbers of anticipated patients and types and categories of injuries and
diseases expected. Consideration must also be given to the type of equipment available in field medical
equipment sets (MESs) and what types of equipment will be required to augment these sets. Disaster
victims will range in age from newborns to the very old; the type of equipment required for pediatric and
geriatric patients is not contained in the standard MES.
•
Anticipated length of the operation.
• The US Army CHS provided in disaster assistance operations may include—
•
Traditional CHS to the employed US Army forces.
•
Management of mass casualty situations (to include triage, treatment, and
evacuation) (Appendix J).
•
Delivery of direct medical, nursing, and other health care and services to
victims of the disaster.
•
Medical evacuation support out of the immediate disaster area to supporting
area hospitals.
•
Preventive medicine support to temporary camps to reduce rodent and
arthropod breeding grounds; establish sanitation facilities; provide training (education) in field sanitation,
personal hygiene, and PMM; and inspect water supplies (to include ice).
•
Veterinary support for livestock, pets, and/or wild animals that are injured or
dislocated and for the inspection of food stuffs for wholesomeness and quality.
•
Combat health logistics support to replenish exhausted medical supplies and
equipment and management, storage, and distribution of donated medical supplies and equipment.
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•
Mental health support to victims and caregivers.
•
Dental support on an emergency basis and for maxillofacial injuries.
•
Occupational therapy (OT) and physical therapy (PT) to provide preventive
and restorative care support.
•
Nutrition care and dietetics counseling and education.
• The CHS requirements can be met in a number of different ways depending upon
the specific situation, such as—
•
Military medical personnel may be used to assist in staffing local facilities.
•
A military field hospital (such as a CSH) could be deployed to the disaster area.
•
Medical evacuation assets could be used to move patients from the immediate
disaster area to a MEDDAC or MEDCEN, or a civilian hospital in the surrounding area for further care.
•
The National Disaster Medical System (NDMS) could be activated.
(The
NDMS is a nationwide medical mutual aid network between federal and non-federal sectors that includes
medical response, patient evacuation, and definitive medical care.)
(4) A communications capability between military participants and civilian agencies must be
established. Ambulances must have a long-range communications capability compatible with their civilian
counterparts in order to coordinate with hospitals and rescue/emergency vehicles. Units deploying for
operations in disaster areas should have all authorized communications equipment on hand. If equipment is
not compatible with the civilian counterparts, arrangements must be made to establish a liaison/messenger
system or additional equipment must be borrowed or procured.
(5) Refer to Appendix K for additional information on disaster assistance operations.
b. Community Assistance. Community assistance operations are the most frequently conducted
domestic support operations. These operations use Army resources to support civilian organizations which
promote the general welfare of the community. These missions and operations include public works,
education, and training. Additionally, mutual support agreements concerning medical, police, or emergency
services may be established with local communities in compliance with existing regulations and directives.
The AMEDD has provided assistance to local communities such as—
• Rescue and evacuation through the Military Assistance to Safety and Traffic (MAST)
Program. This program uses US Army air ambulances to evacuate severely injured civilians from the place
of the incident (automobile accident or job site injury) to an appropriate hospital.
• Rescue of stranded civilians in times of floods, wild fires, or other life-threatening
disasters.
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• Use of a MEDDAC or MEDCEN as a trauma center for serious injuries when the
capability does not exist in the adjacent civilian community, or if the military hospital is closest to the
accident (once stabilized, patients are further evacuated to a civilian hospital).
• Use of the US Army Institute of Surgical Research Burn Center for severely burned
civilians when other burn care facilities are not available.
• Participation in community health care programs such as health screening and educational
presentations.
• Provision of immunization and medical screening clinics (in conjunction with state and
local agencies) in rural areas where civilian medical assets are limited.
c.
Environmental Assistance. Environmental assistance operations aid civil authorities in
preserving, protecting, and enhancing the environment. The US Army strategy rests on the four pillars of
compliance, restoration, prevention, and conservation. Compliance includes responding to small-scale
hazardous material spills and regulatory support to other government agencies. Restoration involves
cleaning up contamination from past operations. Prevention is developing and sharing new technologies
that reduce pollution generation. Conservation focuses on the preservation of natural and cultural resources
such as wetlands preservation and fighting wildland fires. Army support in these areas may be initiated
under disaster assistance or may be executed under separate authority. In the face of a substantial
environmental threat, military medical expertise from the US Army Center for Health Promotion and
Preventive Medicine (USACHPPM) may be employed. On a smaller scale, a civilian community
experiencing a small toxic spill may request PVNTMED support from a neighboring installation to assist in
the assessment process.
d. Law Enforcement Support. Operations in support of law enforcement include assistance in
counterdrug operations, assistance for civil disturbances, special security operations, combatting terrorism,
explosive ordnance disposal, or similar activities. Constitutional and statutory restrictions and corresponding
directives and regulations limit the type of support provided. Combat health support will be limited in law
enforcement support activities and will normally follow the traditional role of CHS for deployed forces and
veterinary support for government-owned animals used in these operations.
3-4.
Foreign Humanitarian Assistance
Foreign humanitarian assistance programs relieve or reduce the results of natural or man-made disasters or
other conditions such as human pain, disease, hunger, or deprivation that present a serious threat to life or
result in great property damage or loss. Humanitarian assistance provided by US forces is limited in scope
and duration. It is designed to supplement or complement the efforts of HN civil authorities or agencies that
may have primary responsibility for providing humanitarian assistance. Most foreign humanitarian assistance
is conducted as joint or multinational operations. The most common operations are disaster relief and
refugee programs. (Refer to Appendix L for information on the provisions of Title 10, US Code.)
a. Disaster Relief.
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(1) Disaster relief operations provide emergency assistance to victims of natural or man-
made disasters abroad. These operations are responses to requests for immediate help and rehabilitation
from foreign governments or international agencies. They may include—
• Refugee assistance.
• Food programs.
• Medical treatment and care.
• Other civilian welfare programs.
(2) Combat health support assistance requires a rapid assessment of the health needs produced
by the disaster and the rapid tailoring of a medical element to deal with the disaster or deployment of SRTs,
if required.
• Preventive medicine plays a key role in the relief effort as natural disasters can
disrupt the ecological balance, causing potential outbreaks of disease. Measures to ensure needed sanitation
and pest management must be planned for and implemented as soon as possible after the occurrence.
Organization of educational efforts and other public health measures to help victims resist potential disease
outbreaks are important aspects of PVNTMED support.
• Medical treatment and other health care will most likely have to be provided in
rudimentary facilities.
• The CHS element must be able to quickly reach the disaster site with the right mix
of medical specialties.
• The CHS element should have the capability to interact with victims in their own
language.
• Stress control measures should be applied during and after the operation.
(In some
instances, stress control measures can be introduced to caregivers prior to their deployment to the disaster
site.) These measures are used to maintain effective performance and minimize post-traumatic stress
disorder among caregivers, as well as victims.
b. Refugee Operations. Refugee operations may entail the rescue of individuals fleeing a nation
and the establishment of temporary safe havens to house and care for these people. Combat health support
resources may be required to ensure that—
• Sufficient sanitation facilities are provided.
• Disease surveillance is conducted and disease vectors are controlled.
• Water sources used in the camps are inspected and water is treated, if required, to ensure
potability.
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• Food wholesomeness standards are maintained.
• Primary health care needs of the refugees are met.
3-5.
Security Assistance
a. Through security assistance programs, the US provides defense materiel, military training,
and defense-related services by grant, loan, credit, or cash sales to further its national policies and objectives.
The Security Assistance Training Program has two primary subcomponents:
• International Military Education and Training Program.
• Foreign Military Sales Program.
b. Military CHS resources may not be used in all types of missions; however, they can be
employed to improve health-related quality of life issues. They are also successful in providing effective
training for the participating US Army personnel. This support is given by such means as—
• Providing training and support in PMM.
• Developing military training packages to enhance skills of medical paraprofessionals.
• Participating in the Department of State (DOS) cultural exchange program by exchanging
US and foreign military medical personnel for visits, training, and education.
• Providing CSC training.
c.
The foreign internal defense (FID) augmentation force is a conceptual, composite organization
which augments the Security Assistance Organization (SAO). When constituted, the FID augmentation
force operates under a US unified command or subordinate joint task force (JTF). Its FID mission is to
assist SAOs with training and operational advice, and to provide assistance to HN forces. It employs mobile
training teams (MTTs) and small detachments to fulfill specific mission requests. Ideally, this force should
be specially trained, area-oriented, mostly language qualified, and available for immediate deployment.
Combat health support augmentation to the FID augmentation force can be provided to some extent in all of
the CHS functional areas. Particularly effective in this arena are medical treatment, nursing, PVNTMED,
stress control, dental, and veterinary resources.
3-6.
Nation Assistance
a. Determining the Heath Service Needs of a Host Nation.
(1) In consonance with and under the direction and guidance of the US ambassador, country
team, and applicable laws, the command surgeon takes a proactive role in helping to determine the health
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FM 8-42
service needs of the various countries within his area of responsibility (AOR). Among the many sources of
information are the—
• Host nation.
• Armed Forces Medical Intelligence Center.
• Department of State.
• Defense Attaché.
• United States Army CA units.
• United States Agency for International Development (USAID).
• World Health Organization (WHO).
• Nongovernmental organizations.
• Private volunteer organizations.
• Religious organizations.
(2) Regardless of how the requirement is initially determined, the command surgeon must be
brought into the planning process at the earliest possible time. This ensures that the necessary military CHS
resources are allocated to accomplish the mission.
(3) As one of the goals of using military CHS resources is to enhance the effectiveness of the
HN government in the medical arena, the parameters used to assess the HN health service needs will vary
with each country. Assessment factors include, but are not limited to—
• State of the general health of the population (to include nutrition).
• State of MH, psychiatric, and social support services.
• State of dental health and dental care services.
• Sanitation and personal hygiene.
• Impact of endemic diseases.
• Status of farm animal health and veterinary services available.
• Primary care capabilities, to include rural areas.
• Morbidity and mortality rates.
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FM 8-42
• Developmental stage of the HN health care delivery system.
•
Adequacy of secondary and tertiary hospital facilities.
•
Accessibility of the health care delivery system.
•
Education and training levels of health care professionals and technicians.
•
Adequacy of public health department resources.
• Availability and production capability for prosthetic and orthotic devices.
• Existence of health education and health promotion programs targeted at the general
population.
• Veterinary medical capabilities in government, industry, and private sectors.
• Status of health care resources.
• Education level of the general population.
(4) An assessment checklist is provided in Appendix E and a medical mission reconnaissance
checklist is provided in Appendix M.
b. Health Care Program Development.
(1) In many Third World countries, medical specialties exist, although in limited numbers.
Consultation programs involving specialists to share knowledge and new techniques can be quite effective.
These programs enhance the HN medical personnel’s skills and provide a method of interfacing with their
peers on the latest developments in their field of expertise. This is especially helpful in countries which do
not have established graduate medical education programs.
(2) In order to develop viable and effective health care programs, a long-term commitment
of assistance is required; the quick fix is not a solution for ensuring that adequate health care services will
remain available to the HN civilian and military populations. Further, the quick fix solution may not further
US national goals for enhancing the stability of the HN government.
(3) Combat health support operations conducted to enhance the stability of the HN
government must be well coordinated with all concerned agencies, such as the—
• Host nation itself and its medical organizations and assets.
• Ambassador and the country team.
• Security Assistance Organization.
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FM 8-42
• United States Agency for International Development.
• Foreign internal defense augmentation force.
• Civil affairs elements.
• Special operations forces (SOF) (Appendix N).
• World Health Organization.
• Private organizations and religious efforts.
(4) Particular attention should be given to the existence of legal authority for providing
training to HN personnel and to the need, in most cases, for reimbursement of the value of training or other
services provided.
(5) It should be emphasized that the medical infrastructure which evolves through assistance
from US forces must pervade throughout the country and be broad based. It cannot only be concerned with
urbanized areas, but must make primary health care available to rural areas also. This often requires
convincing the HN government that the expense of hiring and training additional medical and public health
personnel for providing rural area services will be justified by the amount of support for the government it
quickly generates. For example, the HN health care delivery system can increase access to primary care
despite limited resources and a dispersed population. One method is to use nurse practitioners to provide
primary care in rural areas. These practitioners could also provide training to local basic- and middle-level
health care providers.
(6) The health care programs are tailored to meet the needs of the HN. They should target
the basic health necessities initially, with emphasis on health education and on other preventive measures.
As the programs evolve, they must become institutionalized to ensure their continued success when US
military assistance is withdrawn.
(7) If possible, interregional cooperation between neighboring countries and programs should
be fostered. This assists in strengthening relationships between countries and also optimizes the use of
scarce resources in the training and development arenas.
(8) Resources in most instances will fall short of need. There will rarely, if ever, be
sufficient US personnel, equipment, or supplies to provide care to the entire country, or even for the entire
spectrum of disorders within a small area of the country. It must also be understood that the care of chronic
disorders and of uncorrectable conditions are beyond the scope of these programs. To provide continuity,
these health care programs (carefully coordinated with the HN) require a well-publicized focus to a given
area and a schedule to provide return visits.
c.
Additional Information. Information on Title 10, US Code is contained in Appendix L.
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3-7.
Support to Counterdrug Operations
Combat health support to counterdrug operations is limited in nature.
a. The veterinary service provides care and treatment of MWDs used in these operations.
Further, the veterinary support may become involved in developing animal husbandry programs which can,
in turn, lead to the economic growth of the HN and reduce its dependence on income generated by drug-
related agriculture.
b. United States Army medical evacuation resources may also be used to evacuate injured, ill, or
wounded soldiers involved in these operations.
3-8.
Combatting Terrorism
a. General.
(1) Terrorism has become a reality in the modern world. Terrorism can occur throughout
the operational continuum. It is defined as the unlawful use or threatened use of force or violence against
people or property to coerce or intimidate governments or societies, often to achieve political, religious, or
ideological objectives. Combatting terrorism consists of those actions
(including antiterrorism and
counterterrorism) taken to oppose terrorism.
(2) The tactics used by terrorists include bombings, hijackings, assassinations, and
kidnappings. The immediate objectives of terrorism are recognition, coercion, intimidation, and
provocation. Terrorism is a tactic that is used across the operational continuum.
(3) Further information on combatting terrorism is contained in Joint Publication (Joint Pub)
3-07.2 and FM 100-20.
b. Antiterrorism. Antiterrorism consists of those defensive measures used to reduce the
vulnerability of personnel, family members, facilities, and equipment to terrorist acts. This includes the
collection and analysis of information to accurately assess the magnitude of the threat.
(For the collection of
medical information, refer to paragraph 1-5, Appendix A, and FM 8-10-8.)
c.
Counterterrorism. Counterterrorism is comprised of those offensive measures taken to prevent,
deter, and respond to terrorism. Combat health support elements are not directly involved in the
counterterrorism aspects of an operation. However, these CHS elements provide traditional CHS to US and
friendly forces engaged in these operations.
d. Combat Health Support Planning Considerations.
(1) The CHS commander must plan for and conduct active programs which reduce his unit’s
vulnerability to terrorist actions. A balance must be reached that maintains an appropriate level of vigilance,
security, and confidence. This balance should not adversely impact on the mission and result in undue
suspicion and stress.
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(2) The CHS planner must be aware of the terrorist threat in the planned AO. He must
incorporate appropriate safeguards and considerations into the CHS OPLAN. These considerations
include—
• Medical.
•
Threat capability for the use of NBC weapons/agents and DE weapons/devices.
•
Provisions for laboratory support to identify suspect agents.
•
Special immunization or chemoprophylaxis for potential BW agents.
•
Command information stressing individual protective measures to include
personal hygiene and sanitation.
•
Provisions for safeguarding and inspecting food and water supplies.
•
Provisions for the treatment of contaminated water sources.
•
Stress control resources for debriefing victims, rescuers, and caregivers after
a terrorist attack.
•
Provisions for suspect BW and CW agent therapeutics.
•
Medical evacuation under hostile fire or in adverse terrain (FM 8-10-6).
•
Mass casualty situations (Appendix J and FM 8-10-1).
•
Augmentation or reinforcement of medical personnel, supplies, and equipment.
•
Hospitalization (location and requirements).
•
Plans for continued care in the event the MTF is the target of a terrorist attack.
•
Dispersion of units.
•
Care of government-owned animals used in combatting terrorism operations.
•
Specialty response teams (Appendix I).
•
Nonmedical.
•
Terrorist threat.
•
Potential targets.
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