Many young Medical Service Corps officers have only conducted Medical Operations (MEDOPS) in support of counterinsurgency operations with uncontested airspace. Due to changing threats, the Combat Training Centers (CTCs) have adapted scenarios to replicate decisive action (DA) combat against near peer threats. The DA environment is much different because airspace, communications, and key terrain are all contested. Additionally, near peer threats cause higher numbers of casualties. I have observed the following 10 trends over four DA rotations as a BDE MEDOPS OCT at the Joint Multinational Readiness Center (JMRC). The trends and recommended Tactics, Techniques, and Procedures (TTPs) described below are based on my observations in the field and each represents “a way,” not “the way” to coordinate health service support in the DA environment.
Primary Alternate Contingency Emergency Communications Plan
Communications routinely fail at JMRC due to either terrain or enemy activity. Successful units do two things: have a functioning Primary Alternate Contingency Emergency (PACE) plan and exploit the PACE plan to create shared understanding. The PACE plan must consist of entirely different systems, not simply different channels or systems that operate from a single platform. For example, a PACE plan that includes Joint Capabilities Release (JCR)/Joint Battle Command-Platform (JBCP), SIPR, TACSAT, and FM would be sufficient since none of those methods depend on a common system. One common mistake is to leave FM off of the PACE plan and rely on upper tactical internet (TI), which can be jammed to deny several systems.
Not all aid stations or staff sections are fielded the same communications systems within the BDE. Conducting an assessment of the current communications systems and working with the S6 section to standardize aid station systems may be required. BDE MEDOPS must also ensure that each subordinate unit has the necessary software, communications security fills, and training for the PACE plan. For example, if you utilize JCR/JBCP, ensure that the subordinate battalions (BNs) have the right platforms, software, classification, and training for the JCR/JBCP. This must be repeated for each system. Once this is complete, units should conduct a Communications Exercise (COMMEX) that methodically tests each system forward and backward (PACE and ECAP).
Multinational allies and partners may not have the same communications networks. A multinational PACE plan and COMMEX to incorporate them should be a priority early in the planning timeline. Finally, do not forget that reports can be sent physically if there is a movement traveling to the desired location. A Dutch Role I successfully updated an American BDE MEDOPS section through Polish LNOs with hand written reports. A sound and tested PACE plan maximizes communications when it is available.
Medical Common Operational Picture (MEDCOP)
Units must have a method to exploit their communications to create shared understanding. Successful units standardize a digital and analog MEDCOP that is filled out with information from the medical situation report (MEDSITREP) at least twice daily. Consolidated MEDSITREP information and patient tracking information should be shared with all medical elements in the area.
Some units utilize the medical support operations officer (MEDSPO) to collect, consolidate, and distribute MEDSITREP information. This system ensures all aid stations know the locations of adjacent aid stations, their capabilities and limitations, and their patient census. When communications are degraded or denied, they use this standard analog MEDCOP and the last known information to decide and act on medical evacuations (MEDEVACs). Units exchange information face to face when ambulances pick up patients while communications are down. The end state is that junior leaders are empowered with information and can take disciplined initiative in the absence of communications with higher headquarters.
MEDEVAC in Areas of Operation with Contested Airspace
The DA environment produces such a large number of casualties in such a short time that air MEDEVAC assets cannot evacuate all casualties. Many near peer threats have excellent air defense systems and present a greater threat to air MEDEVAC platforms than the insurgents we faced in Iraq and Afghanistan. Consequently, air MEDEVAC will not be able to evacuate every casualty from the point of injury which will require commanders to make informed decisions about how to employ the forward support medical platoon (FSMP).
Some FSMPs have requested to be located with the Role II to ensure good communications and faster operations. Maneuver and aviation commanders will need to make decisions about when and where the FSMP will be used in light of the Air Defense threat. More importantly, the factors above mean that air MEDEVAC will not be able to cover all MEDEVAC missions and that ground MEDEVAC operations will be a key component of the plan. In MASCAL situations, both ground and air casualty evacuation (CASEVAC) may be needed in addition to available MEDEVAC assets to clear the battlefield of casualties. Medical planners must analyze this problem and present maneuver and aviation commanders with clear decisions on how and when air MEDEVAC, ground MEDEVAC, and CASEVAC will be used.
Prolonged Field Care (PFC)
This is the only trend that doesn’t have current doctrine to assist leaders in training their units. Due to the challenges described above, units can’t evacuate all casualties within the “golden hour.” PFC is simply any field medical care applied beyond doctrinal planning timelines. Since PFC treatment is often different or more complicated than those interventions commonly performed in tactical combat casualty care (TCCC), BN and BDE surgeons should consider designing, implementing, and supervising their own PFC programs.
Units should focus PFC on the appropriate population. The cavalry squadron will likely operate far forward of Role II support. Therefore, the cavalry squadron’s Role I and line medics should be first in priority to be trained. After that, line medics and Role Is from the infantry BNs are the next most likely to require this training. PFC started as a Special Forces program, and 18Ds from the nearest Special Forces Group are often willing to help units develop PFC programs. Also, Next Generation Combat Medic and Prolonged Field Care have great resources.
Mission Authority, Launch Authority, and Patient Tracking
Many units have issues keeping track of 9-line MEDEVAC requests. The simplest answer is to create a standardized nomenclature. This nomenclature should account for three levels of MEDEVAC: from casualty collection point (CCP) to Role I, from Role I to Role II, and from Role II to Role III. Units must assign the appropriate echelon to execute the mission at each role of care. BDE MEDOPS or the SPO can have the authority to resource and launch BDE internal ground MEDEVAC missions. It depends on the unit’s SOP. Authorities need to understand how to request air MEDEVAC. The aviation task force commander usually approves air MEDEVACs.
When the brigade support area (BSA) or the brigade command post jumps, units must have an alternate for mission and launch authority. Units across the brigade need to know this. Units also need to know actions to take if they do not receive a response from higher regarding a 9-line request. A time criterion seems helpful. E.g., “if you do not get a response in 5 minutes, execute the evacuation to the next higher role yourself.” The last part is patient tracking. Align battle rosters to mission numbers to accurately account for personnel during evacuation. This will ensure you can clear the battlefield of casualties with a high degree of accuracy.
Ambulance Exchange Point (AXP) Nomenclature SOPs
To avoid confusion between BN (CCP to Role I), BDE (Role I to Role II) and DIV (Role II to Role III) AXPs, the BDE should have an SOP for AXP nomenclature. This is especially important for the cavalry squadron. They deploy and develop AXPs in support of their reconnaissance before brigade publishes the final OPORD. Battalions should use a different naming convention (e.g., alphabetically or U.S. cities ordered geographically) than brigade. This avoids confusing AXPs with duplicate names in the operating environment. Likewise, units should avoid using the same AXP names in sequential operations if the locations of their AXPs change.
Security
The majority of CTC notional patients who die of wounds or are dead on arrival (DOW/DOA). They expire while waiting for security to escort their ground MEDEVAC or CASEVAC. There are different ways to resource security, but the root problem is deciding which unit will give up combat power to protect ground evacuation. One TTP is to include ambulances with each forward support company (FSC) when it resupplies the BNs. This is essentially one free turn for the brigade support medical company to pick up patients with planned security. However, this is only one free turn and units might not time it appropriately.
BDE and BN MEDOs should discuss security requirements with their respective commanders during the military decision making process. They should consider tasking a unit to provide ground evacuation security. Otherwise, commanders face a time-sensitive decision. They have to chose between sacrificing combat power to escort patients, sending a MEDEVAC without escort, or holding patients longer.
Manned vs Unmanned AXPs
Over the past four rotations, no unit has successfully executed an unmanned AXP transfer between Roles I and II. In contrast, manned AXPs with pre-planned locations and attached security elements have been successful. To achieve a successful unmanned AXP operation, two MEDEVAC missions must communicate to coordinate the transfer. They find each other in time and space, each escorted with its own security element. Then they transfer a patient in a contested environment. By showing vehicle locations, JCR/JBCP assists elements find each other if crews train and field the equipment.
During rotations, Role Is have great difficulty coordinating this unmanned AXP exchanges. They usually give up and send a Role I ambulance to evacuate to the Role II while the Role IIs assets remain unused. A pre-positioned and manned AXP relieves the requirement for communication. The evacuation element automatically takes the casualty to the pre-planned location. The element with the casualty is the only element navigating. They only have to find a single fixed point with an ambulance already waiting.
The unit already resourced security for one MEDEVAC element to launch as soon as they have urgent casualties. If Role II mans the AXPs they ensure that higher Roles are supporting the Role I. This enables the Role I to focus on picking up casualties from Company CCPs. In short, manned AXPs require more coordination prior to the operation. But they make MEDEVAC a much simpler operation to conduct in a contested environment.
Rehearsals
Effective MEDEVAC depends on effective rehearsals. The key to including MEDEVAC in the rehearsal is to engage the Brigade Command Sergeant Major (BDE CSM). The BDE CSM is in the most effective position to ensure the BN CSMs and company 1SGs know the plan. This is important because it will not be the BDE or BN MEDOs running MEDEVAC on the ground; it will be the CSMs or 1SGs.
Units should cover MEDEVAC by phase in their rehearsals. At minimum, they should address:
- PACE plan
- location of aid stations
- location of AXPs
- MEDEVAC routes
- security escort requirements
- MASCAL definition and plan
- response to chemical attacks
Units should address MEDEVAC during the combined arms rehearsal. It is a tactical operation that requires security and affects combat power. Organizations should also rehearse it at the sustainment rehearsal. MEDEVAC is a sustainment function that utilizes sustainment lines of communication.
Medical Resupply
Each unit has to choose whether CL VIII resupply should occur through medical channels or through the regular FSC resupply missions. Most units settle on including CL VIII on the LOGSTAT and resupplying with the FSC. This is because units already coordinate the communications, security, and transportation for FSC missions. If for some reason this system fails, the Role II can provide CL VIII when its ambulances launch to retrieve casualties. This provides a solid primary method of CL VIII resupply and a viable alternative.
Conclusion
DA fights against near peer threats present a different problem set for medical support than the insurgent threats did. Large volumes of casualties, denied airspace, and denied or degraded communications greatly affect medical operations. CTCs attempt to closely replicate the current threat to learn lessons during training rather than combat. The recommended TTPs above represent “a way” for medical planners to adapt to the DA environment. Units can address nine of the ten trends described strictly through home station training. Only one (PFC) is related to the need for new doctrine.
Perhaps the most important trend is this: Units that train at home have fewer problems when they arrive for a rotation. Don’t wait for a CTC rotation to make your own list of lessons learned. Your unit will perform better during the rotation and more importantly, in real life.
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