Ambulance Exchange Points (AXPs) are quintessential to the successful, expeditious evacuation of casualties from Point of Injury (POI) throughout the continuum of care during Large Scale Combat Operations (LSCO) and Multi-Domain Operations (MDO). With our near-peer/peer competitors possessing anti-air assets, air medical evacuation (MEDEVAC) may not always be available to the maneuver unit, especially between the Forward Line of Troops (FLOT) to the nearest Role of Care. Commanders must understand how to best utilize their ambulance squads, how to move AXPs throughout operations, and what tactical considerations to take when selecting AXP.
“Ambulance exchange point is defined as a location where a patient is transferred from one ambulance to another en route to a medical treatment facility. These ambulance exchange points (AXPs) are normally preplanned and are a part of the Health Support Services (HSS) appendix to the sustainment annex to the operation plan (OPLAN). In the forward area, the threat of enemy ground activities, large concentrations of lethal weapons systems, and effective use of antiaircraft weapons may dictate that the AXP be a predetermined rendezvous point for the rapid transfer of patients from one evacuation platform to another. The location of AXPs should be frequently changed to preclude attracting enemy fires” – ATP 4-02.2, Medical Evacuation.
ATP 4-02.2, Figure 2-1. Flow of communication for medical evacuation request
How does a Commander utilize AXPs to support the tactical maneuver plan?
A Brigade Combat Team has five to six Ambulance Squads, and one Evacuation Platoon.
Armored Brigade Combat Teams (ABCTs) and Stryker Brigade Combat Teams (SBCTs), best utilize armored ambulances, the M1133 Medical Evacuation Vehicle (MEV) or M113 Tracked Ambulance, by pre-positioning them forward with maneuver companies so that they can keep pace with maneuver elements and can hastily evacuate any casualties these unit may incur.
“The ambulance squad sends out teams that provide MEDEVAC and en route care from the Soldier’s POI or a CCP to the BAS. Each ambulance team consists of an emergency care sergeant or specialist and two ambulance/aide drivers and is normally dedicated to support a specific company unless otherwise directed by the platoon leader” – ATP 4-02.4, Medical Platoon.
The Brigade Support Medical Company (BSMC) has a Forward Evacuation Squad located in the Evacuation Platoon. Commanders must understand the tactical scenario and pre-position these assets at maneuver units’ Battalion Aid Stations (BAS) when they predict high casualty numbers. Leaders can decrease the time and communication of the MEDEVAC request by placing, staging, or attaching MEDEVAC assets forward before receiving casualties. When BSMC Evacuation Squad (Forward) assets are used in such a way, it provides effective MEDEVAC capabilities from Role 1 to the Role 2 AXP, while the ambulances organic to the maneuver unit can quickly return to the FLOT.
ATP 4-02.2, Figure 2-2. Ground evacuation request in a maneuver unit
“Prior deployment of the BSMC ground ambulances with the maneuver battalion’s organic medical platoons permits uninterrupted and effective medical evacuation from the BAS to the medical company” – ATP 4-02.3, Army Health System Support to Maneuver Forces.
Open and Closed AXPs throughout phases of the operation
Appendix 3 to Annex F (Health Support Services) of the Brigade Operations Order (OPORD) should specify AXP Locations, staffing, and activation triggers. Triggers to open and close AXPs often vary for each unit. A trigger we commonly see at JMRC is a maneuver unit crossing identified phase lines. Incorporating such detail into the Medical Common Operating Picture (MEDCOP) facilitates a shared understanding throughout the formation during the operation. It is important to brief AXP locations at the Rehearsal of Concept (ROC) drill, Combined Arms Rehearsal (CAR), and Sustainment Rehearsal in order to create a shared understanding across the formation.
Medical personnel and non-medical personnel must understand and know the location of AXP locations in the event a CASEVAC mission. Units are the most successful when Medical Platoon Sergeants and Platoon Leaders require their Evacuation Section Squad Leaders to accompany them to each rehearsal. This provides the leaders who are running the evacuation missions to the AXPs with a time/space visual understanding. When briefing AXPs, leaders should utilize the correct military symbol and label them with an 8 or 10 digit MGRS grid to visualize them on the terrain model. Units should label AXPs on the MEDCOP.
During our rotations at JMRC, we’ve observed that units rarely annotate open/close triggers for AXPs on the sustainment overlays and MEDCOP. Units commonly used “closed” AXPs which caused a delay in patient evacuation on multiple occasions. Best practices have shown that capturing these triggers in the OPORD and MEDCOP allows for timely patient evacuation. AXP locations and activation triggers are further understood when incorporated into the Brigade AHS Synchronization Matrix (see example below) by the SPO MED.
“The brigade surgeon section is responsible for developing the BCT MEDEVAC plan. The BSMC commander provides synchronization for the execution of brigade MEDEVAC plan, to include the use of both ground and air assets. The brigade surgeon section medical planner should include the BSMC commander, XO, brigade personnel staff officer, brigade XO, medical platoon leaders, FSMP leader, the brigade support battalion medical plans and operations officer, and the support operations officer in the planning process”( ATP 4-02.2 Medical Evacuation).
What factors should Army Health System (AHS) Planners take into consideration when designating AXPs?
As in any medical planning, AHS Planners must apply the AHS Principles of conformity, proximity, flexibility, mobility, continuity, and control when designating AXP locations. Units must emphasize mobility when designating AXPs locations, as AHS assets must remain in supporting distance to the maneuver forces. Medical Planners, to include the BSMC Commander and Executive Officer, must have a thorough understanding of the Division and Brigade Commander’s ground tactical plan. Units must place AXPs in proximity to the supported unit, but not close enough to impede operations or place MEDEVAC assets in areas of catastrophic danger.
Questions to ask when planning for an operation could be the following; “does the AXP allow the maneuver unit MEDEVAC assets to quickly return to the Forward Line of Troops?” Leaders must consider terrain and obstacles —“can both the supported and supporting MEDEVAC assets easily ingress and egress from the designated AXP?” “Can we easily observe the AXP from a main avenue of approach?” Medical Planners must also understand the Operational Environment (OE) and enemy SITEMP. Different enemy situations will require the request and support of adjacent units for Force Protection (FORCEPRO) support.
“In LSCO, evacuation lines will become extended as maneuver forces achieve success requiring increased synchronization between MEDEVAC units and MTFs to validate AXP and unit locations and status. MTFs must be emptied of patients in order to be capable of moving to sustain proximity with the supported unit(s). This places great demands upon MEDEVAC elements as well as the area support elements in the AO.” (Army Health System Doctrine Smart Book).
AXP Operations Observations from Observer Coach / Trainer’s Point of View
During 2021, we observed five units come through JMRC, which included ABCTs, an SBCT, and an IBCT(A). A common trend observed throughout most of these Decisive Action Training Environment (DATE) exercises is the lack of tactical execution when conducting ambulance exchanges. More often than not, MEDEVAC crews had difficulty with mounted land navigation and trouble finding AXPs that were not located directly off of a road; this was usually the result of lack of reconnaissance (map and/or route) and degraded (or no) communications.
U.S. Army Pfc. Thomas Ray Leonard, a combat medic from the 206th Medical Company Area Support, Kansas City, Missouri, studies a map for ambulance exchang points during Northern Strike 21-2 at the Camp Grayling Joint Maneuver Training Center, Grayling, Michigan, Aug. 3, 2021. Northern Strike maximizes combat readiness by providing adaptable, cost effective training ranging from individualized tactical skills to near-peer contested threat and combined arms environments focused on Joint and Coalition force integration and domain convergence. (U.S. Air National Guard photo by Master Sgt. David Kujawa)
Evacuation crews from both the Role 1 and 2s did not have a far-near recognition plan for signaling which sometimes resulted in AXP compromise by the OPFOR as they did not pull security at the short-halt. Medical professionals generally understand the “why” of an AXP operation, but most lack the proficiency on how to properly execute a successful patient exchange in a tactical environment. Most do not realize that evacuation assets are lucrative/high pay-off targets to opposing forces that don’t adhere to the protections outlined in the Geneva Conventions.
How can units conduct AXP Ops more tactically in a Decisive Action Training Environment?
The LSCO and MDO fight requires Soldiers to “be better at the basics;” Shoot, Move, Communicate, and Medicate. How does this apply to tactically executing AXP operations? Ambulance crews should conduct security at the short halt, be proficient in mounted land navigation (and always carry a map, protractor, and compass), have a Primary Alternate Contingency and Emergency (PACE) communications plan as well as a signaling PACE for far/near recognition of friendly forces, and conduct a thorough patient hand-off. Evacuation Squads should always exercise the Five Principles of Patrolling: Planning, Reconnaissance, Security, Control, and Common Sense.
AXPs are not exclusive to ground-to-ground Evacuation
“Sectors which have a high ground-to-air or air-to-air threat may rely on ground evacuation assets to move the majority of patients. In other sectors where the ground threat is high and comprised of small arms and explosive hazards (mines, improvised explosive devices, and unexploded ordnance), MEDEVAC operations may be more efficiently and effectively executed by air ambulances. An additional consideration in planning MEDEVAC operations is to determine whether armed escorts are required for either the ground or air ambulance mission.”(ATP 4-02.2, Medical Evacuation).
Corpsmen transport wounded from an Army Medivac blackhawk helicopter to Charlie Surgical Support Co, Health Services Battalion (HSB) 1st FSSG forward HQ at Camp Viper, Iraq. Logistics Support Area Viper, 1st FSSG Forward Headquarters, Iraq. Operation Iraqi Freedom. 31 Mar, 03. Operation Iraqi Freedom is the multinational coalition effort to liberate the Iraqi people, eliminate Iraq’s weapons of mass destruction. (Official USMC photo by MSgt Edward D. Kniery)
As the Army transitioned from training for a Counter Insurgency (COIN) fight to training for LSCO, a common misunderstanding is that Air MEDEVAC will never be available due to the threat of surface-to-air weapons that our near-peer/peer competitors possess. If Air MEDEVAC assets are available to the ground force commander, they should always be the primary means of MEDEVAC in the PACE Plan. Army flight paramedics, trained in critical care and possessing a broader scope of practice than that of a regular 68W Combat Medic Specialist, man Air MEDEVAC platforms. Additionally, rotary wing is a faster and more direct form of MEDEVAC to the next role of care. The same principles used to establish a ground-to-ground AXP still apply, and security of the Helicopter Landing Zone (HLZ) AXP is equally important as when conducting an AXP hand-off at a ground-to-ground AXP.
ATP 4-02.2, Figure 2-4. Aeromedical evacuation request
A key difference between ground-to-ground AXP and ground-to-air AXP is the establishment of the HLZ. Soldiers must ensure they find an open area, 100 ft. x 100 ft. (for single ship UH-60, 200 ft. x 200 ft. for two ship) free of obstacles, and no more than a 7 degree slope, for the aircraft to land. Units must mark the HLZ with smoke or VS-17 panel during the day, and IR Strobe/IR “Buzz Saw”, or inverted Y using IR chemical-lights during nighttime. In a tactical environment, the signalman should not employ the method of marking until the MEDEVAC aircraft is within line-of-sight, and should remain concealed and camouflaged until they mark the HLZ.
The greater area required for a ground-to-air AXP also presents a security concern; gun trucks are requested in order to secure the perimeter during patient hand-off which protects both the ground and air ambulance crews. Vehicles must stay concealed and noise/light discipline maintained until the patient hand-off is conducted between the ground ambulance crew and air ambulance crew.
Putting it all together
As we prepare to fight a Near Peer/Peer advisory in a LSCO environment, we need to understand how important the role of timely patient evacuation will be in saving casualties sustained during battle. Being “brilliant at the basics”, and repetitively practicing proper evacuation SOPs and TTPs will enable evacuation crews to complete patient exchanges in a timely and proficient manner while not compromising security or evacuation assets. As you prepare your formation for your next training rotation at a Combat Training Center or a real-world contingency operation, look at your Health Services Support plan and ask your teammates, “are we utilizing AXPs properly?” When your formation understands how to effectively utilize Ambulance Exchange Points, the survivability rate of casualties sustained will inherently increase.
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