COMBAT HEALTH SUPPORT
Section I. Background
The basic Army Medical Department (AMEDD) mission is to maintain the Army's health to conserve its fighting strength (trained manpower). Medical services are employed to provide the most benefit to the maximum number of personnel. Patients are examined, treated, and returned to duty (RTD) as far forward as possible.
Combat health support (CHS) for the Army component in a theater of operations is the ASCC's responsibility. An ASCC surgeon is on the ASCCís special staff.
Normally, the MEDCOM commander or the senior medical commander in the COMMZ functions as the ASCC surgeon. As ASCC surgeon, he provides information, recommendations, and professional medical advice to the general and special staffs. He also maintains current data regarding the status, capabilities, and requirements of the ASCC's CHS. As the medical staff adviser, he is responsible to the ASCC for staff planning, coordinating, and developing policies for ASCC forces' CHS. The CHS func-tions are¾
· Command, control, communications, computers, and intelligence.
· Patient evacuation and medical regulation.
· Health service logistics/blood management.
· Area medical support.
· Dental services.
· Veterinary services.
· Preventive medicine services.
· Combat stress control (CSC) services.
· Medical laboratory services.
For additional information on CHS at corps and below, refer to ST 63-1.
Section II. Echelon IV and V Combat Health Support
The CHS system is a single integrated system. It begins at the forward line of own troops (FLOT) and ends in CONUS. This system entails the effective medical regulation of sick, injured, and wounded patients in the shortest possible time to the medical treatment facilities (MTFs) that can provide the required treatment. All sick, injured, and wounded patients are regulated and evacuated without regard to lateral or rear boundaries. CHS involves delineating support responsibility by geographic area. The system's effectiveness is measured by its ability to return soldiers to duty.
Nonmilitary personnel who accompany combat forces or who function within a theater of operations are authorized both treatment in MTFs and evacuation. The CMO officer, associated civil-military units, and the appropriate command surgeon coordinate required support.
Under the Geneva conventions, medical units cannot transport soldiers discharged from MTFs to their units.
Sick, injured, or wounded EPWs are treated and evacuated through normal medical channels but remain physically segregated from US and allied patients. EPWs are evacuated from the CZ as soon as possible. Only those sick, injured, or wounded prisoners who would suffer a great health risk by being evacuated immediately may be treated temporarily in the CZ. Accountability and security of EPWs and their possessions in MTFs are the echelon commander's responsibilities. AMEDD resources are not used to guard EPWs.
5-3. ECHELONS OF CHS
The echelons of CHS in a theater of operations are referred to as echelons (or levels) I through IV. Echelon (level) V is located in CONUS. Each echelon reflects an increase in capability with the function of each lower echelon being contained within the higher echelonís capabilities. Wounded, sick, or injured soldiers will normally be treated, RTD, and/or evacuated to CONUS (echelon V) through these four echelons. Echelons I through III are discussed in detail in ST 63-1.
a. Echelon IV. At this echelon, the patient may be treated at the general hospital (GH) or the field hospital (FH). The GHs are staffed and equipped for general and specialized medical and surgical care. Those patients not expected to RTD within the theater evacuation policy are stabilized and evacuated to CONUS. At the FH, reconditioning and rehabilitating services are provided for those patients who will RTD within the theater evacuation policy.
b. Echelon V. This echelon of care is provided in CONUS. DOD hospitals (triservice military hos-pitals) and Department of Veterans Affairs (VA) hospitals provide hospitalization at this level. Under the National Disaster Medical System, designated civilian hospitals will care for overflow patients from DOD and VA hospitals.
5-4. COMMAND AND CONTROL
The major EAC C2 units are the MEDCOM and the medical brigades. The MEDCOM's mission is to command, control, and supervise assigned and attached units in the COMMZ. The MEDCOM is as-signed on the basis of one per ASCC. The types and number of CHS units assigned to the MEDCOM depend on various factors such as size, composition, and location of supported forces; types of opera-tions conducted; anticipated workload; and theater evacuation policy. An example of an EAC medical force structure in a mature theater is shown in figure 5-1.
The medical brigade commands, controls, and provides administrative and technical supervision for assigned and attached medical units in its area of operations. The brigade is assigned to the MEDCOM in the COMMZ or the COSCOM in the corps. The medical brigade is assigned to the COMMZ on the basis of one per three to seven battalion-sized units.
Figure 5-1. MEDCOM organization.
5-5. EVACUATING PATIENTS AND MEDICAL REGULATING
Patient evacuation is quickly, efficiently moving wounded, injured, or ill persons from the battlefield and other locations to MTFs. Medical personnel provide en route medical care during patient evacuation. Medical regulating is a system for coordinating and controlling patient movement through the various echelons of care. The system ensures the timely, efficient, and safe movement of patients, often over great distances, to the destination MTF. Medical regulating is executed so that patient welfare is second only to the tactical mission's success. The system entails identifying patients to be evacuated, locating available beds, and coordinating evacuation means so each patient is moved to the proper MTF with the least possible delay.
The preferred means of evacuation from the CZ to the COMMZ is by US Air Force (USAF) aircraft. The medical regulating officer assigned to the senior medical command in the CZ coordinates aeromedical evacuation requirements. If adequate air evacuation is not available, the medical regulating officer will coordinate ground transportation use. When there is an interruption in USAF aeromedical evacuation from the CZ, moving large numbers of patients to and from USAF mobile aeromedical staging facilities and between hospitals and convalescent centers may be done by ambulance buses, ambulance trains, or tactical helicopters (UH-60s and CH-47s) with medical attendants. The USAF will normally evacuate patients from the COMMZ to CONUS. Patient hospitalization and evacuation are shown in figure 5-2.
5-6. ECHELON IV (EAC) HOSPITALIZATION
Hospitalization is part of the theaterwide system for managing sick, injured, and wounded patients. The hospital system is specifically designed to provide patients with surgical and medical resuscitative, definitive, and specialty treatment.
Figure 5-2. Patient hospitalization and evacuation.
Hospitals that are subordinate to the MEDCOM provide hospitalization in the COMMZ. Hospitaliza-tion is provided for patients originating in the COMMZ and for those received from the CZ. All COMMZ hospitals are being equipped with deployable medical systems. The GH and FH are normally employed in the COMMZ.
The FH is a 504-bed facility that hospitalizes patients and reconditions and rehabilitates those patients who can RTD within the theater evacuation policy. Most patients within this facility will be in the convalescent care category. The FH is normally located in the COMMZ but could be used in the corps rear when geographic operational constraints dictate. It is organic to a MEDCOM and may be further attached to a medical brigade. It is 20-percent mobile with organic vehicles.
The GH is a 476-bed facility that stabilizes and hospitalizes patients who require either further evacuation out of the theater of operations or who can RTD within the theater evacuation policy. It can provide specialized and definitive hospitalization to the theater. The GH receives patients from all hospitals in the theater and within its AO. The GH normally is located in the COMMZ. It is assigned to a MEDCOM and may be further attached to a medical brigade. It is 10-percent mobile with organic vehicles.
5-7. ECHELON V (CONUS) HOSPITALIZATION
In CONUS, the casualties are treated in CONUS hospitals that are staffed and equipped for the most definitive care available within the AMEDD CHS system. Hospitals in the CONUS base represent the final level of CHS. Hospitals that fall into this category are¾
· US Army Community Hospitals.
· Other Federal hospitals (sister service hospitals and VA hospitals).
· Civilian hospitals (equivalent to echelon IV and echelon V).
5-8. HEALTH SERVICE LOGISTIC SUPPORT SYSTEM
Health service logistics is an integral part of the CHS system. It encompasses the activities of medical supply (class VIII); medical equipment maintenance; optical fabrication; contracting services; single integrated medical logistics manager for joint operations; and blood management for Army, joint, or combined operations. Characteristics that set the class VIII system apart from the other commodities are¾
· Technical nature/diversity of products and services.
·Clinician-medical logistics/maintenance interrelationship.
· Accountability for health care rests with the AMEDD.
·Protection under the Geneva conventions (materiel and personnel).
· Stringent regulatory requirements.
The organizational structure for the health service logistic support system that provides class VIII supply support and blood products to a theater of operations consists of four types of units: medical
logistics (MEDLOG) battalions (bns) forward (fwd), MEDLOG bns (rear), theater medical materiel management centers (TMMMCs), and MEDLOG support detachments. The MEDLOG bns receive, store, process, and distribute medical materiel. The supporting division-level medical company provides unit-level medical equipment maintenance.
The MEDLOG bn (fwd) provides DS and GS medical equipment maintenance to division units and area support to the corps. The MEDLOG bn (rear) provides DS/GS medical equipment maintenance to EAC on an area support basis. Both MEDLOG bns (fwd and rear) provide single-vision and multivision optical fabrication for all vision correction devices. Blood and blood products are supplied to the MEDLOG bn (fwd) from a USAF blood transshipment center (BTC) using supply point distribution or by the MEDLOG bn (rear) through unit distribution. At EAC, the TMMMC links the complete strategic wholesale continuum and theater MEDLOG units, providing intransit visibility, redirection of shipments, and intratheater cross-leveling.
The general locations of MEDLOG units are chosen as far forward as possible based on current and projected combat operations. Within limitations of the tactical plan, medical supply installations must have access to railheads, ports, airfields, and highways to facilitate medical materiel movement.
5-9. BLOOD MANAGEMENT
Blood management services are provided in a theater of operations to support US military and, as directed, allied military and indigenous civilian medical establishments. The unified commands main-tain individual blood programs to meet their own needs. These programs are theaterwide and interface with the CONUS blood management system. They are a DOD effort. Blood management services in a theater of operations include¾
· Receiving liquid blood and blood components from CONUS.
· Moving, storing, and distributing frozen blood products that are pre-positioned with the theater.
· Collecting and processing liquid blood.
Each unified command has a separate, integrated system for providing blood products to the various component MTFs. The Joint Blood Program Office (JBPO) serves as the single blood manager in the theater and interfaces with the Armed Services Blood Program Office (ASBPO) in CONUS. When the unified command blood program capabilities are exceeded, the JBPO requests assistance from the ASBPO. The ASBPO, in turn, requests support from the services. The blood collected and processed in CONUS is shipped to BTCs located throughout each unified command. The USAF operates the BTCs. They are centers for receiving and distributing blood. The BTCs are located at major airfields with tactical airlift capability.
Once at the BTC, the blood products are under the JBPO's control. Within the unified command, the JBPO will establish area joint blood program offices (AJBPOs). The AJBPOs direct the issue of blood products from BTCs in their area of responsibility to component command blood supply units (BSUs). The main source of blood to support wartime casualty care requirements does not come from collecting and processing blood in theater by the blood management service teams; it comes from the CONUS base.
Echelon II medical treatment elements, as well as the FST, will be able to store Group O blood. The other echelon III and IV hospitals will have blood management systems that will provide limited blood services.
BSUs operating in either the CZ or COMMZ are OPCON to a medical C2 unit that provides commu-nications support. BSUs should communicate with both supporting and supported units by voice, teletype, or data transmission. Direct communication between the BSU and its supported units is absolutely necessary. Direct communication with the BSU and informational communication with C2 elements are encouraged. BSUs should also have access to Automatic Digital Network (AUTODIN) facilities.
5-10. THEATER ARMY MEDICAL MANAGEMENT INFORMATION SYSTEM
The Theater Army Medical Management Information System (TAMMIS) supports medical units' information management requirements worldwide. It was designed to focus primarily on wartime operations, but it is also used for contingency operations and for supporting some peacetime functions. TAMMIS improves the timeliness, accuracy, and resolution of information, including the status of medical units, supplies, equipment, and patients to support the tactical commander on the extended battlefield. TAMMIS consists of six subsystems supporting logistics and patient administration functions. The subsystems supporting logistics are medical supply (MEDSUP), medical assemblage management (MEDASM), and medical maintenance (MEDMNT). The subsystems supporting patient administration are medical patient accounting and reporting (MEDPAR), medical patient accounting and reporting command and control (MEDPAR-CC), and medical regulating (MEDREG).
5-11. MEDICAL INTELLIGENCE SERVICES
Medical intelligence is vital to strategic and operational planning as well as in preparing for all aspects of CHS activities. It is as critical to medical planning and operations as combat intelligence is to tactical planning and operations. Developing medical intelligence involves collecting, evaluating, analyzing, and interpreting foreign civilian and military medical, bioscientific, and environmental information. Strategic and medical planners need this intelligence to develop CHS that is responsive to the unique aspects of a theater of operations. Medical intelligence also assesses foreign military offensive and health service capabilities and health hazards that are unique to a given locality.
Medical intelligence includes foreign epidemiology; public health standards and capabilities; and quality and quantity of military and civilian medical personnel, training, supplies, facilities, and health services. Also considered are foreign animal diseases, health problems related to using local food supplies, and medical effects of and prophylaxis against chemical and biological agents. As new weapon systems are developed, intelligence concerning their biological impact is developed.
In the normal course of duty, medical personnel at all echelons obtain medical intelligence information. Such information should be reported quickly to the supporting intelligence element. Requests for specific medical intelligence should be made to the supporting intelligence element. Before it can be responsive to the consumer's requirements, this element must clearly establish a need for support. The Armed Forces Medical Intelligence Center at Fort Detrick, MD, provides worldwide medical intelligence support in CONUS.
Intelligence elements also may request specialized medical intelligence assistance from the COMMZ and CONUS as required. Plans, intelligence, and operations sections of the MEDCOM HQ and the medical group and/or battalion coordinate and provide medical intelligence support in the COMMZ.
Representative samples of medical supplies and equipment captured from the enemy must be for-warded through command channels to medical intelligence personnel for evaluation and exploitation. When materiel cannot be evacuated, medical intelligence specialists can make onsite evaluations. The capturing unit evacuates all of the remaining captured supplies and equipment to designated collecting points where they are stored, maintained, and distributed IAW theater and major command policies.
5-12. CONUS MEDICAL MOBILIZATION
The medical mission in CONUS upon mobilization consists of four primary functional areas:
· Expand the medical and dental care systems to provide support for the returning theater casualties.
· Expand the AMEDD training base.
· Provide AMEDD professional officer filler personnel to the deploying forces as HQDA directs, and provide enlisted personnel as fillers as USTA PERSCOM directs.
· Provide medical and dental support (examinations, immunizations, optometry services, patient evacuation, troop medical clinic operations, hospitalization, etc.) to the mobilizing and deploying RC force.
The CONUS medical system for contingencies provides patient care in three medical support organizations, each being a part of the expanding base of patient beds. They are DOD hospitals (Army, Navy, and Air Force), VA medical centers, and civilian hospitals [volunteer participants in the National Disaster Medical System (NDMS)].
The Global Patient Medical Regulating Center Officer directs the flow of (regulates) theater evacuee patients into CONUS hospitals based on bed availability reporting procedures; patients are regulated regardless of service origin. By expanding the CONUS medical system into the VA and civilian com-munities, we expand the pool of available beds.
Generally, patients with long-term conditions and those not expected to RTD will be regulated directly into the VA medical system. The USAF will set up aeromedical staging facilities at primary C-141 arrival airfields in CONUS (McGuire AFB, NJ; Kelly AFB, TX; etc.). Patients will be triaged and sorted in these staging facilities and designated for further movement intra-CONUS by land or air transportation or admitted to a local hospital.
To expand the medical and dental systems, RC unit augmentation for a variety of support and aug-mentation missions supports the USAMEDCOM. Current HQDA missions for USAMEDCOM are to maintain care to dependents and retirees; support the deploying Active component, and mobilizing and deploying Reserve forces; and prepare for returning casualties. Individual mobilization augmentees and custom-designed TDA US Army Reserve (USAR) units backfill the gaps the deploying officer filler personnel and designated enlisted personnel leave. Specialty-designated USAR units are packaged to support the graduated mobilization response effort through packages, including installation medical support units that provide a soldier readiness process, veterinary food inspection packages, and blood collection and preparation packages. Additional custom-tailored USAR units will provide expansion capability as needed to respond to the contingency. It is anticipated that some patients in the early RTD category will be routed to the VA because of medical specialty requirements that are not available in the Army or DOD medical system.
5-13. CONUS-BASED MEDICAL LOGISTICS
The US Army Medical Materiel Agency (USAMMA) is the principal operating agency for the CONUS-based medical logistic system. USAMMA's mission is to assist The Surgeon General (TSG) in managing and executing the medical materiel programs that support Armywide health services. The following summarize the major mission areas that support both fixed (TDA) and field (TOE) activities:
· Medical materiel acquisition:
¾ Deployable medical systems.
¾ Medical diagnostic imaging systems.
¾ Integrated logistic support.
¾ Investment equipment management.
¾ Materiel total package fielding.
· Medical materiel sustainment:
¾ Rebuild medical sets, kits, and assemblages.
¾ Maintenance policy and operations.
¾ Depot-level medical maintenance sup-port.
¾ Logistic system development.
¾ Logistic assistance.
¾ Cataloging and support to the whole-sale logistic system.
· Logistic readiness:
¾ Contingency planning and support.
¾ War reserve materiel management.
¾ Readiness assessment.
¾ Domestic engagement.
· Security assistance:
¾ Foreign military sales.
¾ Humanitarian assistance.
¾ New equipment training.
¾ Postgraduate AMEDD Medical Materiel Management Course.
The USAMMA's Armywide mission is carried out at five locations: Fort Detrick, MD; Tobyhanna Army Depot, PA; Defense Depot Tracy, CA; US Army Medical Materiel Center, Europe; and the 8th Medical Bn (Logistics), Korea. Assigned mission and function execution requires direct interface with virtually all medical units/activities, major commands, DLA activities, AMC, the Defense Medical Standardization Board, and Air Force and Navy counterparts.