Download lesson assignment

LESSON ASSIGNMENT
LESSON 1
Combat Health Support in the Theater of Operations.
LESSON ASSIGNMENT Paragraphs 1-1--1-16.
LESSON OBJECTIVES
After completing this lesson, you should be able to:
1-1.
Identify the role of the U.S. Army Medical
Department.
1-2.
Identify the levels of combat health support.
1-3.
Identify the tenets, goals, and principles of the
combat health support system.
1-4.
Identify the elements of the medical threat.
1-5.
Identify the medical threat associated with war,
conflict, and peacetime.
1-6.
Identify the threats to combat health support
associated with war, conflict, and peacetime.
1-7.
Identify the medical capabilities of the combat health
system.
LESSON 1
COMBAT HEALTH SUPPORT IN THE THEATER OF OPERATIONS
1-1. DOCTRINE OF COMBAT HEALTH SUPPORT
a. Keystone Doctrine. The Army's doctrine, the authoritative guide as to how
Army forces fight wars and conduct stability and support operations (SASO), lies at the
heart of its professional competence. Field Manual (FM) 100-5, Operations--the Army's
keystone doctrine, describes Army thinking about the conduct of operations. In
addition, FM 8-10, Health Service Support in a Theater of Operations, and FM 8-55,
Planning for Health Care Service Support, describe Army thinking about providing CHS
to the combat forces.
b. Flexible Combat Health Support System to Support Diversity of
1-1
Operations. The above-named manuals focus on how to win wars. Since wars are
fought for strategic purposes, the doctrine addresses the strategic context of the
application of force. The dynamics of our global responsibilities requires a combat
health support (CHS) system that is flexible enough to support the diversity of
operations (see Figure 1-1).
[Note: Aid Sta = battalion aid station; Tmt/Clr Sta = division treatment/clearing station;
CSH = combat support hospital; FST = forward surgical team; FIELD = field hospital;
GEN= general hospital; MEDDAC = Medical Department Activity (hospital);
MEDCEN = medical center (hospital). COMMZ = Communications Zone, now referred
to as Echelons Above Corps (EAC)]
Figure 1-1. Levels of combat health support.
1-2. THE ROLE OF THE UNITED STATES ARMY MEDICAL DEPARTMENT
a. The United States Army Medical Department (AMEDD) plays a key role in
developing and maintaining combat power. Its mission is to maintain the health of the
1-2
Army. By maintaining the health of the Army, the AMEDD helps to conserve the
Army's fighting strength.
b. Commanders need to retain experienced and seasoned personnel to perform
their particular operational mission. If injured soldiers can be treated and returned to
duty as far forward as possible, the load on the replacement system is diminished and
the requirements for patient evacuation are decreased. On the other hand, the
accumulation of patients within any combat unit restricts the unit's movements. A
perceived lack of CHS may also reduce a soldier's willingness to take necessary risks.
1-3. STABILITY AND SUPPORT OPERATIONS
The range of operations includes war, conflict, and peacetime activities (see
Figure 1-2).
a. Peacetime. The United States classifies its activities during peacetime and
conflict as stability and support operations (SASO). Although the Army's prime focus is
war, its frequent role in SASO is critical. During peacetime, the United States attempts
to influence world events through actions that routinely occur between nations below
the threshold of conflict.
b. Conflict. Hostile forces may seek to provoke a crisis or otherwise defeat our
purpose by creating a conflict. When diplomatic influence alone fails to resolve a
potential conflict, persuasion may be required. The physical presence of the military,
coupled with its potential use, can serve as a deterrent and facilitate the achievement of
strategic objectives. Should this deterrence fail, the United States may use force to
compel compliance, thus entering a more intense environment in order to resolve the
conflict and pursue its ultimate aims. Conflict is often protracted, confined to a
restricted geographic area, and constrained in weaponry and level of violence. The
goal in conflict is to deter war and resolve the conflict.
c. War. War is the sustained use of armed force between nations or organized
groups within a nation. It may involve regular and irregular forces in a series of
connected battles and campaigns to achieve vital national objectives. War may be
limited with some self-imposed restraints on resources or objectives, such as in
Operation Desert Storm in 1990. This was an armed conflict short of general war. A
war may also be general, as in World War I and World War II, with the total resources
of a nation or nations employed and the national survival of the belligerents at stake.
STATES OF
THE
ENVIRONMENT
GOAL
MILITARY
OPERATIONS
1-3
EXAMPLES
WARTIME
CONFLICT
(RESOLUTION)
PEACETIME
Fight
and
Win
WAR
Deter
War
and
Resolve
Conflict
SASO
Promote
Peace
SASO
 Large-scale
combat
operations.
 Attack.
 Defense.
 Strikes & raids.
 Peace
enforcement.
 Support to
insurgency.
 Anti-terrorism.
 Peacekeeping.
 NEO.





Counterdrug.
Disaster relief.
Civil support.
Peace building.
Nation assistance.
The three states of the environment listed above (war, conflict, and peacetime)
could well co-exist at the same time in a given theater commander's strategic
environment.
The commander can respond to requirements with a wide range of military
operations.
Noncombatant operations might occur during war, just as some SASO might
require combat.
Figure 1-2. The range of military operations in the theater strategic environment.
1-4
1-4. THE TENETS OF ARMY OPERATIONS
The Army's success on and off the battlefield depends, in part, on its ability to
operate IAW five basic tenets of Army operations. It also entails the successful
integration of these tenets with CHS goals and principles. To enhance the maneuver
commander's chances of success, medical commanders must apply the tenets of Army
operations in executing their mission. All training and leadership doctrine and all
combat, combat support, and combat health support doctrine derived directly from
these fundamental tenets. Tenets of Army operations are initiative, depth, agility,
synchronization, and versatility. The Army believes that its five basic tenets are
essential to victory, though in and of themselves the tenets do not guarantee victory.
a. Initiative. The first tenet of Army operation is initiative. The tactical operation
must not be affected by a lapse in CHS. To prevent any lapse, CHS units must move
rapidly to provide the continuity of care needed to protect and sustain the force, thus
preserving the initiative. Leaders must anticipate events on the battlefield so that they
and their units can act and react faster than the enemy. Combat health support
commanders must take the initiative to place medical support in harmony with the
movement of the units and casualty projections.
b. Depth. Depth, the second tenet, is the extension of operations in terms of
time, space, resources, and purpose. Most importantly, it means the ability to gain
information and to influence operations throughout the depth of the battlefield in
conjunction with other services. From the CHS perspective, commanders and staffs
must understand the maneuver commander's plan. They must be able to visualize the
battlefield in depth and breadth.
c. Agility. Agility, the third tenet, is the ability to rapidly adjust to changes in the
tactical situation. Agility is a prerequisite for seizing and holding the initiative. It is as
much a mental as a physical quality. Combat health support must be capable of rapid
adjustment to changes in the tactical situation. Success in sustaining the force
depends on a well-developed and responsive CHS system. The medical commander
must retain the ability to shift medical resources to provide CHS to areas of large
patient concentration or density. Responsive CHS is important to the individual
soldier's morale and hastens an early return to duty (RTD).
d. Synchronization. Synchronization, the fourth tenet, means effectively
arranging and integrating activities in time and space for a common end. For example,
the evacuation of patients requires synchronizing movement with logistical support, air
support, and the availability of beds. With unity of purpose throughout the force, every
resource is more likely to be used where and when it will make the greatest contribution
to success. Ideally, with proper synchronization, nothing is wasted or overlooked. The
hallmark of good CHS is creativity. Combat health support commanders must seek
innovative solutions to CHS challenges. Every action must flow from an understanding
of the higher commander's concept of the operation. The CHS requirements must be
1-5
integrated into operational planning to increase the capability of medical units at all
echelons to provide effective support. Ultimately, the product of effective
synchronization is maximum use of every resource to make the greatest contribution to
success. It requires judgment in choosing among simultaneous and sequential
activities. Good synchronization requires a clear statement of the commander's intent.
e. Versatility. Versatility, the fifth tenet, was added as a result of the proliferation
of SASO in recent years. Versatility means the ability of units to meet diverse mission
requirements. (It may not be in your job description of duties assigned, but it has to get
done.) Commanders must be able to shift focus, tailor forces, and move from one role
or mission to another rapidly and efficiently. Versatility implies a capacity to be
multifunctional, to operate across the full range of military operations, and to perform at
the tactical, operational, and strategic levels. Combat health support forces must be
able to move rapidly from one geographic region to another and from one type of
warfare to another in a force projection Army.
1-5. GOALS OF THE COMBAT HEALTH SUPPORT SYSTEM
Combat health support goals must be integrated with the five tenets of Army
operation. By so doing, accomplishment of CHS goals will be more likely. Combat
health support goals are:
a. Reduce disease and nonbattle injury (DNBI).
b. Provide medical and surgical treatment for illness, injury, and wounds.
c. Evacuate patients to appropriate medical treatment facilities (MTFs).
d. Maintain aggressive and robust science and technology base.
1-6. COMBAT HEALTH SUPPORT PRINCIPLES
Combat health support principles must also be integrated with the Army
operations tenets. Combat health support principles are given below.
a. Conformity. Conformity with the tactical plan is the most basic element for
effectively providing CHS. By taking part in the development of the commander's plan
of operation, the CHS planner can determine requirements and plan the support
needed to conform to tactical operations.
b. Proximity. The objective of proximity is to provide CHS to sick, injured, and
wounded soldiers at the right time and to keep morbidity and mortality to a minimum.
The CHS resources are employed as close to the area of combat operations as time,
distance, and the tactical situation allow. Military treatment facilities may be moved to
areas in which the patient population is greatest, but they are not placed in areas that
might interfere with combat operations. Proximity to the patient population without
1-6
hampering combat operations is the desired outcome. This is achieved through
continuous coordination of medical commanders and staff.
c. Flexibility. Combat health support leadership must be prepared to shift
resources to meet changing requirements. Changes in tactical plans or operations
make flexibility in CHS an essential factor. Since all CHS units are used somewhere
within the theater and none are held in reserve, alternate plans must be made for
redistribution of CHS resources, as required.
d. Mobility. The objective of mobility is to ensure that CHS assets remain close
enough to support maneuvering combat forces to be effective. The mobility of medical
units organic to maneuver elements should be equal to the forces being supported.
Major CHS headquarters in the theater of operations (TO) continually assess and
forecast unit movement and redeployment. Through the use of organic and nonorganic
transportation resources, commanders can rapidly move CHS units to best support
combat operations. For example, if one unit is immobilized, a similar unit may be
leapfrogged past it. An immobilized unit may be given priority in evacuating its patients
so it can again become mobile and move forward.
e. Continuity. Continuity in care and treatment is achieved by moving the
patient through a progressive, phased CHS system to an area as far rearward as the
patient's condition requires, possibly all the way to the continental United States
(CONUS). Each type of CHS unit contributes a measured, logical increment
appropriate to its location and capabilities.
f. Control. The objective of the final CHS principle, control, is to ensure that
scarce CHS resources are efficiently employed in support of the tactical and strategic
plan. Control also ensures that the scope and quality of medical treatment meet
professional standards and policies.
1-7. MEDICAL THREAT
The AMEDD views the threat from two perspectives, both of which are rooted in a
potential adversary's capability to conduct combat operations. The first of these
viewpoints is similar to the way in which the threat is viewed throughout the Army, that
is, a potential enemy's capability to disrupt CHS operations. The second perspective
focuses more on the AMEDD's responsibility to anticipate and prevent the degradation
of soldiers' health and performance by environmental hazards and military capabilities.
The second perspective is called the medical threat. Note that the wounds suffered by
the casualty as a result of combat operations are considered to be a part of the medical
threat.
1-8. ELEMENTS OF THE MEDICAL THREAT
a. Naturally Occurring Infectious Diseases. Naturally occurring infectious
1-7
diseases (NOID), also referred to as endemic diseases, represent a significant threat to
United States armed forces deployed the outside the continental United States.
Historically, infectious diseases have been responsible for more lost foxhole days than
battle injuries. Many naturally occurring infectious diseases have short incubation
periods, which may cause significant numbers of casualties within the first 48 hours to 2
weeks of deployment.
b. Environmental Extremes. When troops go into areas with environmental
extremes, the soldiers' performance may suffer if they have not had the opportunity to
get acclimated. Thus environmental extremes can contribute to mission failure. Many
regions of the world where the United States has vital national interests have areas of
high altitude, high humidity, and extremes in temperature.
c. Battle Injuries--Kinetic Energy and Fragmentation Antipersonnel
Ordnance and Munitions. Any injuries that the casualty sustains are part of the
medical threat. Small arms, high velocity weapons, rockets, bombs, and artillery, as
well as bayonets and other wounding devices, may cause these injuries. Protective
gear can help reduce this part of the medical threat.
d. Biological Warfare. Biological warfare (BW) is defined as the intentional use
of disease-causing organisms (pathogens), toxins, or other agents of biological origin to
cause adverse effects on soldiers. If the enemy has the capability for using BW, then
BW is considered to be a part of the medical threat. The goal of BW is to cause
casualties. The causative agents of anthrax, tularemia, plague, and cholera, as well as
botulinum toxin, staphylococcus enterotoxin, and mycotoxins, are believed to have
been developed as BW agents by potential adversaries of the United States. Many
governments recognize the virtually limitless potential of biotechnology as a tool for the
production of BW agents.
e. Chemical Warfare. Russia has the most extensive chemical warfare (CW)
capability in the world. It can deliver chemical agents with almost all conventional
weapons systems, from mortars to long-range tactical missiles available to ground, air,
and naval forces. Chemical warfare continues to be a medical threat because the
technology is being sold. Despite the dissolution of the Union of Soviet Socialist
Republics (USSR), many of our potential enemies continue to be equipped with former
Soviet technology and weapons systems.
f. Laser Blindness. Laser blindness is also a medical threat. Although laser
goggles are issued to United States troops, the troops may not always be wearing the
goggles when they are needed.
g. Combat Stress. Combat environments affect soldiers mentally as well as
physically. Combat stress (battle fatigue, shell shock) can result.
h. Nuclear Warfare. Use of nuclear devices remains a threat.
1-8
1-9. THE MEDICAL THREAT IN WAR
Commanders should anticipate increased casualty densities as compared to
levels experienced in previous conflicts. The elements of the medical threat with the
greatest potential for force degradation are:
a. Battle injuries --injuries due to artillery, small arms, and fragmentation. [Note:
Land mine incidents were one of the primary causes of United States casualties in
Somalia, accounting for 26 percent of the Americans killed in action (KIA) during
Operation Restore Hope (ORH).]
b. Combat stress casualties.
c. Nuclear, biological, and chemical (NBC) casualties and combined casualties
(casualties with both battle injuries and NBC injuries).
1-10. THE THREAT TO COMBAT HEALTH SUPPORT OPERATIONS IN WAR
a. Overload. Significant increases in casualty densities will cause local or
general overload of the CHS system.
b. Premeditated Attack. Premeditated attack upon medical organizations,
personnel, or Class VIII stores is not anticipated, but it cannot be completely ruled out.
The degrees of adherence to the laws of land warfare are adversary-dependent. A
steady erosion of battlefield medical resources will result based on ever-increasing
range of indirect fire weapons, enhanced wounding capacity, and indirect fire on
medical units. Treatment facilities are part of the rear-to-base clusters. The enemy
seeks lucrative, cost-effective targets rich in potential casualties. Knocking out a supply
unit is one such lucrative target. With their proximity in the rear to supply units, MTFs
could sustain injury due to proximity.
c. Disruption of Communications and Logistics Activities. Enemy combat
operations in friendly rear areas will interdict lines of communication and disrupt
necessary logistics activities. This will produce a serious negative effect on the
AMEDD's ability to retrieve and evacuate wounded, sick, and injured soldiers and
deliver medical care. Lack of air superiority will seriously reduce the use of aeromedical
evacuation (AE) in the forward edge of the battle area (FEBA).
d. Intense, Continuous Operations. Prolonged periods of intense, continuous
operations will tax AMEDD personnel to the limits of their physiological and emotional
endurance.
e. Biological or Chemical Strikes. Combat health support organizations are
not expected to be the primary target for biological or chemical strikes.
1-9
1-11. THREATS IN CONFLICT
a. The Medical Threat in Conflict. The medical threat associated with a conflict
closely parallels that associated with war. However, the operational tempo (fervor of
war) will be slower as compared to the tempo of an out and out war. The greatest
difference between the medical threats at these two levels of conflict is in the expected
number of casualties.
b. The Threat to Combat Health Support Operations in Conflict. The threat
to CHS operations in conflict is virtually the same as in war. The major difference lies in
the number of medical personnel exposed to direct and indirect fire. In other words, the
threat is not as great as in war, but the factors remain the same.
1-12. THE MEDICAL THREAT IN PEACETIME
a. Impact on Indigenous Population. The medical threat is traditionally
evaluated on the basis of its impact on United States forces alone. However, when
preparing for and conducting military SASO operations, the impact of the medical threat
on the indigenous population as a contributing factor to social, political, and economic
instability must be considered.
b. Relatively Prosperous or Needy. The relative prosperity and stability of the
local population can vary. Environments can range from peaceful developing countries
with no apparent internal or external instability to countries with limited resources and a
poorly-fed population beset by disease and dependent on humanitarian assistance.
c. Naturally Occurring Infectious Diseases and Environmental Extremes.
During SASO, the most significant elements of the medical threat confronting United
States forces and mission planners are NOID and environmental extremes.
d. Broad Range of Scenarios in Many Locales. Missions could involve nation
assistance, disaster relief, and humanitarian assistance in a number of countries.
e. Environmental Extremes. There are many extreme environments in which
United States forces could be employed. In extreme environments, there is an
increased potential for performance degradation and illness for unacclimatized troops.
f. Threat Possibly the Same as for Conflict and War. The medical threat
associated with peacetime contingency operations will, under certain combat scenarios,
be the same as the medical threat described for conflict and wartime environments.
1-13. THE THREAT TO COMBAT HEALTH SUPPORT IN PEACETIME
a. Possible Lack of Geneva Convention Protection. The protection afforded
MTFs and medical personnel by the Geneva Conventions may be nonexistent in
1-10
peacetime. Insurgent or terrorist groups may perceive combat health support activities
as lucrative targets. Medical facilities will be vulnerable to theft and raids on Class VIII
medical supplies by insurgents or terrorists who need supplies to support their own or
black-market activities.
b. Austere Logistical System. In peacetime, United States assistance forces
will rely more heavily on local food and water sources, host nation (HN) sanitation,
public health, medical treatment, and health industry resources. There will also be
increased reliance on the United States Air Force (USAF) for strategic medical
evacuation resources in SASO scenarios. In SASO, the evacuation policy is lower.
Fewer beds are needed since the number of patients kept convalescing within the TO is
limited. In SASO, more evacuation to CONUS occurs.
1-14. COMBAT HEALTH SUPPORT BATTLEFIELD RULES
a. Combat Health Support Battlefield Rules. The Office of the Surgeon
General (OTSG) has established CHS battlefield rules prescribing an order of
precedence for medical support to conserve the fighting strength and to assist the Army
in achieving its warfighting goals. Stabilization of casualties is critical to realizing goal
number three (saving lives). Clearing the battlefield of casualties (goal four) frees
soldiers to fight.
b. Combat Health Support Order of Precedence.
(1) Maintain a medical presence with the soldier.
(2) Maintain the health of the command.
(3) Save lives.
(4) Clear the battlefield.
(5) Provide state-of-the-art care.
(6) Ensure an early return to duty.
1-15. CONTINUUM OF MEDICAL CARE
Combat health support organizations provide a seamless continuum of care from
a soldier's point of injury to the sustainment base. This system comprises integrated
medical functional areas consisting of modular-designed organizations with the
capability of being task-organized and employed in incremental packages.
1-16. ECHELONS OF MEDICAL CARE
Each echelon (level of care) has the same treatment capabilities as the preceding
1-11
one. In addition, each succeeding echelon has an increased treatment capability that
distinguishes it from the previous echelon. The term echelon of medical care (United
Nations term) may be used interchangeably with level of care (United States Army
term).
a. Echelon I: Emergency Medical Treatment/Advanced Trauma
Management. The emergency medical treatment (EMT)/advanced trauma
management (ATM) includes the use of intravenous fluids and antibiotics, the
preservation of the patient's airway by invasive procedures, treatment for shock, and
the application of more secure splints.
b. Echelon II: Initial Resuscitative Treatment. At this level, the clinical
judgement and skill of a team (physician, physician assistant, and dentist) is applied. A
staff, basic medical laboratory, broad range of medicinal drugs, whole blood, and a
holding ward supports the team.
c. Echelon III: Resuscitative Surgery. Comprehensive, preoperative
diagnostic procedures, and intensive preparation for surgery are available at this level.
There is intensive preparation for surgery with qualified surgical teams, general
anesthesia, properly-equipped operating rooms, and an adequate postoperative,
intensive-care environment.
d. Echelon IV: Definitive Treatment. At this level of care, treatment is adapted
to the precise condition of the patient. Care is provided at the rear of the combat zone
and at the general hospital (GH) in the EAC. As patients are evacuated to the rear,
treatment becomes more definitive.
e. Echelon V: Rehabilitative and Restorative Care. At this level, the care
provided is definitive and convalescent and is designed to prevent or minimize loss of
physical or psychological function. Prosthetic devices may be provided at Echelon V.
1-12