Commanders of medical units in a theater of operations use their resources to effectively evacuate and treat sick, injured, and wounded soldiers. Whether a soldier survives when wounded on the battlefield often depends on the time it takes to receive treatment. Quick responsive care is essential to protecting the force. Under current force structures, corps medical brigades are equipped with an evacuation battalion, each with 3 to 5 air ambulance companies with 15 UH-60s or UH-1s. Corps medical brigades may be augmented by attached air ambulance detachments and companies from the reserve component. The corps commander will task organize these air ambulances in direct support to division and ACR level on a priority basis. For planning purposes, division commanders can expect a company of MEDEVAC helicopters to be in direct support of the division. The air ambulance company will provide the division with responsive MEDEVAC support. However, during high tempo combat operations it may become necessary to reinforce the supporting MEDEVAC unit. If the situation requires movement of a large number of casualties, or if the force commander believes that reinforcing existing MEDEVAC assets is necessary, he may elect to use utility and cargo helicopters to move casualties to a treatment center. This chapter discusses the use of utility and cargo helicopters for CASEVAC.

a. Medical Evacuation. MEDEVAC is defined in FM 8-10-6 as the timely, efficient movement and en route care by medical personnel of the wounded, injured, and ill persons, from the battlefield and other locations to MTFs. The term MEDEVAC refers to both ground and air assets. Divisions are equipped with both ground and air MEDEVAC assets.

b. Casualty Evacuation. CASEVAC is defined as movement of casualties to initial treatment facilities and movement of casualties to MTFs in the combat zone. It does not include en route care by medical personnel and implies that nonmedical assets (UH-60s or CH-47s) are being used to move casualties. CASEVAC should only be used when the unit has a large number of casualties (exceeding the ability of the MEDEVAC aircraft to carry) or MEDEVAC is not available.

c. Casualty Evacuation Support for Operations. Use of CASEVAC aircraft for combat operations will be determined by the force commander. He should always request the use of MEDEVAC aircraft first. If current MEDEVAC support is insufficient to meet his requirements for evacuation of casualties, he should request CASEVAC support from the aviation brigade. If necessary, requests to use utility helicopters for CASEVAC operations will be made through the division G3. MEDEVAC aircraft that are DS to a division will receive their missions through the DMOC. The DMOC is responsible for airspace control measures and mission planning for MEDEVAC assets. Utility and cargo aircraft conducting CASEVAC support will not be controlled by the DMOC; however, coordination should be made between the aviation brigade and the DMOC for deconfliction of aircraft evacuating casualties. Normally, utility and cargo helicopters will be task organized in a DS role no lower than brigade level. If task organized at division level, these assets will be under the control of the main support clearing company, which locates in the division support area. If under the control of a brigade, the aircraft may be under the control of either the FSMC or the FSB SPO. In either case, the ground commander requesting CASEVAC support must understand that CASEVAC support provides transportation for casualties and does not provide any care en route to the treatment facility.

d. Advantages of Using Utility and Cargo Aircraft in the Casualty Evacuation Role.

(1) The aircraft's speed and range make it possible to move casualties by air relatively long distances in a short period of time.

(2) Helicopters can move patients quickly over rough terrain and get into areas inaccessible to ground ambulances.

(3) Because of the range and speed, casualties can be transported to the MTF that can best deal with the patient's condition.

(4) Utility and cargo aircraft can be diverted from other missions, making them available immediately.

e. Disadvantages of Using Utility and Cargo Aircraft in the Casualty Evacuation Role.

(1) There is no en route medical care for casualties.

(2) Aircraft in the CASEVAC role are not protected under the Geneva Convention.

There are four levels of treatment that have a direct impact on patients as they are treated and evacuated from the FLOT to higher level care facilities. Utility helicopter assets can expect to transport patients between levels I and II. Levels III and IV transport will most likely be accomplished by the corps air ambulance company.

a. Level I. Care is provided by designated individuals or elements organic to combat and CS units. Emphasis is placed on those measures necessary to stabilize the patient and evacuate to the next level of care. Level I care includes individual care (self-aid, buddy aid, combat lifesaver) and battalion aid station care.

b. Level II. Care is rendered at a medical clearing station. Here the casualty is examined and wounds and status are evaluated to determine the treatment and evacuation precedence. Level II care includes the brigade medical clearing company, the division medical company, and corps medical assets.

c. Level III. Care is rendered at a medical treatment facility staffed and equipped to provide resuscitation, initial wound surgery, and post operative treatment. Level III care includes corps CSH, contingency hospitals, fleet hospitals, and hospital ships.

d. Level IV. In level IV care the patient is treated in a hospital staffed and equipped for general and specialized medical procedures.

Evacuation of casualties on the battlefield begins with the individual unit. The tiered MEDEVAC system begins at company level. Each successive level provides more life sustaining care. Utility helicopters will interact with this system to ensure that casualties are moved from the fight to medical aid as quickly as possible. Figure 6-1 shows the division medical structure.

a. Company Level Care. Company first sergeants and Xos are normally given responsibility to coordinate CASEVAC for the company. The first sergeant ensures that combat lifesavers have the required equipment on hand, and that company transportation, if available, is prepared to move casualties.

b. Battalion Level Care. Each maneuver battalion contains a medical platoon. If the situation dictates, the battalion aid station may split into two treatment teams. One team is headed by the battalion surgeon and the other by the battalion physician's assistant. These two teams, called the MAS and FAS can operate independently for up to 24 hours. The medical platoon has an ambulance section that has the responsibility of going forward to the maneuver companies and picking up casualties. They transport these casualties from the company collection point to the battalion MAS or the battalion FAS. Battalions may be augmented with a team from the ambulance section of the brigade FSMC.

(1) The MAS consists of the battalion surgeon, medics, and ambulances. At this location patients are evaluated, treated for immediate life sustaining care, and stabilized for transport to a higher level treatment facility. Equipment assigned to the MAS will vary depending on the type of battalion.

(2) The FAS is set up identical to the MAS, except that the primary care provider at the FAS is the battalion PA. It is equipped just as the MAS is and provides the same function.

(3) The MAS and FAS provide the battalion with two Level I medical care facilities. They normally operate in a "leapfrogging" mode. As the battle moves, the MAS and FAS will move to remain in support of the battalion. As one facility sets, the other will move forward of it (leapfrogging). This allows the maneuver battalion to sustain the tempo of the attack without loss of medical care. Additionally, if the battalion loses one aid station they continue to have a medical treatment facility.

c. Brigade Level Care. Casualties are moved from the battalion MAS and FAS to the FSMC located at the BSA. Battalion assets are responsible for transferring patients from the battalion aid stations to AXPs, where responsibility is passed to the brigade medical assets.

(1) Ambulance exchange point. An AXP is a location where casualties are transferred from the battalion to the brigade ambulances. AXPs will be designated in the OPORD under the service support annex. AXPs will be activated and deactivated based on the current situation on the battlefield. The brigade medical company will position ambulances from the ambulance platoon at the AXPs to accept casualties from the battalion. Evacuation will then be to the BSA.

(2) Brigade forward support medical company. The FSMC is located in the BSA. It is a level II treatment facility. The FSMC will establish an LZ within the BSA specifically for casualty movement operations.

d. Division Level Care. The division medical care consists of the MSMC. This level II facility is located in the DSA. Like the medical company in the BSA, this company will establish a casualty LZ located in the vicinity of the medical hospital.

a. UH-60s. UH-60s can provide CASEVAC support to the brigade and division. The number of casualties that can be transported by the UH-60 varies depending on aircraft con-figuration, such as seats in or seats out and other equipment that may be on board the aircraft. Additionally, the severity of the wounds of the casualties, as determined by the company combat lifesavers or battalion medics, may determine the ACL for the UH-60 for particular missions. UH-60s can expect to be used as far forward as possible to evacuate casualties to the battalion aid stations (MAS/FAS) or the FSB medical company.

b. CH-47s. CH-47s can be used for CASEVAC using several different configurations.

(1) Seats folded. With seats folded up, the number of casualties that can be transported is dependent on the type of casualty (ambulatory versus litter) and the severity of the injuries and wounds to the casualties.

(2) Seats down. With seats folded down, the lifting capacity for litter patients will be reduced. Ambulatory capabilities in this configuration will be 30 seated ambulatory casualties and others loaded on the floor, as directed by the aircrew.

(3) Litter configuration. CH-47s can be equipped with a litter kit. This kit gives the CH-47 the capacity to transport 24 litter patients. When set up in the litter configuration, the CH-47 seats are replaced with six tiers of litters, four litters high.

Note: The litter support kit of the CH-47 consists of the poles and supports only. Litters and tie- down straps must be provided by the supported unit. The litters must be provided by the medical assets belonging to the unit the CASEVAC aircraft are supporting.

a. General. During air assault operations, the AATF staff and aviation battalion plan for the use of lifting aircraft to backhaul casualties from the LZ. Additionally, the force commander plans for MEDEVAC aircraft to support his operations. However, flowing MEDEVAC aircraft in during the air assault may become difficult and conflict with the ongoing operation. In this case, the AATFC and AMC will plan for CASEVAC operations by the assaulting aircraft. On air assaults with multiple lifts, the AATF plans for using the lifting aircraft to pick up casualties during successive lifts. On single lift air assaults, aircraft are designated to remain on standby for CASEVAC operations. These aircraft will normally stand by at a central location, most likely the PZ, FARP, or established holding area.

b. Mission Planning. The backhaul of casualties on an air assault is a critical mission for the utility helicopters, and one that requires detailed planning to execute successfully. During the planning stages of the air assault, the AATF S3, S3 (air), AMC, aviation S3, and LNO must all be involved in the planning for this operation. If the AATF commander's intent is to backhaul casualties, then the planning must include the following considerations:

(1) Air assault task force commander's intent. The AATFC must clearly state his intent for casualty backhaul during the air assault. The AMC must inform the commander of the tradeoff between using lifting aircraft for backhaul and continuing with the air assault. If the AATF takes casualties early in an air assault operation, it may become necessary to reduce the amount of lifting aircraft to accomplish backhaul of casualties. The AATFC should determine the number of aircraft he can bump from the air assault to pick up casualties. He may decide not to bump any and conduct all MEDEVAC or CASEVAC after the completion of the air assault, or he may designate aircraft in each lift (such as the last two aircraft) for backhaul of casualties from the LZ. It is imperative that the AMC understand the AATFC's intent on casualty backhaul and advise him on courses of action.

(2) Casualty locations. The AATF should designate an area in the LZ for casualties to be brought. This will facilitate rapid movement and minimize ground time in the LZ for the aircraft. Since most air assaults will occur at night, it is critical that the casualty point be designated and that all members of the AATF know its location. The aircrews, as the arrive at the LZ, will be able to focus on the casualty point and be prepared to accept casualties.

(3) Signaling. Night operations provide a significant challenge for casualty backhaul operations. Light signals should be planned so that aircraft arriving at the LZ can be prepared to accept casualties. For example, a flashlight or chem light coming from the designated LZ casualty location may indicate that there are casualties to be backhauled. This way the aircrews know that they must remain on the LZ and be prepared to accept casualties.

(4) Communications. Once established in the LZ, communications on the CAN or a predesignated radio net can alert the flight of the necessity to backhaul casualties from the LZ.

(5) Designated area for dropping off casualties. The AATF commander must decide where to transport casualties if they occur during the air assault. During the planning process, the AATFC should develop a plan for the use of MEDEVAC helicopters. As the lifting aircraft drop off casualties, they can be loaded on to a MEDEVAC aircraft for transportation to higher level care facilities. Options include the PZ, the FSMC at the BSA, or another designated area. Considerations for selecting a casualty collection point should be--

(a) Casualty status. A site should be selected that is secure and has medical personnel ready to accept casualties.

(b) Aircraft availability. Aircraft conducting casualty backhaul will separate from the serial at some point. The AATF commander must be prepared to effect the bump plan if the aircraft carrying casualties do not return to the PZ for the next lift.

(c) Confusion. A casualty collection point should be selected so that it does not interfere with the air assault that is still in progress. Aircraft arriving at the PZ full of casualties may cause confusion on the PZ as troops are trying to load, and casualties are being unloaded from the aircraft.

(d) Aircraft rejoin. A site should be selected that allows the lifting helicopters to quickly drop off the casualty and return to the PZ to continue the tempo of the air assault operation.

CASEVAC mission planning must be detailed. The air movement planning considerations listed in Chapter 4 apply to CASEVAC operations as well. Units conducting CASEVAC missions should refer to this chapter to thoroughly plan and accomplish the mission. In addition, the following mission planning considerations should also be considered when preparing to conduct a CASEVAC mission:

a. Landing Zones/Pickup Zones. LZs /PZs for CASEVAC operations are the responsibility of the supported unit. For example, battalion aid stations are responsible for setting up the LZ/PZ for CASEVAC operations. LZ/PZ selection criteria for a CASEVAC LZ/PZ are location, marking, communications, capacity, and obstacles.

(1) Location. The LZ/PZ must be in close proximity to the aid station. Casualties may have to be carried by hand to the waiting aircraft. However, the LZ/PZ must be set up at a distance where it will not interfere with aid station operations. If possible, set the LZ/PZ up downwind from the aid station. This will help prevent blowing dust on the aid station. A minimum distance of 150 meters should be acceptable to keep aircraft from interfering with aid station operations.

(2) Marking. LZ/PZ markings must be visible from the air. During the day, marking of the LZ/PZ can be accomplished using a VS-17 panel, smoke, or signal mirror. If using a VS-17 panel, ensure it is visible from the air. At night, an inverted Y is used to designate the aircraft touchdown point. However, this may not be visible from the air. LZs/PZs should also have a far recognition signal, such as a swinging chem light or strobe light, to make the LZ/PZ easier to find.

(3) Communications. Air-to-ground communications should be maintained between the aircraft and the LZ/PZ. Effective communications will make movement times faster and assist the aircraft in locating the LZ/PZ.

(4) Capacity. LZ/PZ selection is based on the number of aircraft and type aircraft that will be used for the CASEVAC operation. The size determines how many aircraft can be landed at one time to load casualties.

(5) Obstacles. LZs/PZs should be free of obstacles. Obstacles such as cables, wires, antennas, large rocks, excessive slope, and large ruts can make the location unsuitable. Obstacles that cannot be cleared from the location should be marked. If communications are maintained with the aircrew, advisories should be provided to the crews as to hazards in the LZ/PZ.

b. Medical Support. As defined, CASEVAC operations do not provide any en route medical treatment. Commanders and medical personnel must consider this when determining if utility helicopters should be used to transport casualties.

c. Litters. Flight crews conducting CASEVAC missions must be told what to do with litters. The battalion aid stations need to have litters resupplied as casualties are evacuated to a higher level of care. Aircraft on CASEVAC missions may need to pick up litters at the drop off location and return them to the casualty PZ to keep the battalions resupplied. For example, once helicopters move casualties from a battalion aid station (MAS or FAS) to the BSA, the MAS or FAS may need the aircraft to backhaul litters for use in further CASEVAC missions. Flight crews must be briefed of this requirement and be prepared to execute litter backhaul to keep the battalion aid stations supplied with necessary litters.

d. Army Airspace Command and Control. If the division has MEDEVAC aircraft attached or OPCON to it, the DMOC will be responsible for planning the A²C² measures that these aircraft will be using. Utility helicopters conducting CASEVAC missions in support of the medical companies of the BSA or DSA should check with the DMOC for the current MEDEVAC airspace structure. These procedures will also be specified in the airspace control order or SPINS.