Military

(1) Combat in urban areas generates a high demand for tires.

(2) The dust and rough handling characteristic of combat in urban areas also places great strains on communication and night observation devices.

(3) The unit armorer and their small-arms repair kits provide only limited maintenance. S4s should plan for increased weapon maintenance demands and coordinate maintenance support from higher headquarters. Based on recommendations from the staff (S3, S4, and motor officer), the commander may choose to consolidate and cross level major items of equipment and weapons.

(1) MEDEVAC. The battalion surgeon (medical platoon leader), in coordination with the S1 and company first sergeants, must plan to expedite the evacuation of the wounded out of the urban area. Forward aid station locations and evacuation routes must be planned and disseminated to the lowest level. Higher casualty rates should be expected and may require stockpiling medical supplies and augmenting medical personnel and nonmedical personnel to serve as litter bearers.

(2) Replacements. The battalion PAC should process replacements quickly and transport them to their new unit. The battalion PAC is responsible for reviewing assignment orders, welcoming soldiers to the battalion, assigning soldiers IAW commanders priorities, obtaining personal information, and collecting medical records and forwarding them to the aid station. It is also responsible for adding names to the battle roster, preparing SIDPERS input, and processing the names into the servicing postal activity. The S1 and PAC should brief the new soldiers on the tactical situation, provide mess and medical support as needed, inspect for combat critical equipment shortages, and coordinate transportation to units. Company replacements should be brought forward from the field trains with the LOGPAC and linked up with their new unit's first sergeant. If replacements are brought forward at unscheduled times, the logistic release point (LRP) should still be used as the linkup point. The S1 must coordinate with the S3 or S4 to transport replacements over long distances and to issue missing individual combat equipment. At night, replacements may need to be sent to their new unit with guides. These groups may be used to carry critical supplies and ammunition forward.

(3) Personnel Accountability. Proper accountability of platoon personnel and accurate strength reporting are essential to support decision making by platoon leaders, company commanders, and the battalion commander. Using battle rosters, leaders in the platoon maintain accurate, up-to-date records of their personnel. At periodic intervals, they provide strength figures to the company CP. During combat, they provide hasty strength reports on request or when significant changes in strength occur.

(4) Casualty Reporting. By-name casualty information is reported by secure means to company headquarters during lulls in the tactical situation. Soldiers having direct knowledge of an incident complete a DA Form 1155 (Witness Statement on Individual) to report missing or captured soldiers, or casualties no longer under US control. DA Form 1156 (Casualty Feeder Report) is used to report soldiers who are killed or wounded. (See AR 600-8-1 for instructions on how to complete these forms.) After being collected and reviewed for accuracy by the platoon leader or platoon sergeant, these forms are forwarded to the company headquarters. These forms provide important casualty information and are also used to determine the platoon's replacement requirements.

(5) Stress Management. The surgeon, in coordination with the S1, must develop a flexible and comprehensive combat health support (CHS) plan to treat and or evacuate those with battle fatigue or combat stress. Medical personnel can provide training to unit leaders on recognizing stress and actions, which can be taken to mitigate its effect. (Refer to FM 22-51 for information on combat stress control for unit leaders.)

(1) Urban combat causes great stress on soldiers and requires great physical exertion. This combination of stress and exertion causes rapid dehydration. Unless potable water is continuously provided, soldiers will seek local sources, which are usually contaminated by POL runoff, sewage, bacteria, or unburied corpses. Soldiers who are not provided sufficient quantities of potable water become casualties due to drinking from contaminated sources or from dehydration. Waterborne contamination can quickly render entire units combat-ineffective.

(2) Water and other liquid supplements such as coffee, tea, or soup that must be brought forward to exposed positions may need to be backpacked there at night.

(1) In the defense, the S4 should prestock as much ammunition as practical in dispersed storage areas. These storage areas should be protected and have easy access from the forward defensive positions. In the offense, attacking troops should not be overburdened with excessive ammunition. Mobile distribution points may be set up as low as company level.

(2) Commanders and S4s must plan to deliver ammunition continuously to the leading elements as they advance. Armored vehicles may carry this close behind the advancing troops or by designated carrying parties. Modern ammunition is characterized by extensive amounts of packing material. The S4 must plan to have an element remove the ammunition depot's overpack before it is transported forward. Resupply by helicopter (prepackaged slingloads) may be feasible.

(3) Removing the outer packaging from large amounts of ammunition can be time-consuming. It may require the efforts of the entire support platoon, augmented by available soldiers. If carrying parties are used to move ammunition forward, an individual can carry about 75 to 90 pounds using a pack frame or rucksack. Carry the bulky and heavier loads by lashing them to litters and using carrying teams (two to four men). Loads up to 400 pounds can be carried moderate distances using four-man teams.

(1) Movement of LOGPACs. Once the LOGPAC is formed in the field trains, it is ready to move forward under the control of the supply sergeant. The support platoon leader normally organizes a convoy for moving the LOGPACs along a supply route to the logistics release point (LRP), where the first sergeant or XO takes control. The LRP is usually a covered and concealed position that offers protection to those distributing supplies (for example, a large enough building that can be secured locally).

(2) Pre-positioned Supplies. Based on METT-TC factors, LOGPACs may be pre-positioned in predetermined locations by the battalion S4. The LOGPAC would be placed in a covered and concealed location where the company retrieves the supplies. This system works best when the company is moving from one location within the urban area to another in a relatively secured area. Care should be exercised to ensure supplies are not left unprotected or pilfered through by the enemy or civilians. For example, the company can provide a two- to four-man security team to the S4 to guard the pre-positioned supplies until the company can recover them.

(1) In Position. This is the most common technique that will be used on urban terrain when the company is conducting operations that require platoons to maintain combat power forward (during contact or when contact is imminent). For example, this technique would probably be used during the consolidation and reorganization phase of an offensive operation where a counterattack is expected. Ammunition, medical supplies, and water would be brought forward by the support element and resupplied directly to the platoons in cleared buildings. All the assaulting platoons would remain in position.

(2) Out of Position. This technique is used when the situation does not require all combat power to be forward (contact is not likely). The XO or first sergeant would establish a resupply point in a covered and concealed position (a cleared building with overhead cover) to the rear of the platoon. Platoons would send selected personnel back to the resupply point, pick up the supplies, and move back to position.

(3) Pre-Position. This technique is most often used during defensive operations when supplies are often cached (pre-positioned and concealed) in buildings throughout the company sector or subsequent battle positions.

(1) LOGPAC vehicles must be prepared to back-haul captured enemy equipment and prisoners. Ensure drivers and company supply personnel are proficient in handling EPWs.

(2) Train and qualify supply personnel to configure and rig supplies for external helicopter lift.

(3) Consider deploying with airload slings and nets, and have procedures in place to expedite resupply operations.

(4) Train resupply personnel to receive container delivery system (CDS) bundles from a C-130 or C-141. This is a viable means of resupply in urban terrain when convoys and Army aviation are limited.

(5) Soldiers must deploy with extra sets of clothing. Uniforms deteriorate quickly in urban combat; especially in hot, humid conditions.

(6) Soldiers must deploy with sufficient toilet articles to sustain them for at least 15 days. Sundry packs are not maintained in the depot system and soldiers may not be resupplied with health and hygiene articles for up to 60 days after deployment.

(7) Soldiers may have compassion for disadvantaged people and may give away clothing and rations. Commanders and first sergeants must monitor this situation, and caution soldiers in austere conditions.

(1) Standardize the way items are carried within the unit. Soldiers should evenly distribute items on their load-carrying equipment (LCE) and the cargo pockets of their BDUs. Do not place anything on the firing side of the LCE that interferes with aiming the weapon.

(2) Distribute loads throughout the unit. Have the assault element only carry the items necessary to accomplish the mission, usually ammunition and water. Designate individuals in the support element to bring additional ammunition, medical supplies, and water forward as the tactical situation permits. Replace ammunition and water carried on the LCE as soon as possible. Medical personnel can only carry medical supplies; carrying ammunition is a violation of the Geneva Conventions.

(3) Designate individuals who will perform breaches and modify ammunition loads accordingly. Rotate these individuals when they tire, or after they have made numerous breaches.

(4) Rotate the assault element after each intermediate objective is secured, as the tactical situation permits. Try to maintain fresh assault troops to the maximum extent possible.

(5) Always consider the use of augmented transportation assets to carry loads. (For example, host nation or allied force vehicles, pack animals, civilian volunteers, wheelbarrows, and bicycles; however, do not procure them without authority.)

(6) Avoid unnecessary movement and displacements. To conserve the soldier's stamina, plan the mission as efficiently as possible.

(7) All leaders must supervise the soldier's load closely, through precombat inspections (PCIs), to ensure that soldiers carry only the items necessary.

(1) Plastic Bags. This technique involves using double or triple stacked plastic bags to preconfigure soldier resupply. Resupply could include prefilled magazines, MREs, bottled water, and first aid dressing. Plastic bags are readily available and do not require back haul.

(2) Plastic Bladders. Plastic bladders used in milk dispenser machines in most military dining facilities make excellent water containers. These bladders hold about five gallons of water, have a spout that permits canteens to be filled easily, and will fit into a rucksack or other container. These bladders have survived 60-foot drops from hovering helicopters when placed inside an empty MRE box. The bladder and MRE box are expendable. A box of 100 bladders is inexpensive and readily available through supply channels.

(3) Water Bottles. In many recent operations bottled water was the standard for supplying water to the soldier for individual consumption. During UO, this type of water distribution can be both a benefit and challenge. Although plastic water bottles are easy to transport and eliminate the need for back haul, they are expensive; usually require a contract with a commercial provider; and, in bulk, come in flimsy cardboard boxes. Regardless, this may be the best solution for water resupply in many situations.

(4) Speed Balls. This technique uses helicopters and preconfigured loads to resupply units. In urban areas, rooftops or secured drop-off points, such as small parking lots or playing fields, are used (Figure 13-1). CSS personnel prepackage supplies in aviation kit bags, duffle bags, or other suitable containers. Helicopters fly as close to the drop point as possible, reduce speed, drop supplies, and leave the area quickly in order to reduce exposure time. Supplies should be prepackaged in bubble wrap or other shock-absorbing material to minimize damage. This technique can work well where there is a minimal or no air defense threat and where the units receiving supplies are light infantry or other dismounted type forces.

(5) Rope. A technique similar to speed balls is to lower water cans or supply containers from a rope. Water cans or containers are attached to the rope using a snap link and slid down. Once the supplies are received, the same rope can be used to back haul empty water cans or other items. Care must be taken to insure that a counterweight remains at the end of the rope to insure that it does not flap into the wind and catch the helicopter propellers. Heavy items can also quickly slide down the rope and damage the supplies, for example a five gallon water can weighs 40 pounds. Multiple water cans and/or "speed balls" can be linked together by means of a sling rope that has a snap link attached. To slow the rate of descent, a round turn can be applied to the snap link holding the supplies. Additionally, the rope can be belayed from the ground, which will also control the rate of descent.

(6) SKEDCO Litters. SKEDCO litters can be used effectively during UO at the squad and platoon level to move supplies and equipment. The litter can be used to move heavier items, such as mortar rounds, through difficult areas such as rubble. Additionally, SKEDCO litters can be used in conjunction with ropes and pulleys to haul supplies along the side of a building or through elevator shafts or destroyed stairwells.

(7) Body Bags. A "human remains bag" (NSN 9930-01-331-6244) Type 2 can be used to move supplies. The word "SUPPLIES" should be clearly stenciled in a bright color on the bag to avoid confusion. These bags are useful because they are durable, waterproof, have carrying handles, can hold a large number of items, and can be folded and carried in a rucksack. They are readily available through supply channels.

(1) Casualty Collection Point (CCP). Although litter teams are labor intensive, they are required for evacuation from buildings, where casualties can occur on any level. Also, rubble in the streets, barricades, and demolition of roads impede the use of ground ambulances, requiring a heavy reliance on litter teams. Casualties are brought to the designated CCP and evacuated from there to the battalion aid station. The CCP is placed in a covered and concealed location that has overhead cover (usually a heavy-clad building that has not collapsed). The CCP should be located at a point where the field ambulances can reach them, yet close enough to the combat area so that casualties do not have to be carried great distances. It must be marked well enough that it is easy to find. By predesignating collection points, soldiers who are wounded but still ambulatory can walk to these points, hastening the CASEVAC effort.

(2) Air Ambulances/Shuttle System. When available, air ambulances equipped with the rescue hoist may be able to evacuate casualties from rooftops or insert medical personnel where they are needed. The vulnerability to enemy fire must be considered and weighed against probable success of the evacuation mission. Pilots must be familiar with over flying urban areas and the atmospheric conditions they may encounter. A litter/ambulance shuttle system with collection points, air exchange points (AXPs), and relay points can be established within the battalion area. The first sergeant or XO can coordinate with the S1 and S4 to determine the location of the AXPs within the urban area in order to facilitate MEDEVAC for the company. By establishing an ambulance shuttle system, the distance required to carry casualties by litter teams is shortened. Air ambulances can also be used at secured ambulance exchange points to hasten evacuation time.

(3) Communications. Communications present one of the biggest obstacles to CASEVAC. Due to the terrain, line-of-sight radios probably will not be effective. Also, individual soldiers normally do not have access to radios. Therefore, wounded soldiers may be difficult to find and evacuate. The unit SOP should contain alternate forms of communications such as colored panels or other types of markers that can be displayed to hasten rescue when the battle is over. (See Appendix I for more information.) Also, a systematic search of the area after the battle may be required to recover casualties. Consideration may be given to marking the CCP so that it is visible to individuals trying to find it. Buildings and streets can cause confusion and disorient individuals trying to evacuate wounded.

(5) Special Equipment. Special equipment requirements include ropes, pulleys, SKEDCO litters and stokes litters, axes, crowbars, and other tools used to break through barriers.

(1) If a soldier is wounded in an open area (for example, crossing a street), the first impulse of his fellow soldiers is to rush to his aid. However, since the casualty is located in an open area and probably exposed to sniper fire, soldiers (who are going out to rescue the wounded) are likely to become casualties. The combat medic should approach as closely as possible to the casualty, while still remaining under cover, and try to verbally determine the casualty's status.

(2) The combat medic may be required to move a soldier before he has the opportunity to fully assess the potential for spinal injury. If the casualty is in imminent danger (such as near a burning vehicle or being exposed to gunfire), the combat medic or another soldier may be required to move him before the application of a cervical collar and or spine board can be accomplished. In this case, the combat medic should try to move the wounded soldier as efficiently and smoothly as possible. The rescuer can grasp the shoulders of the patient and use his forearms to temporarily stabilize the neck while the casualty is being dragged to safety.

(3) The combat medic must remain aware of his location when treating casualties as well as being familiar with information about urban construction and weapons effects to knowledgeably select effective cover for himself and his patients. Some building materials will not stop fragments or small arms. For example, casualties may be moved to a relatively safe area behind the wall of a building; however, if the wall is damaged and there are gaping holes, the medic and his patient may still be subjected to sniper fire through the openings. If the area is enclosed, they may be subject to ricochets, or if the wall is made of wood, depending upon its thickness and density (plywood versus oak), small arms fire will probably penetrate it. Another consideration is the type of building construction (for example, framed or massed), and the potential for collapse if hit by artillery or tank fire.

(4) If casualties are located above or below ground level, it may not be feasible to reach them until a lull in or cessation of the battle occurs. Special equipment, such as collapsible ladders or ropes and pulleys, may be required to reach these casualties. The time required and the complexity of erecting a means to reach the casualty may jeopardize the safety of the rescuers and the accomplishment of the mission.

(5) The combat medic must guard against exhausting or seriously depleting his medical supplies on the initial casualties. The duration of the battle and or the number of patients may increase. Having each soldier carry the medical supplies for his own initial treatment enhances the combat medic's ability to conserve his medical supplies.

(1) While the casualty and combat medic are still subject to hostile fire, there is little medical treatment that the combat medic can provide. If the casualty has a severe hemorrhage, the combat medic may be able to place a tourniquet on it. The combat medic's first priority, however, is to survive and defend himself and his patient. Once the combat medic can move the casualty to a more secure location, such as under cover or behind a wall, he can more fully assess and treat the casualty. This is the same principle as used in emergency medicine—to remove the patient from the source of injury.

(2) One of hardest and most essential tasks the combat medic must accomplish is to quickly and accurately triage the patient conditions he is faced with. EXPECTANT category patients must be protected from further injury and, if possible, made comfortable, but the focus of the combat medic must be directed towards those patients whose chances of survival are greater.

(3) The combat medic ensures that each patient has an open airway, bleeding is controlled, and circulation maintained. Once this is completed, he must assess the mental status of the wounded soldiers. During UO, the outcome of the battle may hinge on the amount of firepower that can be concentrated at critical times. Patients that are wounded but still mentally alert may be able to contribute to the defense of the position. Further, depending upon the extent of injuries, the wounded soldier may still be able to function after being administered a low dose of pain medication.

(4) The combat medic must effectively use all resources available to him; this includes other injured or wounded soldiers. A patient with an altered mental state may not be able to help defend the position, but he may be capable of applying direct pressure to another soldier's wounds. Another example would be for a relatively stable patient to observe a more critically wounded soldier and to alert the combat medic of any change in the patient's condition (such as the reappearance of bleeding or labored breathing).

(5) The patient conditions presenting and the likelihood of multiple traumas may tax the knowledge base of the combat medic, especially if he must sustain these patients for an extended period of time. If secure communications are available, the combat medic should avail himself of telemedicine support (advice) from the supporting battalion aid station (BAS) and or clearing station (forward support medical company [FSMC]).

(6) After providing initial treatment to all of the patients, the combat medic must continually reevaluate the patients' conditions until they can be evacuated. The length of evacuation to the BAS may not be that great. Treatment teams may be able to move closer than normal to the fight due to the available cover afforded by buildings. Urban structures can provide cover and concealment and facilitate light discipline. Engagement ranges are usually short and a few city blocks may provide a relatively secure area for the provision of advanced trauma management (ATM).

(1) Aeromedical Evacuation. Aeromedical evacuation is the preferred method; however, it may not be a feasible option. The threat from small arms fire, rocket-propelled grenades (RPG), and other shoulder-fired weapons may prohibit the employment of these resources. Aeromedical evacuation can also be hampered by the lack of landings zones (LZs) due to narrow streets and heavily-damaged buildings.

(2) Ground Ambulance. Evacuation by ground ambulance may have to surmount obstacles such as rubble, debris, barricades, mines and or booby traps, and wrecked or otherwise inoperable vehicles and or aircraft. If the employment of air ambulances is not feasible, a ground evacuation operation must be executed. Ground ambulances should be—

• Hardened to improve the survivability of the evacuation platform and the safety of the ambulance crew and patients.

• Field-sited as close to the operation as is tactically and physically possible.

• Maneuverable in tight spaces and narrow streets.

(3) Litter. The same obstacles that interfere with effective aeromedical and ground evacuation of patients will be factors in CASEVAC operations. Nonmedical vehicles and aircraft may not be feasible alternatives in MOUT and the only form of evacuation possible may be by litter carries. Litter evacuation is labor-intensive and the tactical commander may not be able to divert his soldiers to the task of performing litter evacuation until a lull in or a cessation of the battle occurs. Planners should push forward as many standard litters as are feasible.

(4) Casualty Rates. Combat health support planners must take into consideration potentially higher casualty rates. The requirement for close combat by infantry will inevitably produce a higher patient workload in a shorter period of time than will operations where forces have more freedom of maneuver. Plans should address secure routes and marking structures for casualty/patient collection points and aid stations. Means of extracting casualties from damaged structures should be planned for, resourced, and, when possible, coordinated with the supporting engineer unit.

(1) Overall Health Status of Soldiers. In addition to rendering EMT to battlefield casualties, the combat medic is concerned with the overall health status of the soldiers he supports. Disease and nonbattle injuries generate significant combat ineffectiveness. The combat medic should be vigilant for the signs and symptoms of infectious diseases. Early recognition and reporting of diseases coupled with early treatment can avoid epidemic situations.

(2) Replacement of Combat Medic. The combat medic should designate one of the combat lifesavers to take his place in the event he is injured. Although the combat lifesaver only has advanced first aid skills, he can effectively coordinate for medical evacuation and treatment support.

(3) Disease and Nonbattle Injuries (DNBI). The prevention of DNBI is a significant responsibility for the combat medic. He must ensure that supported elements are proficient in and practice field hygiene and sanitation procedures. He must also ensure that supported personnel only consume food and drinks from approved sources.

(4) Mine and Booby Trap Awareness. Mine and booby trap awareness is a crucial consideration when operating in urban areas. The combat medic must be able to recognize mines and booby traps and take precautions as required. Additionally, the combat medic must be proficient in the skills and techniques to extract casualties from minefields. (Refer to FM 8-10-6 for additional information.)

(5) Manual Evacuation. Because MEDEVAC is a labor-intensive activity during UO, the combat medic must train his supported personnel in the techniques of manual evacuation. It is essential that those soldiers acting as litter bearers correctly handle the litter. Being proficient in using litters decreases the potential for injury to the litter bearers (muscle strains and back problems) and avoids further injury to the wounded soldier; for example, dropping the litter or tilting it so that the patient falls from the litter. (For information on litter-carrying techniques and manual evacuation, refer to FM 8-10-6.)

(6) Survivability. Soldier survivability is of the utmost importance and cannot be over emphasized. The combat medic should have his fellow Infantrymen train him in these skills.

(7) Navigation. Urban terrain is often difficult to navigate. The combat medic should have a city map available if at all possible. He should be familiar with possible routes from the battle site to the BAS. The routes do not necessarily have to only be established roads. If crossing gardens and yards or going through basements or battle-damaged buildings (holes in walls) is possible and these avenues provide better cover and concealment than is available on established road, then these routes should be used.

(8) Medical Materiel. Under the provision of the Geneva Conventions, medical materiel (supplies and equipment) are protected from intentional destruction. Should friendly units come across civilian or enemy medical supplies, medics and leaders must ensure that soldiers do not intentionally destroy these items. (For a discussion of the Geneva Conventions refer to FM 8-10.)

(1) Wounds. The types and frequencies of wounds and injuries generated by urban combat should be monitored to ensure required specialty teams are available for medical care.

(2) Resupply. The PA and surgeon must ensure that prepackaged emergency medical resupply bundles are prepared prior to the operation in the event emergency resupply by airdrop is required. This may include complete medical equipment sets (MESs) or specific replacement for high use items, such as bandages.

(3) Preventive Medicine. Preventive medicine (PVNTMED) policies and programs must receive command emphasis. This is particularly important with regards to water discipline. Dehydration is a significant threat in the urban environment. Increased water loss may be due in part to the effects of the weather, additional heat stress of body armor and or MOPP gear, and operating in poorly ventilated and confined spaces. Dehydration can affect mental functions and complicate medical treatment in the event of wounding or injury. Medical surveillance programs are essential for the following reasons:

• To ensure the health of the command during UO.

• To provide a baseline of diseases present in the AO in order to facilitate the identification and confirmation of potential use of biological warfare agents against U.S. forces.

• To identify what immunizations, prophylaxis, pretreatments, and barrier creams will be effective in the AO.

(4) Medical Intelligence. Current and comprehensive medical intelligence is a critical factor during UO. Medical intelligence can provide the CHS planner with the information needed to protect the fighting force from preventable diseases once engaged within the city confines. It also assists the tactical commander in evaluating the health status of enemy forces, which, if it is poor, may indicate a degradation of morale and will to fight.

(5) Remains. During UO, it is often difficult to clear the area of remains. Although U.S. forces have always quickly recovered their dead, the enemy may not. The unrecovered remains of enemy dead, civilian casualties, and animals can present serious complications in preventing the spread of infectious diseases. Coordination with supporting civil affairs (CA) units may be required.

(6) Disease. Food and waterborne diseases can quickly decimate a fighting force. Small-unit leaders must ensure that soldiers only eat and drink from approved water and food sources. Although the water system may be intact in an urban area, the water may still be contaminated. Food procured on the local market can contain infectious organisms or parasites. Food and waterborne diseases are preventable. Field hygiene and sanitation measures must be fully understood and enforced.

(7) Triage. The PA and surgeon must ensure triage categories and priorities are ingrained within all medical personnel. In mass casualty situations, the focus of health care delivery is to provide the greatest good for the greatest number. Mass casualty situations develop when the patient workload exceeds the capabilities of medical personnel/facilities available. During UO, this type of situation may develop when a single combat medic must treat, sustain, and manage three or four seriously wounded soldiers prior to evacuation. When a casualty has received massive wounds, making survival unlikely even if treated in a major trauma facility, he should be triaged as EXPECTANT. This permits the combat medic to use his medical skills and scarce resources to treat patients with a better chance of survival. (A description of triage categories is provided in FM 8-10-1.)

(8) Marking System. The PA and surgeon must ensure that a uniform marking system is used to indicate where casualties are located within buildings. This facilitates the quick retrieval and treatment of isolated casualties. The uniform system permits follow-on forces/reinforcements to identify locations where casualties can be found. These procedures should be included in the unit's tactical standing operating procedure (TACSOP). Most combat maneuver units have a system for marking the buildings and rooms as they are cleared. The CHS planner should coordinate with the supported maneuver unit to ensure the location of casualties is also indicated. (See Appendix I for more information on marking systems.)

(9) Mobility. The PA and surgeon must coordinate with supporting engineers to clear medical evacuation routes of rubble, debris, and barricades behind the fighting force. Due to isolated areas of resistance, this may not be possible in all urban scenarios.

(10) Communications. A viable communications capability is essential for successful UO. The PA and surgeon must ensure that medical elements have sufficient communications resources to remain synchronized with the tactical force, locate casualties, and effect telemedicine activities, if required.

(11) Collateral Damage. Although every effort is made to limit collateral damage, some civilian casualties will inevitably occur. The PA and surgeon must develop a policy, in conjunction with the staff judge advocate (SJA), on the care and treatment of civilian casualties. Further, CHS planners will be required to coordinate with the local civilian government and health care community for the transfer of these patients to civilian facilities.

(1) Location. Whenever possible, the BAS should establish the MTF in a location that is accessible to both ground or air ambulances. The location should permit ambulance turnaround, which facilitates the further evacuation of patients from the immediate combat area.

(2) Layout. The actual layout of the BAS will depend upon the type of structure and the amount of space available. The anticipated duration of the operation determines the extent to which the BAS is established. If the BAS is expected to move frequently, only essential elements will be established. If an existing building will be used, the structural integrity of the building should be determined prior to establishing the facility for an extended period of time. Heavy-clad mass construction buildings with good roofing are preferred.

(3) Fortification. The position of the BAS should be fortified when possible. Barricading windows, placing sandbags, or otherwise reducing the vulnerability to attack, provides the physician and PA a more secure location to provide advanced trauma management (ATM). While fortifying their positions, BAS personnel should ensure that observation/firing ports remain to observe the surrounding area and to permit the return of defensive fire, if required. Firing ports can be covered during night operations to facilitate light discipline. If the observation/firing ports are covered with a material that does not blend with the building facade, it must be removed during daylight hours to ensure it does not identify the structure as being in use. Chapter 3 provides information and techniques for fortifying positions; however, in evaluating this information it is important to consider medical requirements. Although it is advisable to move fighting positions away from the wall/window to afford more protection and to reduce the potential that the enemy would recognize the position, it may significantly limit the usable space available to care for patients. Space requirements include a treatment area and a space to hold soldiers awaiting evacuation. Unless the BAS is reinforced/ augmented with cots and additional medical personnel, the BAS may not have a holding capability. During UO, however, wounded soldiers may have to be sustained for longer periods of time due to limitations and delays in evacuation. Further, the BAS must have sufficient space to establish a patient decontamination area, if required.

(1) Ground Ambulances. The employment of ground ambulances forward of the BAS may not be possible due to rubble, debris, and other obstacles. Patients may arrive at the BAS by litter or other means of conveyance or, if ambulatory, they may arrive unassisted.

(2) Casualty/Patient Collection Points. Casualty/patient collection points are preplanned and included on the CHS overlays. Control devices, such as phase lines and check points, can be used as triggers for the movement of these facilities.

(1) Triage. As with the combat medic, the patient conditions presenting at the BAS must be triaged in order to provide the greatest good for the greatest number of patients. Higher casualty rates in UO can quickly attrit units engaged in combat operations. Those patients who can be treated and quickly returned to duty (minor wounds and illnesses-MINIMAL category) should be expeditiously managed. When evacuation capability is limited, patients in the IMMEDIATE category should be stabilized and further evacuated at the first opportunity. ROUTINE and EXPECTANT category patients should be evacuated after patients in the IMMEDIATE category. (FM 8-10-6 provides more information on categories of triage.)

(2) Delays. If delays in evacuation are anticipated, the BAS may be reinforced with a limited holding capability (cots and additional medical personnel) and increased stockage of Class VIII materiel.

(3) Wounds. The BAS must be prepared to treat an increased number of patients with head wounds; missile wounds (shrapnel and shards of brick, concrete, glass, metal, and wood); burns; and inhalation and crush injuries. Medical equipment sets may need to be reconfigured, with the advice of the command surgeon, prior to the mission to ensure adequate supplies to treat trauma injuries are included. When space is a limiting factor, those Class VIII items used for routine sick call may have to be replaced with trauma-related Class VIII items. Routine sick call service may have to be delegated to follow-on forces and coordinated with the supporting medical company.

(1) Litter Evacuation. If ground ambulances cannot go forward of the BAS due to rubble, obstacles, and barricades, evacuation by litter or manual carries to the BAS may be required. When developing plans for CHS during UO, the requirement for additional litter bearers should be considered and resourced as appropriate. Training in the safe handling of litters should be provided to reduce the incidence of injuries to the litter bearers and patients.

(2) Evacuation Routes. Medical evacuation personnel should have the most up-to-date commercial maps available. Evacuation routes should be preplanned, reconnoitered, and, when possible, secured. If commercial maps are not available and strip maps must be used, an ambulance shuttle system should be established. The shuttle system allows the ambulance crews most familiar with the terrain surrounding the BAS to remain in that area, thereby limiting the chances of ambulance crews getting lost and straying into hostile territory. (An in-depth discussion of an ambulance shuttle system is provided in FM 8-10-6.)

(3) Aeromedical Evacuation. See paragraph 13-9c.

(1) CA personnel coordinate with the military police and local police officials for evacuation planning. They plan for establishing evacuation routes and thoroughfare crossing control, and for removing civilians from the military supply routes (MSRs).

(2) CA personnel coordinate with U.S. Army PSYOP assets, local government officials, radio and television stations, newspapers, and so on, to publicize the evacuation plan.

(1) Curfew. A commander may need to establish a curfew to maintain security or to aid in control of military traffic. (Curfews are not imposed as punishment. They are normally established to reduce noncombatant casualties and provide a measure of force protection.)

(2) Evacuation. A commander can require civilians to evacuate towns or buildings if the purpose of the evacuation is to use the town or building for imperative military purposes, to enhance security, or to safeguard those civilians being evacuated. If the commander takes this action, he must specify and safeguard the evacuation routes. Food, clothing, medical, and sanitary facilities should be provided or available at the destination until the evacuees can care for themselves. Evacuated civilians must be transferred back to their homes as soon as hostilities in the area have ceased. The staff must plan for and coordinate the movement and evacuation of civilians to ensure their actions do not interfere with the military operation. The S5, brigade JA, S3, S2, and supporting civil affairs units working with local officials coordinate the movements of civilians.

(3) Forced Labor. The Geneva Accords prohibit the use of civilians in combat. However, they may be used before the battle reaches the city. Commanders will be given guidelines for use of civilian labor. The brigade or battalion TF may force civilians over 18 years of age to work if the work does not oblige them to take part in military operations. Permitted jobs include maintenance of public utilities as long as those utilities are not used in the general conduct of the war. Jobs can also include services to local population such as care of the wounded and burials. Civilians can also be forced to help evacuate and care for military wounded, as long as doing so does not involve any physical danger. Prohibited jobs include digging entrenchments, constructing fortifications, transporting supplies or ammunition, or acting as guards. Volunteer civilians can be employed in such work. Brigade and battalion TF commanders normally will not order forced civilian labor. However, they may find themselves supervising such labor in their area of operations.

(1) Accompanying Civilians. Civilians who are accompanying their armed forces with an identity card authorizing them to do so are treated as enemy prisoners of war (EPWs). For example, when captured; civilian members of military aircraft crews, war correspondents, supply contractors, and members of labor units or service organizations responsible for the welfare of the armed forces.

(2) EPWs. Civilians are treated as EPWs when captured if they—

• Are from a nonoccupying territory and have taken up arms against an invading enemy without time to form regular armed forces.

• Wear a fixed, distinctive insignia that can be seen at a distance and carry their weapons openly.

• Operate according to the rules and customs of war.

Other civilians who provide assistance to such groups may not be entitled to status as combatants, depending upon whether they are actually members of the resistance group. Any person whose status is in question should be treated as an EPW and be accorded all corresponding protections, rights, and privileges. Consult the JA.

(3) Armed Civilian Groups. Armed civilian groups that do not meet the criteria of a legal resistance (civilians accompanying their armed forces and mass conscription) or individuals caught in the act of sabotage, terrorism, or espionage are not legal combatants. If captured, they must be considered criminals under the provisions of the law of land warfare. They should be detained in a facility separate from EPWs and should be quickly transferred to the military police. Reprisals, mass punishments, taking of hostages, corporal punishment, pillage, and destruction of property are prohibited punishments. However, any person whose status is in question should be treated as an EPW and be accorded all corresponding protections, rights, and privileges. Consult the JA.

(4) Civilian Control. The law of land warfare lets a commander control the civil population under the conditions already described using his own resources. However, because of language and cultural differences between U.S. and foreign personnel, it is advised to use native authorities, such as the police, for such purposes. Use of the police does not relieve a commander of his responsibility to safeguard civilians in his area. Infantry units may be required to engage in these type of operations as part of a joint task force.

(1) Legal Targets. If the enemy is using a building or a portion of the town for military purposes—for example, as a supply point or a strongpoint—that building or that portion of the town is a legal target. Before engaging the target, the commander must decide if fire on the target is necessary. Only such destruction as is required for military purposes is justified.

(2) Restricted Facilities/Objects. Normally, religious, historical, and cultural facilities/objects and buildings are not legal targets. They are sometimes marked with symbols to signify their cultural status. Medical facilities, personnel, and equipment are protected under provisions listed in Article 39 (GWS) and shall bear one of the following emblems on a white background: the internationally recognized Red Cross, Red Crescent, Red Lion, or Red Star of David. The fact that such symbols are absent does not relieve a commander of his responsibility to protect objects he recognizes as having religious, cultural, medical, or historical value.

(3) Misuse of Restricted Facilities/Objects. The misuse of such facilities/objects by the enemy is grounds to disregard their protected status. Whenever possible, a demand should be made for the enemy to stop his misuse of the protected object within a reasonable time. If an enemy forward observer uses a church for an OP, for example, a commander would be justified in destroying it immediately because a delay would allow the enemy to continue the misuse of the church. If a religious shrine were used as a telephone switchboard, a warning would be appropriate, since it would take some time to dismantle the wires. Once the decision to order fires on those objects is reached, destruction should be limited to the least necessary in order to neutralize the enemy installations.

(4) Destruction or Damage to Property. The destruction, demolition, or military use of other buildings is permitted under the law of land warfare, if required by clear military necessity. Thus, destroying a house to obtain a better field of fire would be a legal act—destroying it as a reprisal would not be. Likewise, firing on any houses that are occupied or defended by an enemy force is legal.