Military

9-1. Health service support (HSS) includes activities across all levels of war. The following are considerations for HSS across the levels of war.

9-2. Strategic HSS and supporting services include activities under the control of the Department of the Army (DA), Department of Defense (DOD), and Secretary of Defense (SECDEF). These include the U.S. depots, arsenals, data banks, plants, research laboratories, and factories associated with the U.S. Army Medical Materiel and Research Command (USAMRMC) (including the U.S. Army Medical Materiel Agency [USAMMA]), and disease and nonbattle injury (DNBI) surveillance centers (such as the Centers for Health Promotion and Preventive Medicine [USACHPPM]), the DLA, national inventory control point (NICP), military health systems, and Veterans Administration and civilian hospital systems of the National Disaster Medical System (NDMS). Strategic HSS focuses on-

• Supporting force deployment by ensuring soldier medical readiness.
• Medical surveillance and occupational and environmental (OEH) health surveillance.
• Early employment/deployment of preventive medicine (PVNTMED) and veterinary services.
• Medical laboratory services for in-theater confirmatory identification of suspect NBC samples/specimens.
• Mobilizing the industrial base.
• Determining requirements and acquiring medical equipment, supplies, blood, and pharmaceuticals to support force projection.
• Stockpiling and prepositioning medical materiel (prepositioning of medical materiel configured to unit sets and afloat prepositioning).
• Supporting the host nation.
• Medical evacuating, medical regulating, and hospitalization.
• Mobilizing.
• Preserving the force by returning injured soldiers to full health.
• Demobilizing.

9-3. Operational HSS encompasses all of the medical activities to support the force employed in offensive, defensive, stability, and support operations. Operational HSS focuses on-

• Supporting deployment and reception, staging, onward movement, and integration (RSO&I) operations.
• PVNTMED, veterinary services, and COSC.
• Medical facilities in the theater.
• Managing distribution of medical materiel and blood.
• Supporting forward deployed forces.
• Reconstituting medical units in theater.
• Supporting redeployment operations.

9-4. At the operational level, managers balance current requirements with the need to extend capabilities along the lines of communication (LOC) and build up support services for subsequent major operations.

9-5. Tactical planning is proactive rather than reactive. HSS must be thoroughly integrated with tactical plans and orders. Commanders reallocate medical resources as tactical situations change. HSS commanders tailor medical units to adapt to the flow of battle and to meet reinforcement or reconstitution requirements. Elements to reconstitute medical units normally come from the next higher level of HSS. Due to the massive destructive and disabling capabilities of modern conventional and NBC weapons, medical units can anticipate large numbers of casualties in a shorter period. Medical units are flexible. They alter their normal scope of operations to provide the greatest good for the greatest number. However, these mass casualty situations usually exceed the capabilities of local medical units. Key factors for effective mass casualty management are-

• On-site triage.
• Emergency resuscitative care.
• Early surgical intervention.
• Reliable communications.
• Skillful evacuation by air and ground resources.

9-6. Medical personnel may also have to defend themselves and their patients within their limitations. Medical personnel are only authorized the use of small arms for the protection of themselves and the patients in their care. In certain situations, HSS units in rear areas must be able to defend against level I threats and to survive NBC strikes while continuing to support the operation. Medical personnel are not required to perform perimeter defense duties for nonmedical units. Due to the protections afforded medical personnel under the provisions of the Geneva Conventions, medical personnel must be exclusively engaged in their humanitarian duties and can, therefore, only defend medical unit areas.

9-7. Providing HSS is guided by six principles consistent with the principles discussed in JP 4-02:

• Health service support conforms to the tactical commander's operation plan (OPLAN). By taking part in developing the OPLAN, the HSS planner can determine support requirements and plan for the support needed to prevent DNBI and to effectively clear the battlefield of the ill, injured, and wounded.
• Technical control and staff supervision of HSS resources must remain with the appropriate command-level surgeon.
• The HSS staff must maintain continuity of care since an interruption of treatment may cause an increase in morbidity and mortality. No patient is evacuated farther to the rear than his medical condition or the tactical situation dictate.
• The proximity of HSS assets to the supported forces is dictated by the tactical situation (mission, enemy, troops, terrain and weather, time, civilian considerations [METT-TC]).
• The HSS plan must be flexible to enhance the capability of shifting HSS resources to meet changing requirements. Changes in the tactical situation or OPLAN make flexibility essential.
• Mobility is required to ensure that HSS assets remain close enough to combat operations to support combat forces. The mobility of medical units must be equal to the forces supported.

9-8. Health service support is arranged in levels of medical care. They extend rearward throughout the theater to the CONUS support-base. Each level reflects an increase in capability, with the functions of each lower level being within the capabilities of higher level.

9-9. The first medical care a soldier receives occurs at Level I. It is provided by the trauma specialist/special operations forces combat medics (assisted by self-aid, buddy aid, and combat lifesaver skills, and at the battalion aid station [BAS] by the physician and physician assistant). This level of care includes immediate lifesaving measures, prevention of DNBI, COSC preventive measures, patient collection, and medical evacuation to supported medical treatment elements.

9-10. Medical companies and troops of brigades, divisions, separate brigades, armored cavalry regiments, and area support medical battalions (ASMBs) render care at Level II. They examine and evaluate the casualty's wounds and general status to determine treatment and evacuation precedence. This level of care duplicates Level I and expands services available by adding limited dental, laboratory, optometry, preventive medicine, health service logistics, COSC/mental health services, and patient-holding capabilities. When required to provide far-forward surgical intervention, the medical company may be augmented with a forward surgical team (FST) to provide initial wound surgery. The FST is organic to airborne and air assault divisions.

9-11. Level III is the first level of care with hospital facilities. Within the combat zone, the combat support hospital (CSH) provides resuscitation, initial wound surgery, and postoperative treatment. At the CSH, personnel treat patients for return to duty (RTD) or stabilize patients for continued evacuation. Those patients expected to RTD within the theater evacuation policy are regulated to an echelon above corps (EAC) CSH.

9-12. At Level IV, the patient is treated at an EAC CSH. Those patients not expected to RTD within the theater evacuation policy are stabilized and evacuated to a Level V facility.

9-13. Definitive care to all categories of patients characterizes Level V (primarily CONUS-based) care. The Department of Defense (DOD) and Department of Veteran's Affairs (VA) hospitals provide this care. During mobilization, the National Disaster Medical System (NDMS) may be activated. Under this system, civilian hospitals care for patients beyond the capabilities of the DOD and VA hospitals.

9-14. There are ten functional areas within the Army Medical Department (AMEDD). The AMEDD integrates and synchronizes these functional areas, enabling the HSS system to meet the requirements of a force-projection Army.

9-15. Medical evacuation is the timely, efficient movement and provision of en route medical care of sick, injured, or ill persons from the battlefield or other locations to medical treatment facilities (MTFs). It is the responsibility of the gaining level HSS to evacuate or coordinate the evacuation from the lower level. The health care provider attending the patient determines the mode and precedence of evacuation. Air evacuation is the primary means of medical evacuation for urgent and priority casualties. In the combat zone, ground ambulance squads organic to medical sections, platoons, and companies evacuate patients within their AOs. Medical evacuation battalions evacuate patients from Level II MTFs to Level III hospitals. The battalion also evacuates patients laterally from hospital to hospital within the corps area, and from hospitals to U.S. Air Force (USAF) staging areas for evacuation out of the combat zone.

9-16. Strategic evacuation is a function of the USAF aeromedical evacuation system. The theater surgeon recommends a theater evacuation policy through the combatant commander and Joint Chiefs of Staff for approval by the SECDEF. The policy establishes the number of days an injured or ill soldier may remain in the theater to return to duty. Soldiers who will not return to full health within the established time are evacuated to definitive care facilities in CONUS or other designated locations. FM 8-10-6 has more details on evacuation.

9-17. Medical regulating is the coordinated movement of patients to MTFs that are best able to provide timely and required care. The corps medical command (MEDCOM), medical brigade medical regulating office (MRO) and, if established, joint patient movement requirements center (JPMRC) provide medical regulating in the combat zone. In the COMMZ, the theater MEDCOM/EAC medical brigade MROs and the theater patient movement requirements center (TPMRC) provide support. The TPMRC provides both intratheater and intertheater medical regulating. For example, if hospitals of other services within the theater have the necessary capabilities, the TPMRC may regulate Army patients to them. It also coordinates intertheater evacuation with the global patient movement requirements center (GPMRC). The TPMRC coordinates patient movement with the USAF aeromedical evacuation control center or, if air evacuation is not available or advisable, with the Military Sealift Command.

9-18. Hospitalization, provided by the CSH, is part of the theater-wide system for managing sick, injured, and wounded patients. The CSH capabilities include triage/emergency care, outpatient services, in-patient care, pharmacy, laboratory, blood banking, radiology, physical therapy, medical logistics, emergency/essential dental care, nutrition care, and patient administration services. For more information on theater hospitalization see FM 4-02.10.

9-19. The CSH may be augmented by one or more medical detachments, hospital augmentation teams, or medical teams. These may include-

• Minimal care detachment that is capable of providing minimal/convalescent care, nursing, and rehabilitative services in support of Levels III and IV hospitals.
• Telemedicine detachment that provides telemedicine services and clinical reachback capabilities to support the CSH and other MTFs within the division, corps, and theater.
• Forward surgical team that is available to augment the surgical services of the CSH with general surgery and orthopedic surgery capabilities.
• Head and neck hospital augmentation team that provides special surgical care for ear, nose, and throat surgery, neurosurgery, and eye surgery to support the CSH, plus specialty consultative services, as required.
• Special care hospital augmentation team that provides the additional health care personnel to support other military operations.
• Pathology hospital augmentation team that provides pathology support to the CSH laboratories and specialty consultative services, as required.
• Infectious disease medical team that provides infectious disease investigative services and specialty consultative services, as required.
• Renal hemodialysis medical team that provides renal hemodialysis care for patients with acute renal failure and consultative services on an area basis.

9-20. The health service logistics (HSL) system encompasses planning and executing medical supply operations, medical equipment maintenance and repair, blood storage and distribution, and optical fabrication and repair. It also includes contracting services, medical hazardous waste management and disposal, production and distribution of medical gases, and blood banking services for Army, joint, multinational, and interagency operations. The appropriate command surgeon provides technical guidance. The system is anticipatory, with select units capable of operating in a split-based mode. The theater HSL system consists of the following organizations:

• Medical logistics management center (MLMC).
• HHD, MEDLOG battalion.
• Logistics support company.
• Medical logistics company.
• Blood support detachment (BSD).
• Medical logistics support team (MLST).

9-21. The MLMC is subordinate to the theater MEDCOM or senior medical command and control (C2) headquarters in theater. It is responsible for providing theater-level centralized management of critical Class VIII commodities, patient movement items, and medical maintenance within the theater. The MLMC normally uses split-based operations. During an initial employment into an austere theater, the MLMC base normally remains in the CONUS while deploying a support team into the theater, linking the strategic to the operational level of logistics. The support team also links Class VIII management with the distribution system within the AO by co-locating a distribution section with the support operations section of the TSC or a COSCOM. When so designated, the MLMC, with the MEDLOG battalion, serves as the single integrated medical logistics manager (SIMLM) for joint operations. It also serves as the medical contracting manager for the theater.

9-22. The MEDLOG battalion is subordinate to the theater MEDCOM or the corps MEDCOM. It is responsible for providing C2 and supervising operations for a variable number of attached MEDLOG companies, logistics support companies, and a BSD. This overall control covers the whole spectrum of MEDLOG and blood management operations

9-23. The logistics support company (subordinate to the MEDLOG battalion) provides medical materiel, medical maintenance and repair, and multi- and single-vision optical lens fabrication and repair to EAC and corps medical units operating in the AO. It also provides backup support to the MEDLOG company. This company forms the MEDLOG base for the AO.

9-24. The MEDLOG company (subordinate to the MEDLOG battalion) provides medical materiel, medical maintenance, and multivision optical lens fabrication and repair to division and corps medical units operating within the division AO. The MEDLOG company has no organic blood support capability. A cell from the BSD collocates to provide blood support to the division. The company is normally under the C2 of the HHD, MEDLOG battalion. The company has the capability for limited self-sustainment during initial operations, meeting the requirement for early entry into the AO or as part of a task organization.

9-25. Blood support is a combination of four systems: medical, technical, operational, and logistics. The management and distribution of all resuscitative fluids (including albumin) is a HSL function. Theater blood support depends on resupply from the CONUS base. Liquid blood products enter the theater through USAF blood transshipment centers for further shipment to Army BSDs. Army hospitals acquire necessary blood products from these BSDs. Blood support for Level II MTFs (including FSTs) consists of a limited number of group-type O liquid red blood cell units. All hospitals have blood-banking capabilities that allow them to store blood products. The combatant command establishes a single blood management program. The program is theater-wide and interfaces with the CONUS blood banking system. The theater and CONUS blood programs are a combined effort (JP 4-02.1). All components within the combatant command maintain blood programs. The Army Blood Program Office (ABPO) interfaces with the area joint blood program office (AJBPO). The AJBPO interfaces with the Armed Services Blood Program Office in CONUS.

9-26. The BSD (subordinate to the MEDLOG battalion) serves as the Army's blood supply unit (BSU). It provides blood collection, manufacturing, storage, and distribution of blood and blood products to division, corps, and EAC medical units, and to other operations (see FM 4-02.1). The detachment provides flexibility to shift personnel assets between collection and distribution missions as required. Blood and blood products are stored and distributed under rigid specification and managed by standard information systems. Air movement is the preferred method for moving blood and blood products. Army blood support in the AO is the responsibility of the supporting BSD. The BSU collects, manufactures, receives, stores, and distributes blood and blood products on an area basis. The commander of the BSU may also serve as the AJBPO as part of the Theater Joint Blood Program. Primary blood support in the AO during a high tempo operation is based on resupply from the CONUS donor base. Commanders may task the Army BSU to provide blood to other services on an area basis.

9-27. The MLST is a table of distribution and allowances (TDA) organization consisting of MEDLOG personnel (military, DA civilians, and contractors) from the U.S. Army Medical Materiel Agency (USAMMA). The MLST normally deploys with the U.S. Army Materiel Command (USAMC) logistics support element (LSE). The MLST supports the reception and onward movement of APS, unit sets, and sustainment stocks prepositioned in the AO. The MLST provides medical materiel and maintenance capability, equipment accountability, and transfer support of reception operations at air and seaports of debarkation. The MLST is a component of the USAMC and is under the operational control of the LSE until a theater support command is established. The MLST transitions its mission to the theater MEDLOG battalion or the MLMC. After completing the mission transition, the MLST redeploys to CONUS. At the end of the operation, the MLST may again deploy to the AO to support the redeployment of U.S. forces and materiel from the AO to follow-on CONUS or OCONUS locations.

9-28. Within the theater of operations, there are three levels of dental support: unit, hospital, and area. These levels are defined primarily by the relationship of the dental assets supporting the patient population within each level.

9-29. Unit-level dental care consists of those services provided by a dental module organic to divisional and nondivisional medical companies and all special forces groups. This module provides emergency dental treatment to soldiers during tactical operations.

9-30. Hospital-level dental care consists of those services provided by the hospital dental staff to minimize loss of life and disability resulting from oral and maxillofacial injuries and wounds. The hospital dental staff provides operational dental care, which consists of emergency and essential dental support to all injured or wounded soldiers as well as the hospital staff.

9-31. Dental service companies provide dental support on an area support basis. These dental units provide operational care. The dental companies are composed of modular dental teams capable of operating separate dental treatment facilities (DTFs) or of consolidating units and operating one large facility, depending on the METT-TC. Other teams provide far-forward emergency and essential dental care.

9-32. Within the theater, dental service support provides operational care, which is composed of emergency dental care and essential dental care. Another category, normally found only in fixed facilities in the United States, is comprehensive care. These categories are not absolute in their limits; they are the general basis for defining the dental service capabilities available at the different HSS levels of care. Categories are-

• Operational care. Care given for relieving oral pain, eliminating acute infection, controlling life-threatening oral conditions (hemorrhage, cellulitis, or respiratory difficulty), and treating trauma to teeth, jaws, and associated facial structures is considered emergency care. It is the most austere type of care and is available to soldiers engaged in tactical operations. Common examples of emergency treatments are simple extractions, providing antibiotics and pain medication, and temporary fillings.
• Essential care includes dental treatment necessary to intercept potential emergencies. This type of operational care is necessary for preventing lost duty time and preserving the fighting strength. Soldiers in dental class 3 (potential dental emergencies) should be provided essential care as the tactical situation permits. Soldiers in dental class 2 (untreated oral disease) should be provided essential care as the tactical situation and availability of dental resources permit. The scope of operational care includes definitive restoration, minor oral surgery, exodontic, periodontic, and prosthodontic procedures, as well as prophylaxis.
• Comprehensive care restores an individual's optimal oral health, function, and aesthetics. This category of care is usually reserved for force health protection plans that anticipate an extensive period of reception and training in theater. The scope of facilities needed to provide this level of dental support could equal that of Level III medical facilities. FM 4-02.19 has additional information on dental support.

9-33. The U.S. Army Veterinary Service is the executive agent for veterinary support to all services and other U.S. agencies in theater. Appropriate mixes of veterinary units provide this support. These units can be task-organized to support food safety and quality assurance, and the medical care mission for government-owned animals. Services include sanitary surveillance for food source and storage facilities, procurement, and surveillance and examination of foodstuffs for safety and quality. The veterinary unit is responsible for publishing a directory of approved food sources for the theater/AO. Veterinary preventive medicine provides an effective combat multiplier through monitoring endemic zoonotic (animal) disease threats of military significance. The animal medical care mission provides complete medical care to all government-owned animals, especially military working dogs (MWDs), in the AO. The potential of food-borne disease, the threat of NBC contamination of subsistence, the need to assess the zoonotic disease threat, and the need to provide health care to government-owned animals requires a veterinary presence throughout the entire AO. Comprehensive veterinary medical and surgical programs are required to maintain the health of government-owned animals. See FM 8-10-18 for more details.

9-34. In past conflicts, DNBI rendered more soldiers combat ineffective than combat action. Preventive medicine services to counter the medical threat and prevent DNBI are the most effective, least expensive means of providing commanders with the maximum number of healthy soldiers. The Armed Forces Medical Intelligence Center conducts area studies on diseases for all regions. Medical companies of brigade and divisional support battalions, area support medical battalions, separate brigade support battalions, and medical troops of ACR support squadrons provide preventive medicine services. They receive additional support from the PVNTMED detachments of the corps and EAC medical brigades. See FM 4-02.17 for more details.

9-35. Combat operational stress control (COSC) conserves the fighting strength by minimizing losses due to battle fatigue and neuropsychiatric disorders. The focus of Army COSC is on-

• Promoting positive mission-oriented motivation.
• Preventing stress-related casualties.
• Treating and the early detection of soldiers suffering from battle fatigue.
• Preventing harmful combat stress reactions, such as misconduct stress behaviors and post-traumatic stress disorders.

9-36. Brigade/division support battalion and separate brigade medical companies, armored cavalry regiment medical troops, and ASMBs provide COSC support. They receive further support from CSC companies or detachments assigned to the corps and EAC medical brigades. FM 22-51, FM 8-51, and FM 6-22.5 discuss COSC programs and activities.

9-37. Medical companies of divisions, separate brigades, and ACR, and the corps/EAC ASMB provide area medical support. These companies provide Levels I and II medical care throughout the division, corps, and EAC areas. They employ medical treatment squads/teams to establish Levels I and II MTFs and to reinforce medical treatment elements (BAS) of maneuver battalions. The ground ambulance platoons of these companies provide medical evacuation support on an area support basis from Level I MTFs and supported units to Level II MTFs.

9-38. The theater MEDCOM area medical laboratory includes capabilities in endemic diseases, OEH hazards, and NBC. Its focus is the total health environment of the theater, not individual patient care. Its facility conducts studies in pest identification, the efficacy of pesticides, frequency of infectious agents, monitoring immune response, and transmission of zoonotic diseases, and in-theater confirmatory identification of suspect NBC samples/ specimens. Its personnel also function as consultants to hospital clinical laboratory services within the theater. It may task-organize teams and employ them forward to troubleshoot a particular problem. All Level II MTFs provide basic laboratory services within the theater. They perform basic procedures in hematology, urinalysis, microbiology, and serology. Level II MTFs receive, maintain, and transfuse blood products. Levels III and IV MTFs (CSH) perform procedures in biochemistry, hematology, urinalysis, microbiology, and serology. These hospitals also provide blood-banking services.

9-39. Medical information systems facilitate the proper management of medical information that is critical to providing HSS. Decisions, such as those on where to treat casualties and when to evacuate to hospitals, depend on knowing what medical resources are available at all times. An effective medical management information system supports theater HSS operations by providing the capability to track resources, requirements, and patients. In particular, HSL relies heavily on information systems. Arriving with the lead element, units with information systems to manage medical information orchestrate both the arriving medical units in the AO and the interfacing with other information systems (such as movement and personnel) at all levels.