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Combat Health Support
by MAJ David Sheaffer, CSS Observer Controller, JRTC


The combat health support (CHS) mission in support of military operations on urbanized terrain (MOUT) will very likely be significantly different from CHS on the non-urban battlefield. The deliberate attack on an urban area may result in a high number of casualties, with many of those casualties isolated and not treated for long periods of time. CHS planners and those personnel with whom they coordinate must fully appreciate the difficulties they are about to encounter. Primary issues and difficulties are the medical threat, the types of casualties expected, planning and synchronization, medical evacuation, and the employment of medical treatment assets.


Doctrinal references in assisting the CHS planners in the urban environment are found in FM 8-42, Combat Health Support in Stability Operations and Support Operations; FM 8-10-6, Medical Evacuation in a Theater of Operations; and FM 90-10-1, An Infantryman's Guide to Combat in Built-Up Areas. These references provide general information, yet much of the details and tactics, techniques, and procedures (TTP) do not exist in written form to provide for a solid urban combat CHS plan. An important aspect missing from current doctrine is the role and responsibility of the combat health support officer (CHSO) and how he plans to support the urban fight from a CHS perspective.

Additionally, valuable sources that exist within the CALL database are: CALL Newsletter No. 97-2, Combat Health Support Synchronization and Rehearsals, Jan 97; Combat Training Center (CTC) Quarterly Bulletin No. 96-7, The Tenants of Combat Health Support, Jun 96; CTC Quarterly Bulletin No. 97-15, Level One CHS for the Light Infantry Deliberate Attack, Jul 97; and CTC Quarterly Bulletin No. 97-18, The Role of the CHS Officer in the FSB, Sep 97.


The purpose of the CHS plan is to provide a simple, yet effective, process for consolidating, treating, and evacuating battlefield casualties. The CHS plan is critical to any combat operation and therefore must not be oversimplified or omit critical coordination and synchronization details.

Initially, someone must delineate the roles and responsibilities involved with creating, coordinating, and synchronizing the CHS plan. Research of current doctrine contains contradictions of whom the primary CHS planner to develop the CHS estimate and plan should be. According to FM 101-5, Staff Organization and Operations, the responsibility for planning and coordinating CHS operations is placed on the surgeon. According to the FM 7-series, the S-1 battalion personnel officer is the primary staff officer charged with this task at battalion level/brigade level. This individual is usually a junior combat arms company grade or a combat arms field grade officer at the brigade level who has a general understanding of the capabilities and limitations of the medical assets supporting the unit. Therefore, the S-1 should not formulate the CHS plan alone. At the brigade level, the brigade surgeon and the CHSO should work with the brigade S-1. The medical platoon leader at the battalion level should consult with the battalion S-1 on how best to provide medical support to an operation. At brigade level, the CHSO and brigade surgeon are the medical subject matter experts and must be able to integrate the CHS plan with the maneuver plan but must still consult and plan support with the S-1.

As with any military operation, the CHS planners should consider the threat to properly counter it. The medical threat in an urban battlefield involves some wounds, injuries, and diseases not common to the conventional battlefield. FM 8-42 describes the medical threat in detail. Some key issues for consideration:

  • Disease rates will most likely increase due to environmental conditions imposed by urban areas. Disruption of utilities (water, sewage, waste disposal) will increase the potential for disease transmission. Large numbers of refugees and displaced persons will quickly exhaust available resources for personal hygiene and medical treatment.

  • Damaged or destroyed buildings will provide breeding grounds for rodent and arthropod vector populations.

  • In addition to wounds from conventional direct fire and fragmentation, missiles of glass, steel, and stone will cause secondary wounding. Collapsing buildings will result in numerous crushing injuries. Increased burns and inhalation injuries will result from burning fuels, vehicles, and structures.

  • Prolonged combat in urban areas generates significant physical and mental stress. The presence of hostile civilians, the amount of destruction, and extended periods of isolation increase the risk of misconduct stress behaviors and subsequent post-traumatic stress disorders. Trained medical personnel should be on hand to support units when the situation dictates. The CHS plan should include a method to evacuate adversely affected personnel to a safe area for treatment. The best method for stress management is prevention. (Refer to the combat service support [CSS] chapter of this newsletter.)

The CHS planner must take the following battlefield operating systems (BOS) into consideration:

  • Intelligence:
    • Known or suspected enemy situation.
    • Terrain and weather. What kind of road network is in the area of operations? How will the predicted weather impact the trafficability on and off the roads? Are there landing zones along the axis of advance and in or around the urban area? How will the weather impact on the availability of aircraft?

  • Maneuver: What is the combat scheme of maneuver and are there medical assets readily available to care for potential casualties? Particular attention should be paid to the employment of the armored ambulances.

  • Fire Support: Are there any buildings specifically targeted? If so, CHS planners should ensure casualty collection points, evacuation routes, and treatment elements remain at a safe distance away from these buildings to prevent potential fratricide.

  • Mobility/Survivability: Where are the suspected or known enemy or friendly minefields? How does this impact proposed evacuation routes?

  • Air Defense: What is the enemy's capability for interdicting main supply routes (MSR) and logistical elements?

  • Combat Service Support: Typically, the FSB moves a forward logistics element (FLE) toward the battle area to provide support. If this is the case, then how are medical assets integrated into the plan, and, more importantly, where are they positioned in the convoy and how are they secured?

  • Command and Control: Who is the person to call for casualty evacuation, and what are the primary and secondary frequencies? This element is the central point for prioritizing assets and medical evacuation requests. It is imperative that this element is capable of continuous situational awareness through accurate battle tracking.

OBSERVATION 1: CHS planners do not conduct a good intelligence preparation of the battlefield (IPB).

DISCUSSION 1: At the Joint Readiness Training Center (JRTC), the opposing force (OPFOR) normally establishes an "outer ring" of defense 3-5 kilometers from the main defensive perimeter. This "outer ring" is normally composed of counter-recon patrols, combat outposts, and small units effecting delaying actions and spoiling attacks. The CHS planners normally focus on only the urban area and do not consider the potential for casualties at this "outer ring."


From information provided by the S-2, the CHS planners must understand the tactics of the enemy and be prepared for casualties at all possible areas of contact. The CHS planners should be able to gain insight into this matter during the wargaming process. The CHS planners should provide input into the counter-reaction portion of the action, reaction, counter-reaction drill.

Additional information the CHS planners should bring to the course of action (COA) development phase of the Military Decision-Making Process (MDMP) are:

  • Availability of aeromedical evacuation assets--flight windows, number of aircraft, patient configuration.
  • Non-standard aircraft availability and how to trigger their involvement.
  • Non-standard ground asset availability--especially cargo vehicles for a MASCAL situation and how to trigger their involvement.
  • Additional medical assets from higher echelons such as treatment teams, ambulances, push packages of CL VIII.
  • Locations of all available medical treatment units and proposed new locations
  • Class VIII resupply plan.
  • The need for litter bearer teams and special equipment for extracting casualties from buildings and rubble.
  • The impact of civilian casualties on military medical resources. Often the requirement to treat civilian casualties will far outstrip the available military and civilian medical assets.

OBSERVATION 2: Care of civilian casualties.

DISCUSSION 2: According to FM 90-10-1, the commander is responsible for providing aid and protection to wounded civilians. How can CHS planners execute this doctrine and still provide world-class healthcare to soldiers? This is critical because "in this setting, United States public perception of inadequate or delayed medical care to U.S. service personnel could lead to loss of public support and an inability to continue the campaign." (The Army Surgeon General, Army Medical Department Update, Winter 1999.)

TTP: The commander should ensure civilian medical facilities, hospitals, and medical supplies are not destroyed, and ensure the concept of the operation will maintain the integrity of the civilian medical system. The CHS planner must know how to access the civilian health care system and must brief this plan to all personnel responsible for the health and welfare of the civilian population. This point is critical and illustrates the need to coordinate with the civil affairs unit to help in the coordination with the host nation and any international organizations or private volunteer organizations. This will facilitate the rapid transfer of civilian casualties from military medical units to the local healthcare system, enabling focus on wounded soldiers.


The preparation phase of any operation is critical to the success of the operation. Steps taken prior to mission execution can greatly impact the ultimate success or failure of the mission during the execution phase. MOUT operations are no exception.

OBSERVATION 3: Force Protection.

DISCUSSION 3: The most important action during the preparation phase is force protection. Force protection includes physical and force health protection methods. Physical protection includes items such as body armor, NOMEX suits, and eye protection. Force health protection includes field sanitation, vaccinations, and prophylaxis to prevent and ward off diseases. The need for ballistic protection is obvious; however, the need for force health protection is often overlooked. A soldier with dysentery and severe dehydration is just as combat ineffective as a soldier with a gunshot wound.


Leaders must ensure all methods of force protection are executed. CHS planners should identify potential threats and, through command channels, employ appropriate countermeasures.

OBSERVATION 4: CHS Rehearsals.

DISCUSSION 4: Normally the CHS rehearsal is included in the combat service support (CSS) rehearsal, but pushed to the end and often rushed and inadequately executed. Additionally, the CHS rehearsals are not conducted at all levels, compounding the ultimate confusion when attempting evacuation of casualties. The rehearsal is not the time for medical units to coordinate and synchronize the CHS plan. The rehearsal validates the coordinated and synchronized plan, ensures continuity of supporting plans, and verifies the sustainability of the tactical plan within the maneuver commander's intent.


Prior to the CHS rehearsal, a CHS synchronization drill should be held which includes the key leaders of the brigade's medical community. These key leaders include, but are not limited to, the brigade S-1, brigade surgeon, CHSO, forward support medical company commander, medical platoon leaders, forward support medical evacuation team leader, and medical representatives from the field artillery, the heavy team, division medical operations center, and the S-3 from the supporting level III hospital. These personnel identify and resolve problems to ensure a synchronized CHS effort. All ten medical functions must be addressed. Some key issues include:

  • Ambulance exchange point (AXP) locations and contingency plans in case of compromise
  • Ambulance linkup
  • Evacuation routes
  • Augmentation/reconstitution
  • Priority of support
  • Class VIII resupply

The end product of the synchronization drill is a CHS matrix, which will serve as a "road map" for everyone to follow during the CHS rehearsal and during execution of the plan.

  • A separate CHS rehearsal should be planned and executed. All key leaders should attend to ensure complete understanding of the plan. In addition to the personnel involved in the CHS synchronization drill, key leaders include, but are not limited to, the following: brigade executive officer, brigade S-2, brigade signal officer, support operations officer, Air Force aeromedical evacuation liaison team (AELT) representative (if available), and maneuver company executive officers and first sergeants. The brigade executive officer ensures the CHS plan is integrated with the maneuver plan and also ensures proper resourcing of personnel and assets. The brigade S-1 is the rehearsal facilitator since he is the staff proponent for the CHS plan. The plan should be rehearsed by each phase (or event) of the operation by having each leader or representative discuss their actions during that particular phase (event), with focus on treatment assets available (with the understanding of the capabilities and limitations of those treatment assets), acquisition of casualties, means of casualty evacuation, and communications. The end product of the rehearsal is a fragmentary order (FRAGO) describing the finalized CHS plan and CHS synchronization matrix.

  • The brigade signal officer should schedule and execute a communications exercise (COMMEX) to validate the communications plan. The CHS leaders must participate in the COMMEX. The COMMEX should include the expected distances (if tactically feasible) to determine if the communications platforms are adequate. If a receiving-transmitting (RETRANS) station is required, the COMMEX must rehearse this operation. The CHSO and brigade surgeon should ensure all CHS assets are able to communicate with each other, and the maneuver elements are able to call for evacuation. Additionally, as part of the communications plan, there should be alternate means of communication since radio communications become degraded in the urban environment. For CHS planners, this includes methods of marking casualty locations.

OBSERVATION 5: Medical supply tailoring.

DISCUSSION 5: Due to the high potential for specific wounds in the MOUT environment, CHS planners may consider altering medical supply assemblages, especially at the combat medic and treatment team level.


The combat medic and the treatment team should pack Class VIII to attend to the high incident of MOUT-related wounds and injuries, turning over sick call items to the follow-on medical forces, and concentrating on initial trauma management. Items such as intravenous (IV) fluids, bandages, poleless litters, SKEDCO litters, and lightweight blankets can be distributed to combat lifesavers (CLS) and to the individual infantryman to facilitate timely self- and buddy-aid and evacuation to the CCP.


The ultimate success or failure of the mission is determined by how well it is executed by the units. Obviously the planning and preparation for any given mission are key to any subsequent success or failure. However, regardless of the plan or the level of pre-mission preparation, a soldier's or an officer's ability to execute the individual and collective tasks inherent in the mission clearly determine the likelihood of mission success. This task ability is a direct result of disciplined training and repetition. If medical personnel can execute their tasks to standard, then it is up to the CHS leaders to position their assets for success in supporting the force.

The critical aspect of CHS execution is the maintenance of communications with supported and supporting units. This facilitates CHS leaders in battle tracking, enabling the sequential execution of the CHS plan, and the ability to execute contingency plans, if necessary.

Following is an example of a successful CHS MOUT operation at JRTC:

OBSERVATION 6: Casualty evacuation.

DISCUSSION 6: At the JRTC, the maneuver battalion executed casualty evacuation very well due to the dynamic leadership of the junior officers and senior non-commissioned officers. As the battle in the city raged, the medical platoon leader of an infantry battalion, along with the first sergeant of one of the supported companies, effected a casualty collection point 100 meters north of the town. The medical platoon leader remained at the casualty collection point (CCP) with a radio to coordinate movement of evacuation assets. The first sergeant organized aid and litter teams to acquire casualties and conduct manual evacuation from point of injury to the CCP. A treatment team established their operations at the CCP to conduct initial trauma management, thus creating a battalion aid station (BAS) (-) (#1). Initially, the medical platoon leader used the attached M113 ambulances to evacuate casualties from the CCP to a BAS (-) (#2) established by the second portion of the medical platoon. As the battle matured, the forward medical element from the forward support battalion occupied the area, established as BAS (-) (#2), which allowed the medical platoon to consolidate forward at BAS (-) (#1). The M113 ambulances were then used to evacuate the casualties from within the city to the BAS. The casualties were treated and evacuated on wheeled assets to the forward medical element for additional treatment and subsequent evacuation to level III, primarily by air.


This is an example of how casualty evacuation may be conducted. The first thirty minutes after wounding is the most critical to the casualty. Proper treatment, or lack thereof, within that time will determine if that casualty survives. The responsiveness of the leadership enabled casualties to be treated and evacuated in a timely fashion, resulting in a very low died-of-wounds (DOW) rate. The success can be directly attributed to the ability of the medical platoon leader to communicate with supported and supporting units.

OBSERVATION 7: Aid and litter teams.

DISCUSSION 7: The CHS planners developed a plan for and organized aid and litter teams with the mission of conducting manual carries of casualties from point of injury to the CCP to enable medical personnel to treat casualties. However, the aid and litter teams were inserted at the rear of the support convoy and were not able to execute their mission, forcing the impromptu formation of aid and litter teams, thus degrading the combat force.


  • CHS planners should ensure that medical assets, to include aid and litter teams, are properly integrated into the maneuver plan to provide maximum benefit to the combat force. Casualty evacuation by vehicle in a MOUT environment will be very limited; therefore, aid and litter teams should accompany the treatment team to effect timely evacuation to the CCP.
  • Aid and litter teams should have a marking system to alleviate redundant searches and provide for more efficient and timely casualty evacuation, just as the infantry mark buildings that have been secured. Consider adopting the North Atlantic Treaty Organization (NATO) color-coded marking system which includes a yellow marker positioned at the point of entry to indicate a casualty in a particular building. This marking system indicates to the medics and aid and litter teams that casualties inside require treatment and evacuation.
  • To facilitate the extrication of casualties in the MOUT environment, aid and litter teams should have special equipment such as sledgehammers, axes, crowbars, ropes, special harnesses, pulleys, and ladders. These are additional items that must be procured, and a pre-combat check must be conducted prior to execution.


CHS planners must always consider the ten functions of CHS for all operations. For the execution of the MOUT fight, the following functions are particularly critical:

  • Treatment
  • Evacuation
  • Command, control, and communications (C3)

As depicted in Figure 1, the function of C3 is paramount to a successful CHS plan. CHS planners will then only be concerned with the "balance" of treatment and evacuation. If evacuation is readily available and accessible, there is less of a requirement for treatment assets far forward. Consequently, if evacuation is limited, as would usually be the case for urban combat, then there is a greater requirement for treatment assets far forward. CHS planners must understand that this balance is constantly changing and must be prepared to take appropriate actions to meet the CHS challenges presented on the urban battlefield.

Figure 1

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