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Ambulance Exchange Points Operations

by MAJ William E. Carter, Chief, Division Medical Operations Center, 1st Cavalry Division

AMBULANCE EXCHANGE POINT. A position where patients are exchanged from one evacuation platform to another is designated as an Ambulance Exchange Point.

FM 8-10-6, Medical Evacuation in a Theater of Operations

Medical planners (S-1, medical platoon leader, medical company commanders, combat health support officer, brigade surgeon) use ambulance exchange points (AXPs) when the distance between medical treatment facilities (MTFs) is too distant for one evacuation platform (standard or non-standard) to evacuate the casualties the total distance. Medical planners and operators use AXPs when it would be more effective to have the casualty transferred on to another evacuation platform between the sending and receiving medical treatment facility, thereby freeing up the evacuation platform to transport more casualties. An AXP is not only used for the transfer of casualties between ground evacuation platforms, it can be a location where the transfer of causalities occurs between a ground and air evacuation platform. Normally an AXP is used for the transfer of patients between different types of platforms as opposed to transfer between like vehicles, which can only delay evacuation. In these cases where transfer will occur between like platforms, medical planners should consider exchanging vehicles or crews as opposed to unloading and reloading patients onto the vehicle.

This article is written based on how a medical planner and operator could support a typical scenario at the National Training Center (NTC) using an AXP to transport casualties. During a typical rotation at NTC, AXPs are planned and established throughout the battlefield. Because of the vast maneuver area and the scenario at NTC, it is more effective to institute AXPs to support the maneuver units. Typically, an M113 armor ambulance from the forward support medical company (FSMC) pre-positioned at a unit's battalion aid station (BAS) will drive to an AXP located approximately one third the distance from the receiving medical treatment facility (MTF), in this case the FSMC located in the brigade support area (BSA). At the AXP, the patient is transferred to an awaiting ambulance that will drive the remaining distance to the FSMC. The M113 ambulance will return to the battalion aid station and gather new patients for evacuations. This concept in theory decreases the amount of time that an ambulance is unavailable to transport new casualties. Usually at NTC, the transfer of patients occurs between armor ambulances, M113s, to M997 High-Mobility Multipurpose Wheeled Vehicles (HMMWVs) Front-Line Ambulances, (FLAs). Using AXPs at the Joint Readiness Training Center (JRTC) at brigade level is rare because of the short distance between the BAS and the FSMC. When they are established, it is usually done at the brigade boundary and patients are transferred to ambulances from echelon above division (EAD) units for transportation to level III MTF.

There are numerous planning factors that require consideration when determining whether an AXP is needed to support the combat health support (CHS) plan. The medical planners should analyze the casualty estimates, availability of evacuation assets, security, communications, road network, time and distance between the MTFs in determining if there is a need for an AXP. Planning for the use of the AXP cannot be done in a vacuum by the supporting medical unit. An effective CHS plan needs input from others within the staff and especially the supported units. The brigade's CHS plan supports the maneuver battalion's CHS plan, not the other way around. The unit responsible for establishing an AXP must coordinate and understand the CHS plan of the unit they are supporting. For example, a medical company must coordinate the location of their proposed AXPs with the maneuver battalions they are supporting. There is nothing worse than setting up an AXP and watching as a section of Paladins move into your area because, as a planner, you failed to coordinate with the maneuver battalions on the proposed location of your AXP. Or worse yet, smeone calls for indirect fire on your AXP because you placed your AXP on a suspected enemy's main avenue of approach and your element is mistaken for the enemy.

Once the medical planner determines that there is a requirement for a unit to use an AXP, the medical planners and operators, medical platoon leader/sergeant, ambulance platoon leader/sergeant, ambulance crews, should examine and analyze numerous factors. Especially when planning the location of the AXP and determining the decision points to move or relocate an AXP. The medical planners need to determine what will trigger the decision to move the AXP. Will it be based on time, location of friendly forces or an event and who should make the determination to move the AXP? Determining these triggers will be based on mission, enemy, terrain, troops, and times available (METT-T). Additionally, at what point is an AXP too close to the maneuver battalions they are supporting, and, in turn, when are they too far? There are numerous factors that planners and operators must consider. Some of these planning factors include, but are not limited to:

  • The number and types of casualties.
  • Where and when the casualties will occur on the battlefield.
  • The number of standard and non-standard evacuation platforms available for the operation.
  • The road network, to include physical characteristics of the roads such as the surface, width and grades of roads.
  • Location of possible enemy obstacles.
  • Location of friendly obstacles.
  • The enemy's ability to disrupt patient evacuation with indirect weapon systems.
  • Type of terrain and availability of cover and concealment.
  • Percentage of illumination available at night.
  • Weather forecast.
  • The distance between MTF and the excepted time of travel between MTFs.*
  • Traffic density.
  • Possibility of cross-country routes.
  • Line-of-site analysis for communication (done with the battalion signal officer).
  • Natural lines of patient drift.
  • Resupply points for classes I, III, V and VIII.

*NOTE: (IAW FM 8-5, Planning Medical Health Service Support, a wheel-and-track vehicle can travel eight kilometers and return in one hour during combat in a division area. Additionally, because of safety requirements, each area of operations may have a set maximum speed that vehicles can travel.)

RECONNAISSANCE

Whenever practicable, ambulance unit commanders should investigate all routes available or likely to become available within their zones of operation. Such reconnaissance is not only for the purpose of selecting or familiarizing themselves with initial routes, but also for securing information of alternate routes in the event that changes in situation may indicate, or require, the abandonment of the initial route.

FM 8-10, Medical Service Theater of Operations, March 1951

The requirement for reconnaissance to occur before combat operations has not changed over the years. The medical planner as well as the ambulance crews must know their assigned area in which they are expected to operate. The medical planners and operators should reconnoiter the area of operations, proposed AXP, and primary and alternate evacuation routes before any operation. Reconnaissance can be done by actually driving in and around the area since the brigade combat team (BCT) owns the terrain, but only if METT-T and security considerations favor such a reconnaissance. You do not want to alert the enemy of an upcoming operation by driving around the route of the main attack. A map reconnaissance should also be done in conjunction with an actual reconnaissance to validate the roads and key terrain features on the map. Photographic reconnaissance can occur if the unit is unable to conduct an actual on-site reconnaissance. Requesting photographs of the area requires coordination with the battalion or the brigade S-2 (Intelligence Officer). As with an actual reconnaissance, a reconnaissance using photo images should be done in conjunction with a map to validate the locations of roads and key terrain features on the map.

Time and distance factors

Determining time and distance factor is one key analysis tool used by the medical planner in deciding whether an AXP is needed and then determining the location of the AXP. To correctly determine the time and distance factor, the medical planner needs the following:

  • Map.
  • Coordinate Scale and Protractor (GTA 5-2-12), Figure 1.
  • Calculator.
  • Method for measuring the route.*


Figure 1. GTA 5-2-12

*NOTE: The medical planner can use a "map measurer or map measuring instrument" to determine the distance along both the primary and alternate routes. If these tools, which can be ordered at the post exchange or clothing and sales, are not available, the technique for measuring a distance on a map is in STP 21-1 SMCT, Soldier's Manual of Common Tasks, task 071-329-1008, page 53.

Once the distance is determined, the planner needs to anticipate the speed of the vehicles. The determination of the speed is dependent on the mission, terrain and guidance from higher headquarters.

Here is an example of a time-distance problem: An ambulance at an AXP located 15 kilometers from the FSMC travels at a speed of 25 mph and spends 15 minutes at the medical company before leaving to return. (Depending on the experience of the ambulance crew, the personnel at the receiving medical treatment facility, the requirement to exchange equipment and other variables, the time an ambulance spent at a location will vary. It is better to be more liberal on this time than too conservative.) What is the estimated time that the ambulance will be involved in evacuating a one set of casualties?

Step one: Convert kilometers to miles (multiply kilometers by .621371): 15 X .621371= 9.3 miles.

Step two: Determine time on the road from AXP to FSMC (Multiply distance by 60 minutes then divide by the speed): (9.3 X 60)/25 = 22.32 or 23 minutes.

Step three: Add the time on road and time at medical company: 23 (going to the FSMC) +15 (time at the FSMC) + 23 (returning to the AXP) =58 minutes (see Figure 2).

Figure 2

Based on the above problem, it will take one ambulance approximately 58 minutes to do one round trip between an AXP and the FSMC. By determining this and knowing the casualty estimate from the brigade or battalion S-1 (personnel officer), the medical planner can estimate the requirements for evacuation assets for that operation. Additionally, the medical planner must determine when the casualties will occur with assistance from the S-2 (intelligence officer) and the S-3 (operations officer). The key to successful evacuation operations is to have the right number of medical assets in the right place at the right time.

The medial planner needs to determine the time and distance factors for every proposed AXP, not just the first one to get an accurate impression of what is needed to support the maneuver battalions. Therefore, if the unit proposes using three AXP during the operations enroute to the objective, then the medical planner must compute the time and distance factors for each AXP and then combine them together.

Here's another time and distance planning problem: Based on the plan, the battalion that is the main effort during an attack is expected to receive 36 urgent litter casualties at H+2. The BAS is established 10 kilometers from an AXP. The BAS has three M113s available to evacuate casualties to the AXP. The ambulance platoon leader expects the M113 to travel at a speed of 25 MPH and spend 10 minutes at the AXP transferring casualties to awaiting FLAs. The medical platoon leader estimates that it will take 10 minutes to load any awaiting casualties at the BAS for follow-on missions. The AXP location is 15 kilometers from the FSMC. The AXP has three M997 FLAs and the ambulance platoon leader expects the FLAs to spend 15 minutes at the FSMC downloading patients, exchanging property (litters, litter straps), and receiving Class VIII pushes for the BAS, if required. To transport the urgent casualties to the FSMC from the BAS within two hours, how many assets are needed at each level?

Step One: Convert kilometers to miles
BAS to AXP (10 kilometers times .621371) equals 6.2 miles
AXP to FSMC (15 kilometers times .621371) equals 9.3 miles

Step Two: Determine time on road
BAS to AXP (6.2 miles divided by 60/25) equals 14.88 or 15 minutes
AXP to FSMC (9.3 miles divided by 60/25) equals 22.32 or 23 minutes

Step Three: Time in route
BAS to AXP and Back: 15+10+15 = 40 minutes
AXP to FSMC and Back: 23+15+23 = 61minutes

Step Four: Draw timeline (see Figure 3)

Figure 3

In 15 minutes, three M113 ambulances can transport 12 casualties to the AXP. It will take 10 minutes transferring the patients onto the three M997s. For ease, let's call this group of patients "lift" Alpha. The patients from lift Alpha arrive at the FSMC and are downloaded in 38 minutes, for a grand total of 63 minutes of transportation time for lift Alpha. While lift Alpha is being transported, the M113 return to the BAS. Time used by the M113, 40 minutes. The next lift of urgent casualties, lift Bravo, is loaded in 10 minutes and leaves for the AXP. Lift Bravo arrives at the AXP and waits 18 minutes for the M997s to return from the FSMC. These patients are loaded onto the three M997s and they depart for the FSMC. It takes the causalities in lift Bravo a total of 101 minutes to arrive at the FSMC from the time they were ready for evacuation at the BAS. Only 24 casualties arrive in a timely fashion, within 2 hours, from the BAS to the FSMC. Twelve casualties do not reach the FSMC in a timely fashion. It is up to the medical planner to determine the method of augmentation to the AXP or the BAS to transport the additional casualties. In this case, a 5-ton capable of hauling 12 litter casualties or two extra ambulances at the BAS and AXP could have met this requirement.

Using the same logic in determining the time and distance factor, the medical staff should determine whether there is a requirement for an AXP. We will use the same situation in the planning problem above except in this planning problem, we will not have an AXP. In this scenario, three additional M997 FLAs positioned at the aid station will transport the casualties to the FSMC with M113s. The evacuation platforms will travel at the same speed of 25 MPH directly from the BAS to the FSMC.

Step One: Distance
BAS to FSMC (25 kilometers times .621371) = 15.5 miles.

Step Two: Determine time on road
BAS to FSMC (15.5 miles divided by 60/25) equals 37.2 or 37 minutes.

Step Three: Time in route
BAS to FSMC and back: 37+15+37 = 89 minutes (see Figure 4).

Figure 4

If all six vehicles leave fully loaded with 24 patients, they will reach the FSMC and download the patients in 52 minutes (37+15 = 52). The lift of six ambulances will return to the BAS in 89 minutes. The next lift of patients will take 10 minutes to load at the BAS and will reach the FSMC in 136 minutes. Out of the 36 litter urgent casualties, 12 will not make it to the FSMC in the allotted time.

By comparing both scenarios, the medical planner may determine that there is not a need for an AXP and may place three additionally M997 FLAs or a 5-ton truck at the BAS. The medical planner must also consider the METT-T when determining whether to use an AXP. In this example, a convoy of six vehicles, three M997s and three M113s, could impede forward moving traffic and make for a lucrative target by enemy aircraft or forward observers. Or, by placing three additional ambulances with the BAS, thereby enlarging their "footprint" or "signature" on the battlefield, the convoy could possibly compromise the mission of the brigade task force.

The medical planners should not use these time-distance factors solely in determining the location of an AXP and number of vehicles required. The planner should understand that this is only one factor of many needed to properly plan CHS for a brigade. These numbers and formulas used in the problem above are only a technique based on estimates "in a perfect world." The medical planner must fully understand the situation and METT-T along with the time-distance factor. The medical planners must exam all factors when developing the CHS plan in determining whether there is a requirement for an AXP.

Support Requirements

Leaders must be able to anticipate fuel requirements and be proactive as opposed to being reactive. The ambulance platoon leader must determine how many trips an ambulance can make before it requires fuel. In accordance with the technical manual, the cruising range of the M997 is 275 miles. Therefore, an ambulance traveling 25 miles from the AXP to the FSMC and back will require fuel after its 11th trip (275 miles divided by 25 miles). The time to coordinate for fuel is not when an ambulance crew radios to the platoon leader that it is running close to empty. The M997 has a fuel tank of 25 gallons. The M997 should refuel after patients are transported to the FSMC in the BSA. These figures do not consider idling times or fuel usage to run the air conditioner or the heating unit in the back of the FLA.

An M113 armor ambulance has a 95-gallon fuel tank and receives fuel from the combat trains of the unit it is supporting. The fuel consumption rate for an M113 in gallons per hour is shown below.

IdleCross CountrySecondary Roads
6.4188.6

A technique to keep the vehicles at the AXP operational is to have the company first sergeant and the unit's mechanic drive to each AXP during lulls in the battle, if METT-T permits. They can take this opportunity to check the vehicles and correct any deficiencies on the spot, check the health, welfare and morale of soldiers and re-supply the team with supplies.

Rehearsals

Operations at an AXP should be rehearsed at all levels before the mission. The unit establishing the AXP should have a set of battle drills that must be executed upon their arrival at the site. The mission and the size of the AXP will determine what actions must be taken. At a minimum, the following should be rehearsed:

  • Establishing Security.
  • Establishing Communications.
  • Establishing Traffic flow.
  • Establishing Landing zones (LZ)/pickup (PZ) sites.
  • Establishing Tailgate medicine (If a treatment team augments an AXP).
  • Establishing Triage area (If a treatment team augments an AXP).

Execution of Ambulance Exchange Points

"Doesn't anyone know how to read a map anymore?"

--From the movie The Longest Day

An AXP cannot be established if the "team" cannot find that point on the ground. A trend occurring at JRTC and NTC is that ground ambulance crews are having problems navigating, primarily at night, and depend too much on PLGRs (Precision Lightweight GPS Receivers). In TB 11-5825-291-10-2, Soldier's Guide for the PLGR (Precision Lightweight GPS Receiver), the manual states that "the PLGR does not take the place of these basic soldiers' skills: reading a maps, recognizing terrain and using a compass." The PLGR is a navigation tool that augments basic navigation skills. Ground ambulance crews should be able to navigate by using basic military navigation skills, a map and compass, and terrain features as well as the sun and the stars. (The sun will always rise in the east and set in the west. And the North Star (Polaris) will always point north.) The PLGR is one of the soldier's navigational tools, but not the only tool. All the skills a soldier needs to navigate can be found in STP 21-1-SMCT, Soldier's Manual of Common Tasks, pages 23 through 65. The navigation tasks are:

Task NumberTask
071-329-1000Identify Topographic Symbols on a Military Map
071-329-1001Identify Terrain Features on a Map
071-329-1002Determine the Grid Coordinates of a Point on a Military Map
071-329-1003Determine a Magnetic Azimuth Using a Lensatic Compass
071-329-1005Determine a Location on the Ground by Terrain Association
071-329-1008Measure Distance on a Map
071-329-1012Orient a Map to the Ground by Terrain Association
071-329-1018Determine Direction Without a Compass

The ambulance platoon leader or platoon sergeant should write a synopsis of these tasks into the platoon's standing operating procedures (SOPs). Thus, the soldiers could have this information readily available to them. Units should train on these same skills at home station.

Communication

"What we've got here is a failure to communicate."

--From the movie Cool Hand Luke

The most significant aspect of effective evacuation on the battlefield lies in the ability of the personnel responsible for coordinating and executing MEDEVAC to communicate. AXP personnel must be able to communicate with the units for which they are providing direct support and general support, or areas supported and their higher headquarters. Soldiers and leaders in the ambulance platoon should be knowledgeable in using communication equipment. FM 11-43, The Signal Leader's Guide, contains a vast amount of general information on techniques and methods for setting up and using signal equipment available to medical units.

A standard division-level M997, Front-Line Ambulance, is equipped with a SINCGARS (Single-Channel Ground and Airborne Radio System) which has a range of 10 to 40 kilometers depending on the type of systems in use. To maximize the FM radio transmissions, there should be good line of site between sending and receiving units. Large terrain features can block the signal. In other words, you cannot communicate from a gully or behind a mountain. The operators must understand how to overcome these problems by proper placement of antennas. Chapter 3 of FM 24-19, Radio Operator's Handbook, is dedicated to using and setting up antennas, to include field-expedient antennas. Additionally, an ambulance platoon leader or platoon sergeant should conduct a line-of-site analysis of the proposed AXP sites with the battalion signal officer. Instructions for this type of analysis is found in FM 11-43, Chapter 5, Section I. This will assist the medical planner in determining if there might be possible communication problems and in offering possible solutions before the problems occur.

"CINC" AXP and a Dedicated Medical Radio Net

For brigade-level operations and depending on the mission, it may be beneficial to have one individual, usually the FSMC commander, to command and control the movement of evacuation assets to the different AXPs on the battlefield. This AXP command and control (C2) node can relay radio traffic between the different AXPs spread across the battlefield and the FSMC located in the brigade support area. By monitoring the task force command net and using proper battle-tracking techniques, the CINC AXP should be able to anticipate the proper movements of the AXPs and other medical requirements. Additionally, this individual informs the brigade tactical operation center of the location of AXPs and inform the FSMC when casualties are heading to their location. The CINC AXP should be someone with experience in tactical operations and CHS operations along with knowledge of communication systems. The CINC AXP should operate off a dedicated medical net. All MEDEVAC requests and all AXP C2issues should be coordinated on a separate dedicated medical net. The medical planner must coordinate for this separate net with the brigade signal officer before the operation. (The medical company net should be used because of the shortage of communication assets in the FSMC.) The medical planners must ensure that all the medical call signs and frequencies are disseminated throughout the brigade and that this dedicated medical net is included as part of the SOI extract, which is given to all units. Planners can include the call signs and frequencies on the CHS overlay and should be briefed at all rehearsals, at all levels.

Net Radio Interface (NRI)

NRI allows soldiers operating on a SINCGARS to communicate with someone operating on a DNVT (Digital Non-secure Voice Terminal) or MSRT (Mobile Subscriber Radio-telephone Terminal) and vice versa. The division signal battalion establishes NRI stations at various signal extension nodes. NRI permits radio calls to be integrated with the ACUS (Area Common User System) and vice versa. (The ACUS is a communication system made up of a series of network node switching centers of Mobile Subscriber Equipment (MSE) at corps and below.) NRI also provides subscribers a means to overcome the distances between units on the battlefield. The coordinating instructions in the division's SOI explains to the users how to place NRI calls. This technique is for emergency communications only and should not be considered as part of the CHS communication plan. The operator who requests NRI must know how to use proper radio-telephone procedures and follow the instructions of the NRI station operator. The benefit of NRI is that it gives the personnel at an AXP another method to communicate to their higher headers, when all other means fail. Appendix F of FM 25-18, Tactical Single-Channel Radio Communication Techniques, provides more information concerning NRI.

A designated soldier within the company should take all these signal references and develop an abbreviated "unit signal smart book" or a signal chapter in the unit's SOP. This book or chapter needs to be with every vehicle in the company that has a radio and the FSMC's tactical operation center. The book or chapter should be easily understood and not written in "signal-ease." Units should train on these communication tasks at home station and during communications exercises before an operation. Included in the book or chapter should be the following:

  • SINCGARS Operations.
    • Frequency HOP-Substation Operations.
    • Receiving an Electronic Remote Fill.
    • PMCS and trouble shooting.
  • Affiliation of MSRT.
  • Affiliation of DNVT.
  • Method for establishing a field-expedient antenna.
  • Method for establishing an OE254 (method can be found in GTA (Graphic Training Aid) 11-3-20, Installation of Antenna Group OE254).

Markings

Because of the confusion on the battlefield, especially during battles similar to the ones fought at the NTC, the AXP should be well-marked during the daylight hours and at nighttime. Not only will a well-marked AXP assist incoming ambulances in locating the site, but it will help slice elements assigned to the battalions or brigades find the AXP, such as the Military Police and Air Defense Artillery units. One method of marking is with a large flag with a red cross on a M113 or M557. Using the flag will depend on METT-T and guidance from higher headquarters. Additionally, a flag with a Red Cross should provide the unit protection under the Geneva Convention. However, the flag could work against the unit and mark their position to the enemy. Determining under what circumstances to use markings is also important and can be the key to survivability. A large flag with a Red Cross can be seen at night with night-vision devices (NVDs) when illumination is high. If the unit decides to use chemical lights on a radio antenna at night to mark the AXP, the pattern of the chemical light must be unique. Chemical lights look the same under NVD, and if the MPs are using two blue chemical lights on their antenna just like the AXP, the markings becomes fruitless. A technique for guiding the ground and air evacuation platform at night is to have a guide swirl two chemical lights, each going in oppose directions (clockwise and counter-clockwise). To be effective, the AXP must have some easily identifiable, unique means of marking so ambulances and wounded soldiers can find them. This is especially important at NTC since the FSMC routinely positions treatment teams forward in M577s which can be mistaken for command posts or tactical operation centers.

Priority of Work

Ideally, an AXP is an event, something that happens quickly, but this is based on METT-T. Once the "team" arrives at the site of the AXP, the team needs to establish the site using battle drills based on the priority of work. The priorities of work are similar to those used to set up a BAS or an FSMC. Each soldier is given a task and executes. Below is an example of a priority of work for an AXP. Each step can be done simultaneously.

Security
The most important of these tasks is security. A soldier with a set of binoculars, manning a simple observation post on a hill overlooking the battlefield, could meet the security requirements for this operation. The type and the amount of security will depend on METT-T. Security also includes the proper dispersion of vehicles and use of natural terrain and vegetation for cover and concealment.

Conduct a communication check and submit SITREP to higher headquarters
Ideally, communication should be continuous from the time the team leaves the company area. Because of terrain and distance, there may be a requirement for the team to set up an OE 254 antenna. The antenna should be positioned so that it provides the best line of site to the rear. Once an AXP is established or occupied, a situation report or SITREP should be forwarded to higher headquarters; in turn, this location is disseminated to the entire task force. The composition of the SITREP is based on unit SOP.

Establish LZ/PZ (call in the location to higher)
LZs/PZs need to be marked and the location immediately sent to higher headquarters for dissemination to the air MEDEVAC unit, supporting aviation unit and the task force. The method for establishing a LZ can be found in FM 8-6-10, Medical Evacuation in a Theater of Operations, paragraph 10-27.

Establish traffic flow
If time allows, the area should be well-marked by easily recognizable directional signs. It could be as simple as a piece of cardboard on a piece of metal pointing the way in and out of the area. Use chemical lights and coffee cans at night. The unit can take a coffee can or even a large non-transparent plastic bottle to make directional signs at night. Punch small holes on the side of the object in the shape of an arrow, then place a chemical light inside to create directional signs for night operations with minimum illumination. The bottom line is that someone must take control of vehicles as they enter the area. Vehicles need to have an easily identifiable way in and out of the area. The ambulances that transport the casualties beyond this AXP should be pointed toward the exit, with doors open and upper berth trays in the down position ready to take casualties (see Figure 5).

Figure 5

Establish tailgate medicine (if appropriate)
Depending on the mission and the requirements to provide support to slice elements, a treatment team from the FSMC may augment the AXP. The specifics on the establishment of tail-gate medicine depend on the mission and unit's standing operating procedures. The medical equipment taken on this operation must meet the task and purpose of the AXP. Additionally, the members of the treatment team must be able to recover their equipment quickly and be ready to move.

Establish triage area (if appropriate)
This depends on the mission and if there is a treatment team with the AXP. The triage area should be well-marked and a designated soldier needs to control the flow of patients in and out of the area. This person should not be the primary health care provider, or the person controlling the traffic flow.
Remember when establishing an AXP, ideally it is a one-time event on the battlefield, extremely mobile, and is ready to move at any moment.

AXP in Offensive Operations (based on an NTC scenario)

AXP "teams" should collocate and travel with main aid stations (MAS*) of the maneuver battalions at the beginning of the operations. Once the MAS receives casualties, the AXP team will establish the site, treat and evacuate casualties. By being initially collocated with the MAS, the casualties can be immediately transported and the treatment team is free to follow the fight. The MAS, in turn, will follow the battalion's forward aid station (FAS*). Some have described this concept as "leap frogging" and it is not a new concept. The idea of having the AXP "team" initially collocating with the MAS is a unique technique (see Figures 6, 7, and 8).

Figure 6

*NOTE: MAS and FAS are not doctrinal terms. The doctrinally correct term is treatment team A and treatment team B. A main aid station or MAS is a term used by some heavy or mechanized units to describe a treatment team collocated or closely adjacent to the combat trains command post or toward the rear of the maneuver formation. Forward Aid Station or FAS is a term used by some heavy or mechanized units to describe a treatment team located toward the main body in front of the MAS.

Figure 7

Figure 8

Depending on the mission and other planning considerations, the medical company commander could send an AXP "team" consisting of two M997s and a treatment team (a physician or physician assistant (PA), an NCOIC, and two medics) in an M577 to each of the maneuver battalions. According to FM 8-10-1, The Medical Company, treatment teams routinely provide augmentation to maneuver battalion medical platoons. Two AXP "teams" will deplete a medical company of all their wheeled ambulances (there are four M997s in a heavy division's FSMC). The company would need augmentation from the main support medical company or corps medical units for any additional teams above two. Before departing from the company area, the team's NCOIC would conduct a pre-combat inspection (PCI). (See Figure 10.) The PCI occurs before the teams link up with the battalion aid stations they would be supporting. The teams are sent forward to the maneuver units to complete any last minute coordination and to conduct rehearsals with the supporting units. The mission of the treatment team (if required) is to treat patients and to provide C2at the AXP. Concerning treatment, in most cases, the casualties are seen at one of the forward aid stations. A treatment team from the FSMC is present in case a patient's condition worsens while in route to the AXP and requires advanced lifesaving treatment. Additionally, most of the slice elements have limited or no medical care except a combat lifesaver. If a soldier from a slice element, such as a corps transportation unit, is wounded in that area, that soldier can be taken to the AXP and receive immediate treatment by a PA or physician. Another task for the treatment team may be to control the establishment of the AXP. They can also provide communications to the CINC AXP or FSMC about their location and the location of the supporting aid station. The treatment team can also requisition and guide incoming MEDEVAC or CASEVAC helicopters and provide the status of casualties inbound to the FSMC. Depending on the mission and available assets, a M998 command vehicle with a senior NCO or junior officer would be ideal for this task.

AXP in Defensive Operations (based on an NTC scenario)

During the defensive, the AXP would be established to the rear of a task force (TF) battle position or with the TF treatment teams based on planning considerations. A treatment team minus would still augment the AXP "team" (see Figure 9). The unit would establish an AXP C2node to pass on information. The AXP teams are sent forward to the maneuver battalion to conduct final coordination and rehearse with the unit. Ideally, the units will conduct reconnaissance of the primary and alternate routes as well as conduct communication checks. In some scenarios based on the BCT's alignment on the battlefield, an AXP "team" might have to provide support to multiple treatment teams or aid stations.

Figure 9

Summary

For AXP operations to work, the medical planners must begin planning as soon as they receive a warning order or fragmentary order. The planning cannot occur in a vacuum and requires coordination with brigade staff, supporting units and supported units. The medical personnel executing the mission must be knowledgeable not only in their medical skills but also in their basic soldier skills, especially communication and navigation. AXP operations can be successful if they are well-planned, rehearsed, organized and executed in a professional manner.

Pre-Combat Checklist for Ground Ambulance

Vehicle is loaded according to load plan (see TM 9-2320-280-10, Change 4, Appendix F, pages F-16 and 17, for an example load plan for an M997, and FM 8-10-4, Medical Platoon Leader Handbook, pages D6 and D7, for an M113).

Vehicle load does not prevent the crew from executing its mission (can load four litter patients without moving gear, such as duffel bags and water cans).

Medical packing list is available.

Medications are current.

Authorized Medical Equipment Set is stocked.

Oxygen tanks are fully operational and ready for use.

Strip Map and/or road maps are available.

One compass per vehicle.

On-Vehicle Equipment (OVM) is on hand.

All basic issue items (BIIs) and any additional authorized items are present and operational. (For M977, see TM 9-2320-280-10; for M113, see Appendix B and Appendix C, TM 9-2350-277-10).

SINCGARS radio is set and operational.

Current Signal Operating Instruction (SOI) extract is on hand.

GPS receiver is operational with extra batteries.

Two 5-gallon water cans are on hand (numbers will depend on METT-T and unit SOP).

One case of meals, ready-to-eat (MREs) is available (numbers will depend on METT-T and unit SOP).

Night-Vision Devices are operational with extra batteries.

Chemical Detection and Decontamination Equipment are on hand (depends on METT-T and unit SOP).

Personnel receive current intelligence and situational updates.

All individual weapons clean and functional with cleaning kits.

Basic load of ammunition is issued and accounted for.

Vehicle is topped off.

Vehicle dispatch is complete.

Operator manuals and lubrication order (for M997/996, see TM 9-2320-280-10, Appendix A; for M113, see TM 9-2350-277-10, Appendix A) are present for vehicle, radio, and associated equipment.

Soldiers are in correct uniform, including identification tags.

Leader receives a conformation brief from the crew on the mission and the current situation.

Figure 10

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One Billion Americans: The Case for Thinking Bigger - by Matthew Yglesias