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THE TENETS OF COMBAT HEALTH SUPPORT
A JRTC Perspective

by MAJ Jeffry Wood and CPT Anson Smith
"Combat Health Support is a team effort. It is the responsibility of all soldiers -- not just the medics. This includes combat lifesavers, infantry squad leaders, staff officers, the medical platoon leader, and the battalion commander." -- FM 7-20

FACT: At the Joint Readiness Training Center (JRTC), approximately one out of every four soldiers dies of wounds sustained in combat.

Such a Died of Wounds (DOW) rate is totally unacceptable. This article presents Combat Health Support techniques and procedures that maneuver and support units can use to greatly reduce their actual DOW rate at the JRTC, and more importantly, during actual combat operations. The key is to use every possible Home-Station training opportunity to become proficient in Combat Health Support operations.

« TERMINOLOGY »

Within the military medical community, new terminology is in place. What used to be called Health Service Support is now doctrinally termed Combat Health Support. To leaders and soldiers outside the medical community, common usage applied to medical support still centers around CASEVAC and MEDEVAC, i.e., casualty evacuation and/or medical evacuation.

For maneuver and support commanders, it is important to realize the Combat Health Support (CHS) goes beyond CASEVAC. CHS encompasses an entire system and consists of three tenets: 1) Treatment 2) Evacuation and 3) Command, Control and Communications (C3). Never lose sight of the fact that each tenet relates to the other tenets, at all tactical levels. So even if squad leaders do everything right, that's no guarantee of later success if the battalion/task force doesn't adhere to the tenets. Therefore, the success or failure of CHS ultimately is every soldier's job, and responsibility.

The balance of this article will discuss problems and results of those problems within each of the tenets. A brief vignette illustrating the problems is followed by some techniques and procedures to eliminate the problems.

« TREATMENT »

Treatment: Encompasses procedures performed by soldiers, medics and doctors.

So, you can start with buddy aid and end up in surgery in a field hospital. It's all part of treatment.

PROBLEMS:

1. Time: Misuse of time is the biggest CHS "enemy." The actions taken during what's known as the Golden Hour, that first hour following a trauma, are the singularly most crucial actions in determining whether a patient lives or dies.

2. Lack of forward-positioned health care providers to perform Advanced Trauma Management (ATM).

3. Failure of maneuver or support elements to carry forward the necessary ATM equipment and supplies for subsequent use by medical personnel.

RESULT: Excessively high DOW rates.

The battalion task force had been conducting combat operations. As Bravo company entered the woodline, three shots rang out. Each round found its mark, critically wounding three soldiers. The enemy quickly broke contact. The company collected its casualties and moved them approximately 300 meters to the nearest landing zone (LZ). With a great sense of urgency, the company loaded its casualties onto the floor of a nonstandard evacuation helicopter (a UH-60L Blackhawk helicopter with no medical equipment or personnel on board for en-route care). Although the battalion aid station (BAS) was less than a kilometer away, the unit's leaders decided not to evacuate the casualties to the BAS. Instead, the casualties were evacuated to a level III facility (i.e., an Army hospital) which was an hour and a half flight away by helicopter. As a result, none of these casualties received advanced trauma management from the battalion surgeon or the physician's assistant. As the helicopter touched down on the level III facility's helicopter LZ, the crew chief assisted the hospital's litter teams with carrying the three corpses off the aircraft.

Techniques:

1. Units must provide the highest level of care available as far forward in the combat area as possible.

2. METT-T factors to consider for forward positioning include at least:

  • enemy situation
  • casualty estimate
  • availability of viable evacuation routes (ground and air)
  • helicopter landing zone locations
3. Missions where the Treatment Forward concept is particularly critical because of the distance separating the executing elements from main body support:
  • dismounted infantry infiltrations
  • cross FLOT deep attacks

« EVACUATION »

PROBLEMS:

1. Units do not maximize the use of all available evacuation assets. Too often, only medical evacuation aircraft are considered for casualty evacuation.

2. Aeromedical evacuation units do not have habitual relationships with their support unit(s).

3. Few medical planners understand the limitations and constraints of Army aviation.

4. Few medical evacuation pilots understand the ground tactical plan; many do not have the tactical background and expertise to understand the doctrinal basis behind tactical planning.

5. Too many medical evacuation leaders are not included in the development of the CHS plan.

6. Units too often fail to rehearse evacuation procedures.

RESULTS:

1. Medical evacuation specific aircraft are overtasked and overused, while other ground and nonstandard evacuation assets sit idle.

2. Too many 911 calls for help; these missions rarely prove effective.

3. The lack of specific planning and rehearsal leads to a "You call, we haul" mission execution; this invariably results in an excessive, and preventable DOW rate.

Combat Action--Deep attack. The battalion had taken casualties for the last three or four hours and had been reasonably successful in collecting their casualties. A treatment team administered lifesaving care and stabilized the most critical patients. The health care providers worked feverishly to keep these soldiers alive with the limited medical supplies and makeshift treatment facility. Hours passed as they waited for evacuation helicopters to arrive and transport the casualties back to a field hospital where doctors would perform lifesaving surgery. The battalion had attacked deep and thus did not have a ground line of communication back to friendly lines. The evacuation plan was neither synchronized nor rehearsed and key players had never been involved in the planning process. The medical supplies began to run out as the battalion medical platoon leader screamed into a radio in a frantic call for evacuation helicopters. With each passing hour, more patients died of their wounds. As the numbers of dead grew, one of the health care providers, his fist raised against the sky, was overheard yelling, "I can't believe these guys are going to die after we've worked so hard to keep them alive!"

Techniques:

1. Practice CASEVAC during Home-Station training that uses nonstandard evacuation assets.
    EXAMPLES:

  • use vehicles being evacuated to the rear for repair as carriers for patients not requiring urgent evacuation.

  • plan to use any ground or air assets moving from the FLOT to the rear area as a CASEVAC asset. This requires coordination coupled with timely situational awareness. When ground assets move to pick up Class I, or Class V, etc., use these vehicles for evacuation.
2. Evacuation rehearsals must go beyond detailed briefbacks. It is the final opportunity to test if the evacuation plans will viably translate into evacuation success when needed.

3. Develop evacuation procedures at Home Station. They should be incorporated into the unit TACSOP, and then practiced during every possible field training exercise. Maximizing procedures that are understood and trained to standard minimizes the amount of discovery learning during the conduct of CASEVAC. Standing operating procedures facilitate detailed planning.

« COMMAND, CONTROL AND COMMUNICATIONS (C3) »

PROBLEMS:

1. Units fail to rehearse their communications plan.

2. Too many communications operators lack sufficient training.

3. A consistent lack of communication systems pre-combat inspections.

4. Too often, signal officers are excluded from CHS planning.

5. Too few units have implemented a CHS operations center to battle-track, to situationally prioritize treatment and use of available evacuation assets.

RESULT: Additional losses of time because of conflicting evacuation priorities. This slows the entire process, which again results in an excessive DOW rate.

At 0100, the light infantry battalion was inserted in a helicopter LZ near a village. The battalion immediately began to take casualties. Soldiers fumbled around in the night trying to find the casualty collection points. There were no designated collection point markings, and the soldiers had not rehearsed their collection plan. As the casualties eventually arrived, initial treatment was administered by combat medics. Immediately the unit's leaders attempted to contact evacuation assets. The medics were good, but many of the wounds were beyond their limited treatment capability, and immedicate evacuation was required. The leaders were unable to talk to the unit's CINC-MEDEVAC. CINC-MEDEVAC was on a ground convoy en route to the area of operation that would not arrive for hours. Evacuation helicopters were loitering nearby, but were unaware of the critically injured patients in the area. The pilots did not know the locations of the planned pickup zones (PZs) or the PZ markings. The CINC-MEDEVAC finally arrived in the area of operations, but discovered that he was unable to communicate with his unit because his radio antenna was inoperable. There was no communication exercise prior to deployment and a critical piece of the antenna was left behind in the intermediate staging base. Pre-combat inspections (PCIs) on the communications equipment had not been performed, and no leader checked if the PCIs had been accomplished. One soldier died of his wounds, then another. The unit leaders frantically ran into the closest field and attempted to flag down a passing helicopter. A passing MEDEVAC helicopter saw the leaders and landed. The crew chief jumped out to assess the situation. Because the crew had no communications with the unit on the ground, they were unaware of an ongoing firefight just to the east. Suddenly a shot rang out as a sniper's bullet found its mark in the crew chief's chest. The crew chief fell mortally wounded. The copilot jumped out of the aircraft to assist. As he reached the crew chief, 18 rounds from an enemy 82-mm mortar impacted around the helicopter. The flying shrapnel ripped through the aircraft and ignited the fuel. The aircraft and crew disintegrated into a ball of bright yellow flame.

Techniques:

1. Conduct CHS communications systems exercises at Home Station. Ideally exercise the communications systems in conjuction with field training exercises where CHS should be routinely integrated into the training.

2. Train communications operators to standard on their equipment; train operators on primary and alternate means of communications.

3. Ensure that pre-combat inspections become a routine requirement executed by appropriate leaders at all levels. This is basic troop leading.

4. Include the unit signal officer in the CHS planning process. The signal expertise will be invaluable, for example, in identifying potential communication problems before they occur. Thus, when units deploy, their systems and procedures should be already battle-tested.

5. Appoint a Commander-in-chief, MEDEVAC (CINC-MEDEVAC). Units doing so streamline CHS C3 by centralizing the prioritization of assets and MEDEVAC requests. Provide the hardware and software assets necessary to allow this cell to maintain 24-hour-per-day situational awareness and accurate battle tracking. Units employing such a medical regulator technique execute CHS more successfully than units that don't use a CINC-MEDEVAC.

« CHS TENETS AT ALL LEVELS »

CHS tenets equally apply from squad level to theater level. Each rifle squad member must know how to mark his buddy, day or night, who's become a casualty. Each squad member has to know where the medic is and how to contact the medic. Everyone must know the location of casualty collection points and the closest treatment facility. At battalion level, the medical platoon leader and medics must know the location of company collection points and have rehearsed the routes to them.

Any breakdown of CHS tenets, at any level, can cause the system to fail. This inevitably leads to the unnecessary loss of soldiers' lives. Such breakdowns are preventable. The attached matrix (see figure 1) portrays CHS tenet application at levels from squad to theater.

Procedures: For OPORDs from squad level and above:

1. Specifically address the CHS tenets appropriately in the ORORD.

2. Incorporate the tenets procedurally in unit TACSOPs to the greatest extent practical. This will limit what must be specified in OPORDs.

During a JRTC rotation, while being interviewed by a member of the JRTC Operations Group, a young soldier, about to "die" from simulated wounds said, "They wouldn't really let me die, would they?"

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Table of Contents
Foreword
Building an Engagement Area: A Blueprint for Success



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