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Military

CHAPTER IV

HEALTH SERVICES

Individual Force Protection TTPs for a Combat Support Hospital and
for Multifunctional Medical Task Force Soldiers

by MAJ Michael Rowbotham, while serving as Commander,
47th Combat Support Hospital

The 47th Combat Support Hospital (CHS) is a caretaker unit that currently has a full-time cadre consisting of only 17-percent of its total personnel staff. The remaining 83 percent of its personnel must come from the Army's Professional Officer Filler System (PROFIS). Limited staffing, such as this, will be the norm, since the Army is reducing active component deployable hospitals in both numbers and fill levels. With the majority of the hospital units being PROFIS personnel, and the turnover rate of cadre personnel being high, training force protection skills to proficiency in these hospital units becomes a great challenge. As a result, force protection of the Army hospital suffers. This article provides some individual tactics, techniques, and procedures (TTPs) that should keep soldiers in medical units aware of their force protection and safety responsibilities.

These TTPs were taken from the 47th CSH/Task Force 47 Force Protection TTP handbook. The goal of the handbook was to produce something concise and easily understood by the newest soldier in the unit. The force protection issues and accompanying TTPs pertain to all unit personnel: physicians, nurses, pharmacy technicians, clerks, ambulances drivers, cooks and mechanics, and address common individual tasks specifically covering force protection and other security/safety issues. The specific topics and prescribed actions reflect the author's strategy as a commander to protect the force and secure the unit, not to defend the area. It serves as a point of departure for new soldiers' inquiries and discussion. New soldiers will not get any answers until they first know what questions to ask.

PREFACE

Force protection encompasses all the passive and active measures taken to protect the medical staff and patients from hazards. These measures include enemy activity, environmental threats, as well as the safety of weapons and equipment. These TTPs focus on force protection matters that all individuals face in their routine work/rest/eat/hygiene cycle in the hospital or task force headquarters area. The TTPs are generic, and each medical unit must supplement and modify the list to address their diverse missions, procedures, settings and conditions. Some other common topics are included as an aid to living and working in the unit area.

Air Defense TTPs

1. We must be able to identify threat aircraft operating in the area. Use graphic training aids (GTAs) for training.

2. When threat air is spotted - DO NOT - automatically fire at it. Do not ignore it. DO take cover and warn others that it is approaching.

3. If the aircraft does attack by either direct fire or delivery of chemical spray, DO return fire. See Spot Report.

Air horn signals

1. Three short horn blasts - NBC attack.

2. One long horn blast - Attack or intrusion is imminent or in progress. Quick reaction force (QRF) will respond.

Artillery. See - Indirect fire.

Battle Damage Assessment (BDA) After any hostile activity or an attack, personnel must assess the unit's ability to continue its mission. After any such event, sections must immediately:

1. Account for all personnel, assigned and attached. This includes soldiers who are off shift or working elsewhere under your control. Soldiers detailed to work elsewhere, i.e., security forces, KP, etc., will be accounted for by their temporary leader or supervisor.

2. Examine all essential equipment and supplies, assessing what damage or theft has occurred. Determine the section's ability to continue its mission. Forward this report to the tactical operating center stating what damage occurred, the impact of the loss or damage, and reconstitution or reinforcement requirements.

Battle drills

1. The entire unit will conduct drills or rehearsals to ensure proficiency in critical tasks related to force protection. Expect rehearsals of actions taken upon receiving indirect fire, enemy air, snipers, NBC attack and ground intruders.

2. Sections must supplement generic responses based on their mission and specific conditions.

3. Initiate Battle Damage Assessment (BDA) as part of reactions to hostile activity.

Bombardment. See - Indirect fire.

Challenge and password

1. Each day, there is a challenge and password or sign and countersign as designated by the signal operation instruction (SOI).

2. The soldier must know the challenge and password before leaving the unit area. Learn the challenge and password for the next period if it will change before your planned return. Do NOT write it down.

3. When approaching a gate guard or sentry, expect to be halted at a safe distance. If approaching in a vehicle, the track commander (TC), assistant driver (AD), or ground guide will vouch for the party in the vehicle. Be prepared to provide a count of the occupants of your vehicle and having the vehicle searched. The sentry guard should challenge you in a low voice, using the challenge in a sentence. Reply using the password in the same manner. This is done to avoid compromising the challenge and password.

Communications, Electronic

1. The CSH is equipped with international maritime satellite (INMARSAT), mobile subscriber equipment (MSE), AM radio and FM radio for external communications.

2. MSE system is accessed through any of the digital nonsecure voice terminals (DNVTs) that are installed throughout the unit. Personnel can use a DNVT to contact other sections within the unit if those sections have a DNVT.

3. Other forms of internal communications include handheld FM radios (two nets - PRC 127 and Motorola) and TA-312 field phones. Sections must run the wire for their systems from their location to the switch or junction box.

Communication, information. It is vital to the success of the unit to establish and use clear chains of command and communication. Section officers in charge (OICs) and non-commissioned officers in charge (NCOICs) must stay abreast of current operations and not simply pass out administrative announcements. The information must flow down to soldiers with "value added," section-specific information from their leaders. Conversely, leaders must take the initiative to analyze information from their sections, thereby, contributing to the command and control processes of the unit.

Defense. See - Security.

Enemy Prisoners of War (EPWs). U.S. Army medical units routinely evacuate and treat EPWs.

1. The echelon commander is responsible for providing guards for EPWs. The CSH will request support from a Military Police unit for this task.

2. In the absence of EPW guards, the staff must be prepared to search, disarm and guard an EPW(s) during evacuation and in the CSH.

3. Care providers and others coming in close contact with an EPW(s) must not carry weapons or items that could be used as a weapon, i.e., scissors.

4. Health care providers must not pass between the guard and EPWs.

Hardening the Facilities. The unit is inherently a soft target that is vulnerable to attack by direct and/or indirect fire. The unit will continue to harden the facilities to reduce the risk of injury and damage to the patients, staff, equipment and supplies.

1. Host-nation contract labor may be available to support work details.

2. The unit will continue to improve the site. Sand bagging is one of the most effective methods of providing protection from direct and indirect fire. Each member of the staff will fill some number of sandbags each day to be used to protect patient care areas, perimeter protective positions, command and control areas and troop concentrations.

3. The unit will develop a plan to emplace bunkers with engineer support as improvements continue.

Geneva Convention on the Wounded and Sick (GWS). See also - Security.

1. The unit will make maximum use of protective markings in accordance with the Geneva Convention (GC).

2. The unit will place Red Cross panels over every patient care area.

3. Red Cross flags will be posted in at least three places around the perimeter.

4. Large Red Cross panels (4'x4') will be placed just inside the hospital perimeter. Placement of these panels will be done so as to prevent outsiders, hostile forces, or looters from using the panels as an aid in breaching the unit's obstacles.

Ground Guides. Every vehicle will have a ground guide in the unit area.

  • Use a light at night.
  • Dismount at the main gate.

Hygiene. See also - Laundry and Showers.

1. The unit will establish adequate facilities for daily hygiene. Facilities will improve over time to include warm water and heated tents.

2. The unit will establish laundry and bath services within a few days of establishing the hospital.

Indirect fire (artillery/mortars/bombs)

1. Get down low - immediately.

2. At the first opportunity, move to better protective position on the floor or ground.

3. Perform Battle Damage Assessment after the attack.

Intruders. Hostile forces may breach the unit's perimeter and obstacles and roam the unit's area. These hostile forces will present a threat to unit personnel and equipment.

1. Locate and engage hostile individuals appropriately as outlined in the Rules of Engagement (ROE). The quick reaction force (QRF) will take the lead in engaging the intruders.

2. During such a situation, the risk of fratricide is high. Reduce this risk by minimizing friendly activity in the area.

3. Staff should assume a low profile and prone position in the work areas.

  • Section leaders will post internal armed guards at key entrances to their areas, in prone position.
  • Soldiers must ensure that any rounds fired at intruders and inadvertently toward tents are UP and high at the target. This way the round will pass over fellow soldiers in the prone position and medical equipment.

4. Security forces and the staff at large will report the location of intruders to the TOC.

Latrines. Soldiers will take all of their equipment to the latrines. At the minimum, wear boots, helmet, MILES (if equipped) and weapon.

  • If there is small arms fire in the distance, get out and move to a covered position or any designated post or duty.
  • If small arms fire is in the immediate area, lie on the floor. Do not get in the way of the QRF. Get out when you think it's safe and report the action to the TOC.

Laundry. Priority of laundry is to support CMS and hospital linens. It is likely that the unit will have the capacity to launder a small number of personal items for each member of the unit every three days.

Lights

1. Within the hospital area, the unit will make maximum use of lights to identify the site as a hospital, marked with appropriate GC identification markings, and to observe any potential belligerents in the area.

2. The unit will position two 500-watt halogen light sets about every 50 meters around the perimeter to illuminate the concertina obstacles.

3. Sentries and roving guards will use hand-held spotlights. Soldiers will use them from behind a covered position, since they serve as such a good target for hostile fire.

4. Personnel will practice light discipline when operating in other unit's areas and on the roads.

Media

1. All media encounters will be coordinated through the headquarters.

2. Soldiers will not speak to any unaccompanied or uncredentialed media representatives.

3. If given the opportunity to speak with legitimate media representatives, soldiers will take the opportunity to tell their story and the unit's story to maintain the support of the American people.

4. Things to remember:

  • Talk about what you know.
  • Do not discuss rumors, hearsay, what others may be doing, or speculate.
  • Stay in your lane.
  • Do not disclose specific unit capabilities, times, locations or future plans.
  • Do not discuss the number and types of injuries received.

Mission-Oriented Protective Posture (MOPP). See also - NBC. MOPP is a progressive series of levels prescribing when Chemical Protective Over-Garments (CPOG) and protective mask will be worn and carried.

  • MOPP 0 - Carry the CPOGs and mask.
  • MOPP 1 - Wear the jacket and trousers.
  • MOPP 2 - Add the boots.
  • MOPP 3 - Don the protective mask.
  • MOPP 4 - Don the gloves.

Movement, Ground Vehicles. See also - Ground guides, Vehicle passes, and Challenge and Password.

1. The traffic pattern within the compound will consist of a series of one way roads. They will generally be laid out in three concentric loops:

a. Ambulance or Emergency Medical Treatment.

b. Periphery of hospital for fuel tankers and latrine support vehicles.

c. General logistic support traffic for other sections.

2. Vehicles leaving the area must be properly checked and dispatched.

3. Vehicles must be equipped with basic issue items (BIIs) and topped off.

4. Crews will check out through their headquarters.

5. Crews should have clear directions and a strip map.

6. Crews must be briefed on what to do in case of ground attack, vehicle breakdown, encountering mines, obstacles and chemical contamination.

NBC. See also - Mission-Oriented Protective Posture.

1. Contaminated persons and casualties must not enter the hospital site. Personnel will make a strong effort to prevent contamination of the hospital. If the hospital becomes contaminated, it would be closed to all other casualties indefinitely.

2. The unit will coordinate with supported units to establish decontamination sites (opposite wind directions) away from the hospital site and prepare to receive NBC (probably chemical) contaminated casualties in that location.

3. In addition to individual protective measures, sections must prepare to minimize the damage to equipment and supplies from a chemical attack.

4. Unit sections should prepare to support the transportation, set up, security, cleaning and other extensive manpower requirements of this mission.

Priority of Work. See also - Teams, Set up.

1. The unit will focus its efforts in the following order, working concurrently in all three areas and shifting emphasis as tasks are completed:

  • establish security.
  • establish communications.
  • establish support operations.

2. Within the CSH, priority is to establishing EMT, TOC, Landing Zone (LZ), operating rooms and CMS with power and intensive care unit.

Quick Reaction Force. The QRF is a dedicated force of one or more squad-sized elements. They will not perform other duties (on the ward, driving, cooking, showering, etc.) while they are on call or duty. They will remain in a central location under the control of the Sergeant of the Guard (SOG). They will remain dressed with equipment at hand to drill and respond immediately to any actual or suspected hostile actions.

Rules of Engagement

1. The command will provide guidance outlining how defensive force (potentially deadly) may be used against unfriendly intruders.

2. Soldiers will always have the ability to defend themselves.

3. In general, force used should be the minimum required to accomplish the mission, and responses or retaliation should be proportional.

4. Higher headquarters will publish a mission-specific ROE.

Security. This commander's intent is as follows:

  • We will observe the requirements of the Geneva Convention.
  • We will clearly mark our facility and identify it as a hospital.
  • We will fly the Red Cross flag, mark our treatment areas with the Red Cross emblem, identify and mark the facility with signs outside the perimeter, and light the unit area at night.
  • Other corps-level units are not afforded the same protection under the Geneva Convention and will not choose to be near us. We will not set up as part of a base cluster with non-medical units.
  • We may no longer be required to harden our position and be prepared to defend against a deliberate uniformed organized hostile threat; however, we will have to contend with looters, saboteurs, terrorists, bandits and other hostile belligerents with weapons that are equal to, or superior to, our own. They may attempt to breach our security and interfere with our mission at any time. We must deter this threat.
  • Our mission will be to secure, not defend our area.
  • We will protect our patients, facility, equipment, and ourselves, and will direct our efforts toward that goal.
  • We will emplace concertina wire to define clearly our unit area and other warning devices and obstacles to monitor and restrict movements though our area.
  • Emplacing improved fighting positions could be viewed as demonstrating an intention to engage the enemy. I do not hold this view. We will construct an appropriate number of positions that will afford our soldiers adequate protection to perform their mission.
  • A single roving guard would be a naive and unrealistic approach to securing the site.
  • We will deter aggressors with obstacles and clear signs that we are not a legitimate target.
  • We will not employ our unit to invite attack. However, should we be required to defend against a belligerent, I intend for our solders to prevail and live to tell about it.
  • If, despite these measures, we do come under a small arms attack, plentiful protective positions and stacks of sandbags will be of far greater comfort to our soldiers than the moral high ground that we played fair and the bad guys did not. This view is consistent with the Group Commander's guidance, the emerging ROE at the JRTC and perhaps, most importantly, with realistic requirements for a deployment to perform our most likely mission in a Stability and Support Operation.

Showers

1. The unit will establish laundry and bath services within a few days of establishing the hospital.

2. Showers should be available on alternate days.

3. Staff may wear PT uniform with helmet, LBE and mask to the shower facility.

4. Your weapon will be secured per section leader's instructions.

Sleep Tents

1. The unit will erect large general-purpose (GP) tents for sleep tents.

  • Allow an area about 20 x 50 feet.
  • Sleep tents will be hardened with sandbags during site improvement. Sand-bagging priorities for sleep tents will first go to the outside walls of the outside tents.
  • Each tent will accommodate 15-25 personnel.
  • Guards will sleep in a separate tent located near the Headquarters and Headquarters Company (HHC)'s command post (CP). This will facilitate relief, training, communication, command and control of the guard force.
  • Cooks and KPs will sleep in a separate tent near the NCD/Unit Mess.
  • The senior occupant of each tent will maintain a roster/diagram of occupants posted on the pole at the most common entrance.

2. If the unit area comes under attack from indirect fire, immediately lay flat on the ground. Seek cover and adopt the appropriate MOPP. Perform battle damage assessment after the attack.

3. If the unit comes under attack from direct fire or an intruder, lay on the ground. Post guards with weapons trained on entrances and be prepared to defend against hostile intruders. Exercise extreme caution to prevent fratricide.

Snipers. Stay away from open or exposed areas whenever possible. If engaged, immediately drop to the ground and seek cover and concealment. Report the incident to the TOC. Perform Battle Damage Assessment.

Spot Report. Whenever individuals encounter suspected hostile activity, they must report the information to the TOC, where they can process the information as intelligence. Use the pneumonic "SALUTE" to easily remember the important elements of information:

Size - Number of persons and or vehicles spotted.
Activity - What they were doing, which way they were moving.
Location - Grid coordinates or other description.
Unit - Numeric designation or uniform description.
Time - Time of the encounter.
Equipment - Items of military significance spotted.

Teams, Set up. See also - Priority of Work and Communication.

1. Much of the unit's equipment requires a great deal of manpower for setup (tents, dollies, obstacles, etc.). The unit is not staffed with dedicated guards, cargo handlers, engineers, etc., to help in the setup. Establishment of the unit is according to a priority of work that is consistent with the tactical situation. The unit must detail staff from their normal duty sections to serve as part of these setup teams. Some sections and personnel complete their tasks quickly and are disbanded; others are required longer.

2. Communication is critical, and, ironically, most difficult during this transition period. Team leaders must provide leadership and assume responsibility for their team members while the team is together. Leaders must meet with their HQs continually during this turbulent time since many communication systems are not in place, requirements change, related teams and tasks may lag or progress quicker than planned. Teams must be prepared to adjust their missions.

Uniform. See also - Weapons, Latrine, and Showers. Unless otherwise directed by the commander, the uniform is weather-appropriate battle-dress uniform (BDU), helmet, load-carrying equipment (LCE), and protective mask.

Vehicle passes. See also - Movement, Ground Vehicles.

1. Whenever a unit vehicle leaves the unit's area, the departing personnel will check out at the TOC. The TOC will issue a vehicle pass that identifies that vehicle as part of the unit.

2. The driver will display the pass while exiting, hide it during the trip, and again display the pass when returning.

3. Failing to display the pass will signal the unit guards that the vehicle has been captured or the crew is being held hostage.

4. Vehicles coming in from another unit will not display a pass, and will be searched closely.

Weapons. See also - Enemy Prisoners of War.

1. Patients will be disarmed; coordinate with Patient Administration Section and HHC. Simulated patients will retain their weapons.

2. Doctrine and MTOE do not provide weapons for the entire CSH staff.

  • Staff armed with pistols should retain personal control of their weapons at all times.
  • Depending on the tactical situation, staff armed with rifles may rack their weapons in their section per section leader's instructions, while the CSH is operational (setup). Sling or stack nearby with guard while working details (KP, tents, obstacles, dollies, etc.).

3. Keep weapons away from EPWs.

4. Do not keep rounds chambered but do keep weapons on safe. Exercise caution with blanks as well as live ammunition.
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