2. Traditional Army Medical Wartime Structure

To understand how the medical requirements of OOTW differ from those of traditional wartime medical support, we start with a baseline of how the AMEDD is structured to support its traditional wartime mission and to provide health care services to its beneficiary population.

How the Army Health Service Support System Is Organized

The Army's health service support system is designed to be a single, integrated system that reaches from the combat zone in the theater to CONUS. The underlying idea is that the system is a continuum of care in which a soldier injured on the battlefield will be provided a full range of services, from simple first aid in the theater to more definitive care at a fixed facility within CONUS or Europe.[1]

The deployable Army medical force is made up of units and personnel from both the Active Component (AC) and the Reserve Components (RC), with 75 percent of its wartime structure being in the RC. The Army Medical Department (AMEDD) is responsible not only for supporting the Army's wartime mission, but also for maintaining the delivery of health care to its beneficiary population.

The peacetime structure in CONUS primarily comprises Army hospitals--medical centers (MEDCENS) and smaller medical activities (MEDDACs)--under the command of the U.S. Army Medical Command (USAMEDCOM). These fixed facilities are referred to as the Table of Distribution and Allowance (TDA) units. The wartime structure comprises Table of Organization and Equipment (TOE) medical units assigned to combat organizations under the command of U.S. Army Forces Command (FORSCOM). The medical personnel required to staff the TOE combat units are actually assigned to the TDA units when not deployed or during peacetime. These personnel work within these Army hospitals or the peacetime structure and are designated as Professional Officer Fillers under the Professional Officer Filler System (PROFIS). PROFIS enables the AMEDD to use its wartime requirement of professionals on an everyday basis during peacetime in the delivery of health services to the Army's beneficiary population (i.e., active-duty personnel, their dependents, and retirees). Thus, under PROFIS, military health care professionals are able to maintain their clinical skills and individual level of readiness when not deployed by working within peacetime facilities.

Structure Supporting the AMEDD's Wartime Mission

The process by which the AC and RC are employed to fulfill the AMEDD wartime mission is as follows. During mobilization or a contingency operation, PROFIS personnel (active-duty personnel) are pulled out of Army hospitals or military treatment facilities (MTFs) to join the combat medical unit they have been assigned to. RC TOE medical units may also be part of the deploying force. Other RC TDA hospital units or individuals are then used to backfill CONUS hospitals or hospitals within Europe that lost deploying PROFIS personnel. In addition, RC TDA medical units and individual reserve personnel can provide mobilization expansion capability, if required, by supplementing deploying active-duty medical units either as individual fillers--e.g., specialists not normally part of the wartime structure or specialists in the low-density areas of concentration (AOCs)--or as an entire unit.

Further, during wartime, the system is to shift its focus entirely to its wartime mission. In the past, transition to war meant shifting beneficiary care to the civilian sector under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), with only active-duty service members continuing to be cared for in Army hospitals within CONUS or outside of CONUS (OCONUS). In this way, CONUS and OCONUS beds could be freed up in anticipation of Army hospitals being filled by casualties from the theater.

However, beginning with Operation Desert Storm (ODS), this policy changed. Guidance for ODS from the Army Chief of Staff (CSA) stipulated that there was to be no degradation in the care of beneficiaries as a result of this war. This policy has held ever since and is applicable to OOTW as well as to war.

This new policy fundamentally changed how the AMEDD does business, since the AMEDD now must perform its wartime mission and support OOTW while simultaneously maintaining the delivery of health care to the Army's beneficiary population. Thus, wartime and peacetime care have become inseparable, and military medical planners must now factor in how to minimize a deployment's impact on beneficiary care. Thus, the medical mission and the backfill mission are integral components of the planning process.

The Wartime Medical Mission: Conserve the Fighting Strength

The AMEDD's wartime mission is to support the line commander by conserving the fighting strength so that he may accomplish the military mission. The AMEDD's wartime mission then encompasses the following objectives:[2] (1) save lives; (2) clear the battlefield of casualties; (3) provide state-of-the-art care; (4) return a soldier to duty as rapidly as possible or evacuate him back to a higher echelon of care for more definitive treatment; and (5) provide the most benefit to the maximum number of personnel.

In operational medicine, the physician or combat medic will have a limited set of resources with which to save lives, treat and return a soldier to duty as far forward as possible, or stabilize and evacuate a soldier to a more definitive level of care. In addition, the theater medical support system is designed to reduce the incidence of disease and nonbattle injury (DNBI) through good preventive medicine support to the troops.[3] Further, the medical commander must maintain enough flexibility in the theater medical system to deal with a near-overwhelming or overwhelming casualty situation.[4]

Echelons of Care

To meet these wartime needs, health service support in the theater of operations is organized into echelons of care. These echelons extend rearward throughout the theater and depend on a reliable evacuation system.

Echelon I. Echelon I--the first medical care a soldier receives--is unit-level health care that includes treatment and evacuation from the point of injury or illness to the unit's aid station. This echelon includes immediate lifesaving measures, DNBI prevention, combat stress support,[5] casualty collection, and evacuation to supporting medical treatment. At this echelon, medical care encompasses self-aid, buddy aid, combat lifesaver, combat medics, and a treatment squad (battalion aid station).[6]

Echelon II. Echelon II is division-level health service support, which includes evacuating patients from the unit-level aid stations and providing initial resuscitative treatment in division-level medical facilities. This echelon includes medical companies, support battalions, medical battalions, and forward surgical teams, as well as intratheater patient evacuation assets. At Echelon II, emergency care, including beginning resuscitation procedures, is continued. Soldiers who can be returned to duty within 24 to 72 hours are held at this echelon for treatment.

Echelon III. Echelon III is corps-level health service support, which includes evacuating patients from supported divisional and nondivisional units and providing resuscitative and hospital care. In addition, Echelon III includes providing area health service support within the corps' area to units without organic medical units. Echelon III care is provided by units such as mobile army surgical hospitals (MASH), combat support hospitals (CSH), evacuation hospitals (EVAC), and field hospitals (FH). Patients unable to survive movement over long distances receive surgical care in an Echelon III hospital. In these theater hospitals, patients receive care that will either allow them to be returned to duty or stabilized for evacuation out of the corps or out of the theater altogether.

Echelon IV. Echelon IV is communications zone-level health service support, which includes the receipt of patients evacuated from the corps. This echelon involves treating the casualty in a general hospital and other communications zone (COMMZ)-level facilities. Here, patients receive further treatment to stabilize them for their evacuation to CONUS.

Echelon V. Echelon V is the most definitive care provided to all categories of patients in CONUS and OCONUS Army hospitals. Echelon V is the CONUS-sustaining base and is where the ultimate treatment capability for patients from the theater resides, including full rehabilitative care and tertiary-level care.

Given these different echelons of care, health service support in the theater of operations is made up of a number of different elements, including hospitalization, command elements, laboratory services, medical logistics and blood management assets, evacuation assets, combat stress support, preventive medicine support, dental services, and veterinary services. All of these are components of Echelons I through V that have to be integrated to form the theater medical system. In this report we focus on the hospital units (Echelon III), but we address, where appropriate, issues specific to other types of units and other echelons of care as they affect the overall performance of the theater medical system.

Planning the Support Requirements

Although mission guidance will come down from the Joint Staff to the warfighting CINC who will develop the operational plan, the CINC designated to perform the mission will plan the support requirements with input from the supporting unified commands and the component service commands of the supported and supporting CINCs who provide the forces. Upon receipt of the mission, the supported CINC, with the assistance of assigned service component commands, will initiate the planning process for developing a concept of operations and related tasks; this concept determines the forces needed to accomplish the mission. As part of this process, the medical planners will undertake their mission estimate and analysis based on the mission statement and mission guidance provided by the JCS. Given the specific mission, this process may involve coordinating health service support requirements with allied or other friendly forces involved in an operation.

Planning factors for the medical mission itself will include: (a) the number of troops to support, (b) the population at risk, (c) the expected casualty or combat intensity rates, (d) the expected DNBI rates, (e) bed availability, (f) the expected admission rates, and (g) the theater evacuation policy.[7] The theater evacuation policy will state the maximum period that casualties who are not expected to return to duty (RTD) may be held within the theater for treatment before being evacuated out.[8] This policy is established by the Secretary of Defense upon advice of the JCS and recommendations of the designated CINC.

In addition, planning takes into account what is available locally, whether the U.S. military will be going into a region with an underdeveloped medical infrastructure or one that has been completely destroyed, and what is available in surrounding countries in terms of medical facilities and other resources.[9] All these factors will determine the support requirements, the evacuation policy, and how the echelons of care get set up.

Planning for the medical mission also will take into account a unit's readiness level, where it is in the training cycle, whether it has trained for a particular type of operation, and the experience of its commander and his staff. It also takes into account whether RC units or reserve medical personnel may be used for a given operation. Moreover, planning takes into account how to minimize the impact of a deployment on operating tempo (OPTEMPO) and personnel tempo (PERSTEMPO). Finally, planning takes into account the backfill requirements and how to minimize the impact of a deployment on beneficiary care.

All of these items factor into the selection of medical units, the number and mix of medical personnel required, and the planning of subsequent rotations.

Assumptions Underlying Health Service Support in a Theater of Operations

Given the design of the U.S. military's health service support system, a series of explicit and implicit assumptions underlie the planning process in terms of the nature of the medical mission, how the theater medical system or the medical structure will be organized, what patient populations will be served, and what the demand for medical services will be. Underlying all of this is the fact that the system itself is designed specifically to support the U.S. military's wartime mission. This in turn will have implications for planning in terms of the medical intelligence requirements, specialty mix of medical personnel and type of units required, preventive medicine support needed, equipment and supplies required, and organization of the echelons of care for a given operation. As this report will show, these assumptions break down in a number of key areas when the mission is to support OOTW or peacetime contingency operations involving a multinational force. The important assumptions underlying health service support in a theater of operations are summarized below.

Assumptions About the Medical Mission

The U.S. Army's health service support system is designed to support specifically U.S. troops versus foreign contingents, civilians, or children. As discussed below, this has important implications for the nature of the patient population expected to be served.
The U.S. military is accustomed to establishing the medical policy for an operation.[10] This means that historically:
- In general, the United States does not expect to have to deal with differences among coalition partners in medical objectives or medical policies for a given operation. It also does not expect to have to account for differences in the quality of deploying forces' medical assets or variation in levels of physical readiness among their troops.
- The United States does not expect to have to support or coordinate with civilian relief organizations or local community medical providers in an operation.
- In the past no repatriation policy has been necessary, since the U.S. military expects all forces to abide by the evacuation policy set for the mission.
A fundamental tenet underlying the health service support system is that the United States "takes care of its own" (i.e., only U.S. military personnel will provide care to U.S. soldiers). So if U.S. soldiers are sent to fight for their country, then they are assured of receiving the highest quality of medical care available within the United States.

Assumptions About the Medical Structure

Health service support will be a single, integrated system that reaches from the forward area of a combat zone as far rearward as the patient's condition requires, including to CONUS.[11]
The different echelons of care will be connected, allowing for the uninterrupted care and treatment of the wounded, injured, or sick.[12]
Fixed facilities will exist at Echelons IV and V to which patients can be evacuated from the theater.
The system is geared toward stabilizing and evacuating patients from the theater when necessary to a more definitive level of care.
A viable and timely evacuation system exists with dedicated MEDEVAC aircraft and personnel assigned to the mission.
A viable medical logistics supply system exists that is based on U.S. FDA standards.
The U.S. military's standards of quality of medical care and of equipment, units, personnel, and training will be adhered to.

Assumptions About the Nature of the Patient Population

Troops will represent a healthy, young adult population (and predominantly male).
Troops will have a high level of medical and dental readiness, minimizing the number of chronic and acute medical conditions that may require treatment in the theater of operations.
Troops will have good preventive medicine support throughout the course of deployment and during the predeployment phases.

Assumptions About the Demand for Services

The demand for medical services will tend to be primarily for trauma and surgical care, since good preventive medicine support and a high level of physical readiness of troops will serve to minimize disease and nonbattle injuries (DNBIs) requiring treatment in the theater itself.
The range of diseases expected to require treatment in the theater will be limited to naturally occurring and common infectious diseases (such as upper respiratory infections) and to diseases endemic to a particular region.

[1]Health Service Support in a Theater of Operations, FM 8-10, Headquarters, Department of the Army, 1 March 1991, p. 3-1.

[2]Operational Branch Concept Combat Health Support, Directorate of Combat and Doctrine Support, U.S. Army Medical Department Center and School, Fort Sam Houston, TX, 8 September 1994, p. 6.

[3]Health Service Support in a Theater of Operations, FM 8-10, Headquarters, Department of the Army, 1 March 1991, p. 1-8.

[4]A key difference between operational medicine and peacetime health care delivery is that the physician in the peacetime setting is able to draw on a broad set of clinical skills, support personnel, and equipment and supplies to provide comprehensive care to the patient. In operational wartime medicine, a physician has a limited and fixed set of resources and personnel to support the line commander, with the goal being to maximize the health benefit for the greatest number of personnel.

[5]Combat stress support is often a critical asset in OOTW missions. In these operations, coalition troops can find themselves dealing with such extreme problems as refugee populations, starving individuals, atrocities, etc. Limitations on troops' ability to respond to attacks (i.e., strict rules of engagement (ROEs)) can serve as another stressor. Although peacekeepers are "noncombatants," these troops may frequently come under sniper fire or attack.

[6]Health Service Support in a Theater of Operations, FM 8-10, pp. 3-3 and 3-4.

[7]Planning of the medical support is based on the doctrinal employment of medical units and the organizational capability of these units. In addition, for UN missions there is often a force cap imposed that sets in advance the total size of the U.S. force. The force cap in turn highly constrains the size of the medical component of the U.S. force.

[8]Doctrine for Health Service Support in Joint Operations, Joint Pub 4-02, 26 April 1995.

[9]That is, how far away you are from the nearest tertiary care facility in a neighboring country. Tactical planners also consider what might be the largest force that gets engaged.

[10]Historically, the U.S. military has had the opportunity in combined exercises to train with other medical forces and their combat units and has supported combined operations in World War II, Korea, and Vietnam. In addition, the NATO War Surgery Handbook is a coalition-agreed-upon text that outlines echelons of care and other clinical issues. However, whether units and personnel are currently trained to anticipate the impact of combined operations is a different question.

[11]Doctrine for Health Service Support in Joint Operations, Joint Pub 4-02, 16 April 1995, p. 1-6.

[12]Ibid.

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