Jan - Feb 2012: Article

Medical Evacuation Planning in Support of the Brigade Combat Team

At the National Training Center (NTC) at Fort Irwin, California, units routinely struggle with casualty evacuation, even when mission rehearsal exercises have vast infrastructure, semistatic locations, and degraded enemy capabilities. As we begin to prepare for conflict with a "near peer" adversary as identified in Training Circular (TC) 7–100, Hybrid Threat, medical planners must develop evacuation plans that are synchronized with the tactical plan and are understood and rehearsed at the executor level. This article identifies friction points and potential ways to overcome the obstacles that will prevent us from clearing the battlefield.

mechanic with the 1st Maintenance Company

Medevac Planning
Medevac planning is not a complicated concept; it is simply planning for the movement of our wounded using dedicated assets and personnel. However, in practice, medevac planning is much harder and units struggle from the beginning with the roles and responsibilities of the various medical planners and executors because doctrine is vague on who should conduct what part of the process.

This vagueness is intentional to allow units the flexibility to support different personalities and capabilities within their organizations. However, in order for medevac planning to be successful, someone must act as executor and the responsibilities of the brigade surgeon section (BSS), brigade support battalion (BSB) medical planners, brigade support medical company (BSMC) commander, and task force medical platoon leaders must be identified.

This article outlines a way to determine medevac planning roles and responsibilities based on doctrine. This recommendation is based on observations of more than 15 NTC rotations, where the BSS often lacked the experience to heavily influence the outcome of the medevac plan and the BSB commander or the support operations officer (SPO) often took responsibility for plan development and system enforcement.

mechanic with the 1st Maintenance Company

Field Manual (FM) 5–0, The Operations Process, states that the command surgeon is responsible for the synchronization of Army health system support planning and execution. However, the BSS must accomplish four primary missions for the brigade combat team (BCT)-level medevac plan:

  • Develop the patient estimate.
  • Provide clinical and technical oversight for all medical assets in the BCT, including medevac. The surgeon, who is a member of the BCT commander's special staff, must serve as the eyes and ears of the medical community and ensure that specified, implied, and essential medical tasks as well as facts and assumptions are captured and considered during mission analysis and the military decisionmaking process (MDMP).
  • Articulate requirements and the commander's intent to the other medical planners in the BCT by remaining integrated into the BCT plans cell and constantly communicating with the other planners. Although the final product of MDMP is an order, the BSS must consider subordinate units' needs while it develops a plan with sufficient detail to ensure success.
  • Work with the BSB medical operations officer (MEDO) to develop a solid common operational picture of the medical assets within the BCT. This will provide the surgeon with the ability to allocate additional assets to help fill shortfalls in the task force's evacuation plan.

    The planning relationship between the BSS and the BSB MEDO should be similar to that of the BCT S–4 and the BSB SPO, and constant communication during the planning process must be ensured.

The BSB MEDO is a key player in developing a medevac plan that enables the BCT to clear the battlefield. FM 4–02.2, Medical Evacuation, states that the BSS is responsible for the BCT medevac plan. However, the critical link here is the passing of BCT-level generic mission planning to the BSB for synchronization and execution.

During the course of the MDMP, the BSS should identify the requirements needed to meet the BCT commander's intent and support an all-encompassing planning method. However, finalizing, synchronizing, and resourcing the plan should fall on the MEDO in the SPO as his focus should be on developing plans to fill shortfalls with BSMC assets, just as the SPO must plan for class V (ammunition) resupply to the task force level while the BCT S–4 develops the number of rounds required.

This medevac plan should include detailed evacuation routes analyzed against the terrain, the enemy, and friendly movements. It should include ambulance exchange points (AXPs) that shorten lines of communication, and it should identify medevac air corridors (planned by the brigade aviation element or forward support medevac platoon leader) that allow casualty evacuation by air without interfering with airspace coordination. The plan must also direct the placement of BSMC assets forward with the battalion aid station or combat trains command post and depict templated casualty collection points identified by the battalion MEDOs for the supported battalions. The plan must include a communications architecture that facilitates medevac communication but does not hinder the abilities of commanders to control the fight. Finally, the BSB MEDO must produce a health services support synchronization matrix similar to the logistics synchronization matrix that drives decisions and asset moves based on the tactical plan and triggers.

In order to fully develop the medevac plan, the SPO MEDO must actively communicate with his supported units to understand not only the battalion medevac plans but also any perceived shortfall in assets.

Medical Platoon Leaders
Task force medical platoon leaders and the battalion MEDOs play critical roles as they truly are the tip of the spear in the Army's medevac process. FM 3–90.5, The Combined Arms Battalion, places the responsibility for planning Army health system support on the professional filler system (PROFIS) field surgeon, who by doctrine is also the platoon leader with assistance from the MEDO. However, in practice, the MEDO, a Medical Service Corps officer, is not only the medical platoon leader but also the principal medical planner for the task force while the PROFIS field surgeon focuses on patient care and treatment. Whoever serves in the role of medical planner for the task force must plan its evacuation process concurrently with the BCT medical planners, ensuring communication at all times.

At the battalion level, the medevac plan should include placing medics and ground evacuation assets with company trains and locating casualty collection points at the company level. It should include evacuation routes within the battalion's operational environment and articulate the battalion internal communications architecture that will enable casualty information to be passed without interfering with the fight.

Finally, MEDOs must articulate their plans to the BSB MEDO and BSS with shortfalls so that additional assets can be allocated and the common operational picture can be generated. The task force plan must be backbriefed to the BSS and BSB MEDO in a battle rhythm event either articulated in the orders process or driven by standing operating procedure.

mechanic with the 1st Maintenance Company

The final key player in developing a solid medevac plan at the BCT level is the BSMC commander and his direct executor, the BSMC ambulance platoon leader. As the BSB MEDO develops medevac plans based on requirements from supported units, the commander's intent, and the operation plan, he must quickly issue the medevac plans to the BSMC so that troop-leading procedures can begin.

At the BSMC, considerations must be made to ensure dedicated security for movement from AXPs to the brigade support area (if the enemy situation template dictates) and the allocation of mission command at AXPs. The question must be asked, "Who is the decisionmaker at the forward location?" so that as the fight develops, decisions are made in accordance with the commander's intent.

Determining Casualty and Patient Estimates
Once clear roles and responsibilities have been established, medical planners must pay close attention to mission analysis at all levels to ensure proper allocation of assets against time and space according to the maneuver plan. The first planning consideration must be the patient estimate, which is determined by the surgeon. Planners then must understand their patient movement capability and how that capability can be degraded by various effects, including the enemy's capability, disposition, and location.

The BCT S–1 is responsible for producing a casualty estimate so that the commander can make decisions about personnel replacement operations and unit aggregate strength during and after operations.

Two questions must be answered to have a sound patient estimate: How many? And when and where? Many tools are available to help planners estimate casualties based on the type of terrain, enemy disposition, type of operation, and so forth. Common tools are the Medical Course of Action Tool, the Medical and Casualty Estimator, and the Logistics Estimate Worksheet. Although no tool has been officially endorsed, all of these tools can help develop the number of patients. However, casualty estimate tools should be used only when historical casualty data are not available.

All of the patient estimate tools outlined above will tell you a number by precedence of patients, but the true mission analysis that medical planners must conduct estimates when and where the casualties will occur based on tactical actions. An understanding of the operation plan and good wargaming are the best tools available to determine these data requirements.

mechanic with the 1st Maintenance Company

Identifying Available Assets
Once a requirement based on time and space is determined, the next consideration is what assets are available to support the mission. Medical planners must know what standard and nonstandard evacuation platforms, both air and ground, are available for medevac within their formations.

BCT medical planners generally track medevac assets that are available within their formation, such as M113 armored personnel carriers, field litter ambulances, and UH–60 Black Hawk helicopters. However, when requirements exceed the assets available to move patients, medical planners must look at other assets, including nonstandard platforms. Medical planners must know what nonstandard platforms are available to move patients, what their capabilities are, and how to plan for their use. Most importantly, they must understand that these resources must be tasked in the orders process, or units will be hesitant to reduce their combat power. Finally, when planning to use nonstandard platforms, either air or ground, planners must consider the loss of en route medical care provided by medevac platforms and the survivability reduction associated with that loss.

Planners also must consider what can degrade capabilities. Often, planners track the total number of ground assets that are available but plan for their employment at a 100-percent operational readiness rate without accounting for other mission-critical components, such as communications or manning the assets. One way to track these assets is to treat them as systems or crews in much the same way that a combined arms battalion treats its Abrams tanks and crews.

The final asset consideration for medevac is for air evacuation. Consistently, medical planners treat air medevac as the primary method instead of the preferred method of evacuation, so they often do not truly plan for the use of these limited assets. Using the patient estimates, planners must account for the number of turns required to move patients, based on time, distance, load time, and available security. Urgent patients are transported using air assets first. Any excess capability then can be used to move priority and routine patients, but a ground plan must be in place first.

Medevac Planning Considerations and Tools
Countless ways exist to provide casualty evacuation from a battlefield based on certain terrain, assets, and enemy templates. However, several basic practices should be considered for most operations.

Casualty collection points (CCPs) must be planned at the company, battery, or troop level, and planners should consider locating evacuation assets at the CCP under the direction of the first sergeant. At the task-force level, casualty transportation should use dedicated standard assets to quickly and efficiently move patients from the CCPs to the battalion aid station when possible.

By breaking the operational environment into smaller pieces, AXPs are an effective means of shortening lines of communication and helping to ensure better understanding of the operational picture. To maximize the use of AXPs, planners must lay out the locations of the AXPs, determining the proper placement based on the enemy situation template, terrain, and accessible routes.

AXPs are not generally used at the battalion level but instead are usually a BSMC ambulance platoon responsibility. BSMC ambulances should be positioned at the battalion aid station to evacuate to the AXP. Within the hybrid threat environment, security assets for these AXPs and evacuation routes must be planned and, once tasked, AXP security should be that element's primary mission.

Medevac by air in the hybrid threat environment will require considerations that are not required in the contemporary operating environment. Enemy air defense artillery capability could limit the range of forward advance for medevac aircraft, in which case AXPs could become not only transfer points between tracked and wheeled vehicles but also between ground and air assets.

Finally, the use of air corridors to deconflict airspace will become more important. The current perception of troops in contact as high-intensity, lower-frequency events will be replaced by high-intensity, high-frequency events across large fronts. This will require a dedicated airspace management plan to deconflict artillery fires, attack aviation, and medevac.

mechanic with the 1st Maintenance Company

Planning Meets Execution—Medevac Rehearsal
The final step in developing a detailed, resourced, synchronized medevac plan should be a rehearsal. To ensure that the rehearsal does not become a synchronization meeting, several tools must be used to articulate the plan before the rehearsal occurs. At NTC, failures at the time of execution are generally caused by planning shortfalls, but even the best plan, if not rehearsed, has great potential for failure. FM 5–0 discusses the different levels of rehearsals and the resources necessary to execute them.

In a perfect world, all BCT-level rehearsals would be chaired by the BCT commander, but in reality, countless competing demands can take him from the medevac rehearsal. If not the BCT commander, then preferably the BCT deputy commander or executive officer would chair the meeting, with the final choice being the BSB commander.

Every attempt should be made to have the executors of the plan available for the rehearsal, including—

  • Task force MEDOs (executors of the medevac plan at the task-force level).
  • Task force executive officers (honest brokers who ensure that the task force medevac plan is sound and synchronized with maneuver plans and that any shortfalls are identified and filled or otherwise mitigated).
  • The brigade surgeon and planner.
  • The BSB MEDO and SPO.
  • The BSMC commander and ambulance platoon leader.
  • The forward support medevac platoon leader.
  • A ground ambulance company representative (if attached).
  • A brigade aviation element representative.
  • The brigade S–2 to brief the enemy situation template.
  • The brigade S–3 to brief the concept of the operation and deconflict maneuver issues.

Although there are several rehearsal methods, this example will cover rehearsal of phases of the operation by unit. The following outlines a way to execute this rehearsal.

The brigade executive officer, serving as the rehearsal director, introduces the rehearsal and outlines the agenda.

The S–3 reads the mission statement of the headquarters and discusses friendly unit locations.

The S–2 discusses the enemy's most likely course of action and most deadly course of action.

At this point, the rehearsal leader transitions the first phase of the operation. Each subsequent phase will have the same order of briefers. Each briefer's discussion should begin with the trigger that ended the previous phase and end with the trigger that moves the unit into the next phase of the operation.

As each subsequent phase of the operation begins, the S–2 should briefly discuss the enemy situation and the enemy's most likely course of action, which introduces the subsequent phase.

The S–3 should follow by discussing the friendly maneuver plan for that phase and each friendly maneuver unit's task organization, task and purpose, and disposition.

The BSB MEDO should then sketch the BCT's medical concept of support for the phase, including the medical task organization, evacuation means, evacuation routes, treatment facility capabilities and locations, and active helicopter landing zones, airfields, and mission control procedures.

The forward support medical platoon leader or air medevac liaison officer should then discuss aircraft availability and locations for the phase, including both casualty evacuation and medevac aircraft and air corridors.

Task force MEDOs should discuss the—

  • Battalion scheme of maneuver.
  • Task organization (organic and BSMC assets).
  • Maneuver units' tasks and purposes.
  • Medical capabilities and locations.
  • Patient estimate numbers by location for the phase.
  • Casualty evacuation plan from the forward line of troops to the rear, including CCPs, methods and priorities of evacuation, helicopter landing zones, routes, and the number of required turns for evacuation assets to move the estimated number of patients.
  • Mission control plans within the battalion, including net management.
  • Class VIII (medical materiel) resupply "movement plan forward and request to rear."

The BSMC commander should discuss level II capabilities and location, forward positioned assets (evacuation and treatment), AXP locations, mission control, and class VIII resupply plan forward and request to rear.

Dialog during the rehearsal should cover what the executor is doing; who he is calling, on what net, and with what traffic; and what he anticipates the other party to do. The BSMC commander should then confirm or deny the previous brief when his turn to rehearse comes.

The rehearsal leader must ensure that the desired end state is met before moving from one phase to the next.

When all phases of the operation are complete and the standard is met, the recorder of the rehearsal should read back notes for all attendees. If all attendees agree that all issues have been resolved and appropriate adjustments to the plan have been made, the notes should be turned into a BCT fragmentary order and updated synchronization matrix.

A sound medevac plan is not just the procedures for calling a 9-line medevac request on a radio. This will especially be true as we transition into hybrid threat operations. To be successful, medical planners must first clearly delineate and accept responsibility for planning. There are many ways to do this, and doctrine is vague in order to allow units room to make decisions based on the personalities and capabilities of planners.

Medical planners must understand their requirements. How many casualties will there be? When and where will they occur? When these requirements are understood, medical planners then must understand their capabilities to meet those needs. What assets are on hand? How can Murphy's Law mess the plan up? Medical planners must ensure understanding and synchronization of the plan with a thorough rehearsal.

Every effort must be made to ensure sound planning and understanding of that plan because Soldiers' lives are at stake and the American public expects us to care for its sons and daughters.

Captain Matthew L. Tillman is the brigade support medical company senior combat trainer at the National Training Center at Fort Irwin, California. He holds a B.S. degree in business administration from Colorado State University. He is a graduate of the Army Medical Department Officer Basic Course and the Combined Logistics Captains Career Course.


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