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Redefining the Role of the BSMC in Operation Iraqi Freedom

Brigade support medical companies find themselves sidelined from their doctrinal roles. What new roles can they adopt to better support their BCTs?

“We’re just vultures right now,” replied the first sergeant from one of my sister medical companies when I asked him what his company was doing 4 months into its deployment to Baghdad in support of Operation Iraqi Freedom (OIF). “We’re just sitting around waiting for something to happen.” It was a sobering statement that reflects the way that many medical companies describe their current mission in Iraq.

A typical National Training Center or Joint Readiness Training Center rotation teaches that the brigade support medical company (BSMC) is the critical centerpiece of a brigade’s medical support plan. It is the link between initial treatment at a level I battalion aid station and evacuation to surgical care at a level III combat support hospital (CSH). But in Baghdad, this first sergeant’s medical company was task-organized to a brigade combat team (BCT) operating within the Green Zone (the heavily guarded area of central Baghdad where coalition officials live and work). With the local CSH only three blocks away, most casualties in his sector were evacuated there, leaving his company idle unless a mass casualty (MASCAL) incident occurred.

The high use of combat lifesavers and nonstandard platforms in Iraq is a huge success for the medical community, which has preached for years about the need for combat units to include these assets in their medical support plans. It also speaks well of the ability of combat units to adapt their standing operating procedures for the noncontiguous battlefields of the Iraqi theater. However, these trends have left most divisional medical companies uncertain about their roles and missions in support of their BCTs while deployed to OIF.

The BSMC Conundrum

The following missions are most often associated with BSMCs—
• Clearing battalion aid stations of casualties so that they can continue to maneuver with their supported units.
• Reinforcing task forces with additional ambulances and treatment teams in anticipation of, or in response to, a MASCAL.
• Establishing a medical treatment facility in the brigade support area (BSA).

These functions are the ones most exercised during a typical combat training center rotation, and it is common for medical company commanders to equate their ability to accomplish these missions with success on the battlefield. However, BSMCs, as level II treatment facilities, have three additional missions that are just as important to the success of the brigade but far harder to train outside of a deployment.

First, medical companies hold patients under limited nursing care. This provides a single brigade triage point for the limited operating table and bed space available at a CSH. It also keeps lower priority patients under nursing supervision rather then sending them to the CSH to lie on a litter in a triage area as they wait for an open operating table or bed.

Second, medical companies receive and distribute all class VIII (medical supplies) to the BCT. This often overlooked role becomes critical under the new BCT task organization because there is no longer a division medical supply office (DMSO) supervising division class VIII ordering and distribution. This leaves the new BSMC brigade medical supply office (BMSO) as the sole link between the corps medical logistics company supporting the theater and the end users in the BCT.

Third, medical companies provide ancillary medical services in the BCT. These services cover emergency dental care, medical laboratory support, and x-ray support. Under Army transformation, BSMCs also follow the Force XXI concept of having an organic preventive medicine section and a combat stress control team. Having these assets in the BSMC reduces the overhead on the supported task force, the medical evacuation system, and the supporting CSH. Drawing a blood sample at a forward operating base (FOB) and then sending only the sample, rather than the Soldier himself, to the CSH not only conserves unit strength but also reduces the number of Soldiers on ground convoys to the local CSH.

BSMCs in Iraq

Although the Iraqi theater looks very different from one region to another, several common factors have marginalized BSMCs in some of their doctrinal support roles. One factor is the prevalence of air medical evacuation (MEDEVAC) in theater. Combat training center rotations and recent examples of high-intensity combat teach that air MEDEVAC generally takes place no farther forward than an ambulance exchange point (AXP), which will be anywhere from 5 to 15 kilometers or more behind the forward line of own troops. Even then, availability of air evacuation assets is often tightly controlled by the chain of command. This may be necessary in high-intensity combat to deconflict air corridors and not expose the location of friendly positions.

By comparison, air ambulances in OIF enjoy coalition air supremacy combined with a static, nonlinear battlefield on which CSHs are located in well-developed and strategically located FOBs. This means that air ambulances can be deployed close to the point of injury. The MEDEVAC approval process is a decentralized “911” system. The requesting unit needs only to make contact with the air ambulance company and establish security at the proposed landing zone. Once a casualty is in the air, it generally takes as much time to get him to a CSH as it does to get him to a level II facility. Unless all local CSH intensive care beds are filled or casualties are sustained on isolated supply routes, evacuation to a level II facility makes little tactical or medical sense.

When air ambulances cannot reach the point of injury or it is not feasible to wait for MEDEVAC, patrols usually self-evacuate using available tactical vehicles as nonstandard evacuation platforms. Again, the nonlinear nature of the OIF battlespace renders most level II facilities, which often are located deep in a central brigade “super FOB,” extraneous. In dense urban terrain such as Baghdad, the FOB containing the local CSH may be as close as, or closer than, the nearest level II facility by ground. Even when it is not, the time required to pass through FOB force protection measures leaves many combat leaders thinking very hard about whether a level II aid station, which may be located behind multiple entry control points, is the best place to evacuate a casualty.

For example, at the start of my brigade’s deployment to OIF, the task force operating in the sector that experienced the heaviest casualties always ground-evacuated to a small corps logistics base instead of to the “super FOB” in which my level II facility was located. While this logistics base only had a small treatment squad for medical support, it was capable of immediate stabilization, provided a secure landing zone for air evacuation to the CSH, and required the patrol to cross only one entry control point. It was a smart plan by the task force that made the best use of time, terrain, and available assets to save the lives of many Soldiers. It also highlighted how completely out of position my level II facility was in relation to the current brigade fight. Because of the restrictions of terrain (or in this case, allocation of FOBs), my existing mission to provide medical support to the FOB, and the level of risk acceptable to the forward support brigade (FSB) chain of command, we could not reposition treatment assets to better support the fight the way we might “jump” a forward logistics element at the National Training Center.

Eventually, a new entry control point, closer to my level II facility, opened up on our FOB. As more enemy contact occurred in the sector closer to my aid station’s side of the FOB, more combat casualties were evacuated to my aid station. Later, offensive operations outside of the original BCT sector also required the echeloning of company treatment assets outside of the FOB. This shows how the reality of the OIF battlespace sometimes can fly in the face of traditional support doctrine. Instead of shifting the proximity of BSMC assets to better support the brigade in battle, the location of the brigade fight had to shift before the medical company assets became relevant.

Level II facilities in Iraq also frequently find their patient-hold areas completely empty. This is chiefly due to the outstanding FOB living conditions that most Soldiers enjoy. With climate-controlled trailers a common feature, it makes more sense for doctors to put sick Soldiers “on quarters” rather than keep them on a patient-hold cot. Patients who require 24-hour nursing supervision are evacuated directly to the CSH, where a shortage of beds is less of an issue because the Air Force has secure mobile aeromedical staging facilities that can strictly enforce the theater evacuation policy.

BSMCs also have seen their traditional role of reinforcing task forces dwindle in OIF. This is not caused by a lower requirement for medical personnel in the task forces; many units, particularly field artillery and engineer units, find that they do not have enough medics to cover all of their daily patrols. However, the decentralized nature of the BCT battlespace, with each task force focused on an assigned sector, makes it difficult to provide medical company assets to other BCT units since the brigade support battalion (BSB) also will have an assigned sector (which may be the FOB itself). To keep maneuver task force Soldiers on patrol, BSMC personnel often serve with other BSB Soldiers on guard towers or FOB work details. These duties, daily sick call, and FOB ambulance coverage leave few medics to help task forces with patrols.

How BSMCs Can Be Employed in OIF

These limitations frustrate the BSMC commander who attempts to employ his unit in the same way that he would during a combat training center rotation. To support his BCT effectively, a medical company commander should approach OIF with four “most likely” missions in mind: ancillary services, FOB support, class VIII and medical maintenance program management, and maneuver task force reinforcement.

Ancillary services. The commander must understand that his company’s center of gravity in OIF will be his ancillary services, including the treatment platoon area support squad (laboratory, x ray, and dentistry), the preventive medicine team, and the combat stress control team. This is a giant cultural shift for most Medical Service Corps officers, who were taught that their ambulance platoon (through evacuation and AXP operations) was the company’s center of gravity. This attitude is often reinforced during predeployment field training events, where units may establish AXPs and evacuate patients without concession to current force protection doctrine on size and composition of convoys.

Emergency evacuation is a minor part of the mission of most BSMCs in OIF, and AXPs are virtually nonexistent. In 7 months in Baghdad, my company performed only two ground-evacuation missions for incidents outside the FOB, compared to well over 200 laboratory tests, 200 x rays, and over 600 patient contacts by my combat stress control team.

The number of civilian contractors and Reservists, many with age and health histories significantly different from the Active Army military population, made lab and x-ray services critical to our treatment mission. My two-Soldier combat stress control team was requested frequently for critical-incident debriefings following patrols that had suffered casualties. My preventive medicine team also worked with coalition and local-national contractors on developing the infrastructure of not only our FOB but also Iraqi facilities such as the Iraqi National Guard Academy. In northern and eastern Iraq, where malaria is a greater threat than it is in Baghdad, preventive medicine had a critical role in surveying insect populations and making recommendations to sustain the health of the command.

FOB support. The BSMC commander must understand that FOB support will occupy most of his company’s time. FOB support means more than supplying manpower for guard duty or FOB work details. It also means developing and manning an ambulance coverage plan for the FOB, drilling the company to support FOB MASCAL incidents, and ensuring that the resources exist to treat a patient population with age and health problems that may depart from normal expectations. During a multi-day offensive operation in April 2004, I sat glued to the brigade command net in case a MASCAL developed in the sector. Although a combat-related MASCAL never happened, my treatment platoon did receive two contractors from inside the FOB who had possible heart attacks after an average day of work in 90-plus degree heat—a situation with which most combat medics have little experience.

Class VIII and medical maintenance program management. The BSMC, in conjunction with the BSB support operations office (SPO), oversees brigade class VIII management and the medical maintenance program. This duty is frequently overlooked in garrison and at the combat training centers because DMSO supervises all class VIII management and because the daily requirements are low for class VIII in both environments. As a result, many BSMC commanders and support operations offices deploy unaware of the level of planning and oversight required to maintain class VIII flow and medical maintenance properly in the BCT area. This cannot continue now that the DMSO has been removed in favor of BMSOs owned and supervised by the BSMCs.

Medical company commanders must take a personal interest in the standards outlined in Army Regulation 40–61, Medical Logistics Policies, and in how their BMSOs (normally run by junior lieutenants with 10 weeks of training) do business. Taking the time to contact the supporting medical logistics unit to discuss availability of operational readiness floats for critical biomedical equipment such as x-ray machines, a schedule for medical maintenance contact team visits, and synchronization of their class VIII delivery plan with the corps and BSB LOGPAC (logistics package) schedule can reap huge benefits over the course of the deployment.

Maneuver task force reinforcement. Medical companies must be ready to reinforce the maneuver task forces. This does not always mean providing them with additional medics or ambulances. Medical companies also can supervise the brigade combat lifesaver program, organize and command convoys to the nearest CSH for routine referrals and appointments, provide physicians and medics to help with the screening and instruction of Iraqi National Guard medics, and maintain a ready posture for FOB MASCAL support. Providing daily sick call and transfer physicals for detainees in the brigade internment facility are also missions that often fall to the BSMC and are critical to both daily operations in theater and the legitimacy of the overall mission. By taking on these necessary support missions, the BSMC can keep the task force medics available for missions in their sectors.

Sometimes a medical company can reinforce a BCT in the most unexpected ways. For example, a Green Zone-based medical company, through its contact with the Iraqi healthcare community, obtained intelligence for its BCT on local insurgent activities. Ensuring that medics and doctors are aware of the commander’s critical information requirements and can recognize and report key intelligence while treating or working with local nationals can contribute in vital ways to the overall operation.

Preparing the Medical Company

Because of the requirements of the OIF battlespace, BSMC commanders must keep several factors in mind when preparing their units for deployment.

First, they should make sure that their area support squad members know how to operate and repair their equipment. Our closest medical maintenance support consisted of a single medical equipment repair specialist, who was located 2 hours away by ground convoy. During a semiannual service visit, the corps medical maintenance contact team taught my x-ray technician how to conduct several simple repair tasks so that he could make minor repairs to our sole x-ray machine without evacuating it from the FOB. BSMCs should cross-train their combat medics as secondary and tertiary operators on their dental, lab, and x-ray equipment. This will allow units to send area support squad Soldiers on environmental leave without losing operational capability.

Second, BMSCs should train medics on sick call and trauma procedures before deployment and also provide an aggressive in-country sustainment training program. Medics will spend an inordinate amount of time on sick call patients, and their patient population often will include older Reservists and civilian contractors who have health conditions not normally taught as part of healthcare specialist (military occupational specialty 91W) initial training or sustainment training in modification table of organization and equipment (MTOE) units. Medics must be trained and proficient at primary assessments of both medical and trauma patients. Training Circular 8–800, Semi-Annual Combat Medic Skills Validation Testing, provides a good starting point for training and assessing these skills.

Third, the BSMC commander, in coordination with the BSB SPO, should establish a BCT class VIII distribution plan while in garrison. All customer units should understand how to open and maintain accounts with the BMSO. The SPO medical officer should develop a class VIII authorized stockage list (ASL) in conjunction with the BSMC commander and the BCT healthcare providers. This will ensure that proper items and quantities are brought to theater for resupply during the first 90 days. Garrison demand data will not provide an accurate picture of what the BCT “ go-to-war” class VIII ASL needs to include to support the medical mission. The ASL should be developed in concert with the brigade surgeon and task force physician assistants to ensure that it meets their needs. One technique for constructing a BCT class VIII ASL is to use the expendable component listings of the trauma and sick call medical equipment sets, the current medic bag used by task force medics (usually the surgical instrument supply set individual [SISSI] bag), and the combat lifesaver bag as a starting point. A panel of BCT medical providers and senior medics can then add and delete items and quantities to the ASL based on their experiences.

Finally, BSMCs must have a good Professional Officer Filler System (PROFIS) integration plan. PROFIS designates qualified Active Army Medical Department personnel serving in table of distribution and allowances units to fill positions in Army Forces Command early-deploying MTOE units. The commander should find out who his “fillers” are and try to schedule an opportunity for them to see the medical equipment sets and planned contingency stocks of class VIII before they are deployed. The participation of PROFIS officers during early predeployment activities taught me more about what to pack for an initial entry contingency stock of class VIII than any other event in my military career. Establishing a working relationship and defining lanes of responsibility with PROFIS early will streamline operations while deployed. I had been deployed for 5 months before I realized that my PROFIS registered nurse (attached for the MTOE purpose of supervising my empty patient-hold tent) could best support the company by streamlining initial triage procedures during sick call and supervising medical training. These were essentially the daily duties he had in garrison as the officer in charge of an installation primary care clinic.

OIF presents an environment significantly different from that in which most medical companies are trained to operate. An understanding of the commander’s intent and the need to shift the company’s focus from evacuation to treatment and area support as your center of gravity will set you up for success as you prepare to deploy and support your BCT in combat.

Captain Ralph T. Nazzaro is an Army Medical Department Officer Basic Leadership Course instructor at Fort Sam Houston, Texas. He was the Commander of Company E, 15th Forward Support Battalion, 1st Cavalry Division, when it deployed to Operation Iraqi Freedom in 2004. He is a graduate of the Army Medical Department Officer Basic Course, the Combined Logistics Captains Career Course, and the Combined Arms and Services Staff School.