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.
Black Hawk MEDEVAC helicopter departs a medical company
area to take casualties to the 31st Combat Support
Hospital in Baghdad.
The BSMC Conundrum
The following missions are most often associated
• 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
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.
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
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
new BSMC brigade medical supply office (BMSO) as the sole link between the
medical logistics company supporting the theater and the end users in the
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
an organic preventive medicine section and a combat stress control team.
Having these assets in the BSMC reduces the overhead on the supported task
the medical evacuation system, and the supporting CSH. Drawing a blood sample
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.
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.
examines a Soldier’s ears during sick call
in a level II medical facility in Iraq.
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
Second, BMSCs should train medics on sick call and trauma procedures before
deployment and also provide an aggressive in-country sustainment training
will spend an inordinate amount of time on sick call patients, and their
patient population often will include older Reservists and civilian contractors
have health conditions not normally taught as part of healthcare specialist
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.
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
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]
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
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.
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
lanes of responsibility with PROFIS early will streamline operations while
deployed. I had been deployed for 5 months before I realized that my PROFIS
nurse (attached for the MTOE purpose of supervising my empty patient-hold
tent) could best support the company by streamlining initial triage procedures
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
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.