FM 4-02.21 DIVISION AND BRIGADE SURGEONS' HANDBOOK (DIGITIZED) TACTICS, TECHNIQUES, AND PROCEDURES

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FM 4-02.21 



DIVISION AND BRIGADE 
SURGEONS' HANDBOOK 

(DIGITIZED) 

TACTICS, TECHNIQUES, AND PROCEDURES 



HEADQUARTERS, DEPARTMENT OF THE ARMY 



DISTRIBUTION RESTRICTION: Approved for public release; distribution is unlimited. 



FM 4-02.21 



FIELD MANUAL 
NO. 4-02.21 



HEADQUARTERS 

DEPARTMENT OF THE ARMY 

WASHINGTON, DC, 15 November 2000 



DIVISION AND BRIGADE SURGEONS™HANDBOOK 

(DIGITIZED) 
TACTICS, TECHNIQUES, AND PROCEDURES 



TABLE OF CONTENTS 



PREFACE 



CHAPTER 


1 


Section 


1 




1-1 




1-2 


Section 


II. 




1-3 




1-4 




1-5 


Section 


III. 




1-6 




1-7 




1-8 




1-9 




1-10 




1-11 


Section 


IV 




1-12 




1-13 


Section 


V 




1-14 




1-15 




1-16 




1-17 


CHAPTER 


2, 


Section 


1 




2-1 




2-2 


Section 


II. 




2-3 




2-4 



DIVISION MEDICAL STAFF 

Division Surgeon 

Duties of the Division Surgeon 

Responsibilities of the Division Surgeon 

Division Surgeon Tl s Sectio n 

Missions and Capabilities of the Division Surgeon 1 ^ Section 

Organization 

Functions 

Staff and Command Interface 

Interface with the Division Staff 

Interface with the Major Commands of the Division 

Interface with the Corps Medical Units 

Interface with the Division Support Battalion 

Interface with the Forward Support Battalions 

Interface with the Maneuver Battalions 

Command Post Setup and Communications 

Command Post, Division Headquarters 

Information, Communications, and Digitization 

Combat Health Logistics and Blood Management 

Class VIII Resupply 

Assemblage Management Reporting Under Unit Status 

Reporting 1-27 

Medical Equipment Maintenance 

Division Blood Management 

BRIGADE MEDICAL STAFF 

Brigade Surgeon 

Duties of the Brigade Surgeon 

Responsibilities of the Brigade Surgeon 

Organization and Functions of the Brigade Surgeon Tl s 

Section 

Mission of the Brigade Surgeon 1 ^ Section 

Responsibilities and Functions of the Brigade Surgeon™s 
Section 2-3 



Page 



1-1 
1-1 
1-1 
1-1 

1-4 
1-4 
1-4 
1-9 

1-11 
1-11 
1-13 
1-16 
1-22 
1-22 
1-22 
1-23 
1-23 
1-23 
1-25 
1-25 



1-29 

1-30 

2-1 

2-1 

2-1 

2-1 

2-3 
2-3 



DISTRIBUTION RESTRICTION: Approved for public release; distribution is unlimited. 



FM 4-02.21 



Page 



CHAPTER 



Section 



Section 



APPENDIX 



APPENDIX 



APPENDIX 



2-5. 
2-6. 
2-7. 
2-8. 



I. 

3-1. 

3-2. 

3-3. 

3-4. 

3-5. 
II. 

3-6. 

3-7. 

3-8. 

3-9. 
3-10. 
3-11. 
3-12. 
3-13. 

3-14. 
3-15. 

A. 

A-l. 

A-2. 

A-3. 
A-4. 
A-5. 

B. 

B-l. 
B-2. 



C-l. 
C-2. 



Medical Plans and Operations Cell 2-4 

Patient Disposition and Reports Cell 2-5 

Information and Communications 2-5 

Medical Standard Army Management Information System 2-10 

DIVISION AND BRIGADE COMBAT HEALTH SUPPORT 

OPERATIONS 3-1 

Planning Combat Health Support for Division and Brigade 

Operations 3-1 

Division Combat Health Support Planning 3-1 

Division Operation Plan and Operation Order 3-2 

Brigade Combat Health Support Planning 3-4 

Brigade Operation Plan and Operation Order 3-4 

Rehearsal 3-9 

Conducting Combat Health Support for Military Actions 3-12 

Force Projection 3-12 

Combat Health Support for the Offense and the Defense 3-12 

Combat Health Support for Maneuver and Enabling Operations 3-16 

Combat Health Support During Night Operations 3-20 

Combat Health Support for Stability Operations 3-24 

Combat Health Support for Support Operations 3-26 

Mass Casualty Operations 3-26 

Combat Health Support in Nuclear, Biological, and Chemical 

Defensive Operations 3-27 

Force Protection and Security Measures 3-28 

Combat Health Support Tactical Standing Operating Procedures 3-29 

GUIDE FOR GENEVA CONVENTIONS COMPLIANCE A-l 

General A-l 

Distinctive Markings and Camouflage of Medical Facilities and 

Evacuation Platforms A-l 

Self-Defense and Defense of Patients A-2 

Enemy Prisoners of War A-2 

Compliance with the Geneva Conventions A-2 

TACTICAL STANDING OPERATING PROCEDURE B-l 

General B-l 

Sample Tactical Standing Operating Procedure B-l 

BRIGADE SURGEON'S SECTION INITIAL BRIGADE COMBAT 

TEAM C-l 

Mission of the Brigade Surgeon's Section C-l 

Brigade Surgeon's Section C-l 



FM 4-02.21 



Page 

C-3 . Duties and Responsibilities of the Brigade Surgeon C-3 

C-4. Medical Plans and Operations Cell C-4 

C-5. Information and Communications C-4 

C-6. Medical Standard Army Management Information System C-5 

C-7. Brigade Combat Health Support Planning C-6 

C-8 . Combat Health Support Tactical Standing Operating Procedures C-6 

GLOSSARY Glossary-1 

REFERENCES References-1 

INDEX Index- 1 



PREFACE 

This publication provides information on the structure and operation of the division and brigade head- 
quarters medical staff. It is directed toward the surgeons and staff members of the division surgeon's 
section (DSS) and brigade surgeon's section (BSS). 

This field manual (FM) outlines the responsibilities of the division and brigade surgeons and their staffs 
for the heavy conservative divisions (digitized). It provides tactics, techniques, and procedures for directing, 
controlling, and managing combat health support (CHS) within the division. It describes the interface 
required of the DSS and BSS, other division elements, and the interface with supporting corps medical 
elements in accomplishing the CHS mission. It further defines each cell of the DSS and BSS. This manual 
is the foundation for the continued development and refinement of division CHS doctrinal fundamentals, 
tactics, techniques, and procedures for Army XXI. In that light, it serves as conceptual "mark on the wall" 
for thinking about experimenting with and employing new right-sized medical units/elements in the Army 
XXI light infantry, airborne and air assault divisions, separate brigades, and armored cavalry regiments. 

This FM is not a stand-alone reference. It is a doctrine publication that speaks to the digitized division 
and brigade CHS and will require the user to be familiar with FMs 8-10, 8-10-1, 8-10-3, 8-10-4, 8-10-5, 
8-10-6, 8-10-7, 8-10-9, 8-42, and 8-55. Users should also be familiar with the coordinating drafts of FMs 
63-2-2, 63-20-1, 63-21-1, and 63-23-2. 



FM 4-02.21 



This publication implements the following North Atlantic Treaty Organization (NATO) Standard- 
ization Agreements (STANAGs) and American, British, Canadian, and Australian (ABCA) Quadripartite 
Standardization Agreement (QSTAG): 

Title STANAG QSTAG 

Marking of Military Vehicles 2027 512 

Orders for the Camouflage of the Red Cross and 

the Red Crescent on Land in Tactical Operations 2931 

When amendment, revision, or cancellation of this publication is proposed which will effect or violate 
the international agreements concerned, the preparing agency will take appropriate reconciliatory action 
through international standardization channels. 

As the Army Medical Department (AMEDD) transitions to the 91 W military occupational specialty 
(MOS), positions for 91B and 91C will be replaced by 91W when new unit modification table(s) of 
organization and equipment (MTOE) take effect. 

Users of this publication are encouraged to submit comments and recommendations to improve 
the publication. Comments should include the page, paragraph, and line(s) of the text where the change 
is recommended. The proponent for this publication is the United States (US) Army Medical Depart- 
ment Center and School (AMEDDC&S). Comments and recommendations should be forwarded directly 
to Commander, AMEDDC&S, ATTN: MCCS-FCD-L, 1400 East Grayson Street, Fort Sam 
Houston, Texas 78234-6175, or by using the E-mail addresses on the Doctrine Literature website at 
http://dcdd.amedd.army.mil/indexl.htm (click on Doctrine Literature). 

Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively to men. 

Use of trade or brand names in this publication is for illustrative purposes only and does not imply 
endorsement by the Department of Defense (DOD). 



IV 



FM 4-02.21 



CHAPTER 1 



DIVISION MEDICAL STAFF 



Section I. DIVISION SURGEON 



1-1. Duties of the Division Surgeon 

The division surgeon, a Medical Corps (MC) officer (Lieutenant Colonel [LTC], area of concentration 
[AOC] 60A00), is a division level special staff officer. He normally works under the staff supervision of 
the division chief of staff. The division surgeon is responsible for the technical control of all medical 
activities in the command. He oversees and coordinates CHS activities through the DSS. The division 
surgeon advises the division commander on all medical or medical-related issues. These issues include, but 
are not limited to— 

Health of the command. 



Preventive medicine (PVNTMED). 

Medical treatment provided to personnel in the division area of operations (AO). 

Status of wounded. 

Medical surveillance. 

Medical evacuation. 

Combat health logistics (CHL). 

Medical intelligence. 

Combat stress control (CSC). 

Dental services. 

Medical training. 

Civil -military operations. 



1-2. Responsibilities of the Division Surgeon 

The division surgeon, assisted by the DSS, is responsible for— 

• Advising on the health status of the command and of the occupied or friendly territory within 
the commander's area of responsibility. 



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• Briefing the division commander on CHS operations and/or his representative during all 
routine and emergency division briefings. This is normally accomplished using Combat Service Support 
Control System (CSSCS). 

• Participating in the preparation of division operation plans (OPLANs) and contingency 
plans and identifying potential medical hazards associated with geographical locations and climatic 
conditions. 

• Determining reporting frequencies (the times that reports are submitted) for digital reports 
using, Force XXI Battle Command Brigade and Below System (FBCB2) and CSSCS. 

• Advising on the health effects of the environment. 

• Advising on the health effects of nuclear, biological, and chemical (NBC) devices/weapons to 
include operational exposure guidance (OEG). 

• Exercising technical supervision of subordinate brigade surgeons, physicians, and physician 
assistants (PAs). 

• Providing consultation and mentoring to subordinate brigade surgeons, physicians, and 
physician assistants. 

• Advising on the health effects of directed-energy devices/weapons. 

• Determining requirements for the requisition, procurement, storage, maintenance, distribution 
management, and documentation of Class VIII supplies within the division. 

• Providing the Assistant Chief of Staff (Logistics) (G4) a list of medical items that should be a 
part of the CSSCS commander's tracked items list (CTIL). 

• Determining requirements for medical personnel and making recommendations concerning 
their assignments. 

• Coordinating with medical unit commanders (to include leaders of medical platoons and 
sections) for continuous CHS. 

• Submitting to higher headquarters those recommendations on professional medical problems 
that require research and development. 

• Recommending use of captured medical supplies in support of enemy prisoners of war (EPW) 
and other recipients. 

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• Advising on medical intelligence requirements (including the examination and processing of 
captured medical supplies as directed by the corps surgeon). 

• Providing recommendations on allocation and redistribution of AMEDD personnel, CHL, and 
CHS during the reconstitution process. 

• Advising commanders about the PVNTMED aspects of reconstitution and availability and use 
of CSC teams. 

• Forwarding the Command Health Report (RCS MED-3 [R7]) according to Chapter 3, Army 
Regulation (AR) 40-5. 

• Advising commanders on the effects of accumulated fatigue, radiation exposure, possible 
delayed effects from exposure to chemical or biological agents, and use of countermeasures and pre- 
treatments. 

• Advising commanders on disposition of personnel exposed to lethal, but not immediately life- 
threatening, doses of radiation or chemical and biological agents. 

• Preparing the division CHS annex to all division plans. For CHS planning factors, see 
FM 8-55. 

• Ensuring that clear and accurate patient records are maintained of all clinical encounters for 
supported deployed personnel through the use of a Department of the Army (DA) Form 8007 -R or through 
the use of digital patient records as they become available. See AR 40-66 and FM 8-10-1 for management 
of individual health records in the field. Also, digital patient records at the division and brigade level will 
be available through the fielding of Medical Communications for Combat Casualty Care (MC4) and the 
Theater Medical Information Program (TMIP). 



NOTE 

The purpose of a medical record is to provide a complete medical 
and dental history for patient care, medicolegal support (for example, 
reimbursement and tort claims), research, and education. A medical 
record also provides a means of communication where necessary 
to fulfill other Army functions (such as, identification of remains). 
Therefore, each time a patient encounter occurs, an entry will 
be made on the medical record. It is the responsibility of the divi- 
sion and brigade surgeons to ensure that written or digital entries 
made in patient records in the field are transcribed or downloaded 
to the patients' permanent medical or dental records as soon as 
possible. 



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FM 4-02.21 



Section II. DIVISION SURGEON'S SECTION 



1-3. Missions and Capabilities of the Division Surgeon's Section 

a. The DSS's mission is to plan, coordinate, and synchronize the division's CHS under the 
supervision of the division surgeon. 

b. The DSS is also responsible for coordinating relationships of organic medical units and 
medical units/elements under operational control (OPCON) or attached to the division for general support 
(GS) or direct support (DS). 



1-4. Organization 

Figure 1-1 shows the typical organization and staffing of the DSS. The DSS is normally located with the 
division main and consists of a medical plan and operations cell, a CHL cell, a patient disposition and 
reports cell, and a PVNTMED cell. 





DIVISION 

SURGEON'S 

SECTION 






































MED PLANS/ 
OPS CELL 




CHL 
CELL 




PNT DISP & 
RPTS CELL 




PVNTMED 
CELL 



Figure 1-1. Division surgeon 's section. 



for- 



a. Medical Plans and Operations Cell. The medical plans and operations cell is responsible 



• Developing and coordinating patient evacuation support plans among the division and 
corps medical evacuation elements. 

• Coordinating corps-level CHS for the division with the corps medical command 
(MEDCOM)/brigade. 

• Submitting Army airspace command and control (A2C2) requirements for aeromedical 
evacuation elements to the division Assistant Chief of Staff (Operations and Plans) (G3) (Air). 



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• Ensuring A2C2 information is provided to supporting corps air ambulance assets. The 
A2C2 information is normally provided by the G3 (Air) at division and by the brigade Operations and 
Training Officer (US Army) (S3) (Air) in the maneuver brigades. 

• Coordinating for aviation weather information from US Air Force (USAF) weather 
(WX) detachment in the aviation brigade. 

• Obtaining updated road clearance information from the division movement control office 
(MCO). All road clearance information is passed to ground ambulance assets. This information should 
include— 

The NBC threat. 

Priorities for use of evacuation routes. 

Information reported by medical evacuation assets. 

Road and weather conditions. 

Security. 

• Monitoring medical troop strength to determine task organization for mission accomplish- 
ment. 

• Forwarding all medical information of potential intelligence value to the division Assistant 
Chief of Staff (Intelligence) (G2) and G3 staffs . 

• Obtaining updated medical threat and intelligence information through the G2 and G3 
staff for evaluation and applicability. 

• Managing the disposition of captured medical materiels according to tactical standing 
operating procedures (TSOPs). 

• Coordinating corps CSC support to forward areas as required. 

• Monitoring optometry services. 

The medical plans and operations cell is typically staffed with a— 

• Chief medical planner. 

• Plans and operations officer, medical evacuation. 

• Plans and operations officer. 

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FM 4-02.21 



• Chief operations sergeant. 

• Senior medical noncommissioned officer (NCO). 

• Medical intelligence NCO. 

• Medical operations sergeant. 

(1) Chief Medical Planner. The chief medical planner (LTC, AOC 70H67) assists the 
division surgeon with developing and maintaining the medical troop basis. He recommends task organization 
for mission accomplishment. He is the chief of the medical plans and operations cell. He is the primary 
architect of the division CHS plan, based on the division commander's intent and guidance from the division 
surgeon. He monitors brigade and division operations to ensure adequacy of CHS for the supported force. 

(2) Plans and Operations Officer, Medical Evacuation. The plans and operations officer for 
medical evacuation (Captain, AOC 67JOO) coordinates patient evacuation to corps-level medical facilities 
by Army assets. This officer develops and coordinates medical evacuation plans with the supporting corps- 
level and joint medical elements. He coordinates with division A2C2 elements to ensure that the supporting 
corps aeromedical evacuation units receive up-to-date overlays and A2C2 information. He coordinates for 
aviation weather information from the USAF WX detachment in the aviation brigade. 

(3) Plans and Operations Officer. The plans and operations officer (Major, AOC 70H67) 
assists the medical planner with developing and coordinating the division CHS plan. He monitors and 
tracks CHS operations and updates the chief medical planner and division surgeon as necessary. He 
coordinates with division command and control (C2) elements to ensure task organization for mission 
accomplishment. This officer deploys with the division forward tactical operations center (TOC). 

(4) Chief Operations Sergeant. The chief operations sergeant (E-9, MOS 91B50) assists the 
medical planner in accomplishing his operational duties. He coordinates and supervises the administration 
functions within the DSS. 

(5) Senior Medical Noncommissioned Officer. The senior medical NCO (E-8, MOS 91B50) 
assists the medical planner. He assists the chief operations sergeant with supervising the activities of 
subordinate enlisted personnel assigned to this branch. 

(6) Medical Intelligence Noncommissioned Officer. The medical intelligence NCO (E-7, 
MOS 91B40) reviews medical information of potential intelligence value. He coordinates with the G2 and 
G3 to receive and pass medical information of potential intelligence value and intelligence of a medical 
nature. He works in conjunction with the G2 staff in determining likely threat movement and expected 
actions that will affect CHS requirements. He assists in coordinating the disposition of captured medical 
materiel with the medical logistics (MEDLOG) battalion. This NCO prepares and monitors the division 
medical intelligence program. 

(7) Medical Operations Sergeant, Medical Evacuation. The medical operations sergeant 
(E-6, MOS 91B30) assists the plans and operations officer, medical evacuation in accomplishing his duties. 

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b. Combat Health Logistics Cell. The CHL cell is responsible for planning, coordinating, and 
prioritizing CHL and medical equipment maintenance programs for the division. The specific responsibilities 
of the CHL cell include the following: 

• Providing the division CHL input to the CHS plan through the plans and operations 
cell. 

• Coordinating medical maintenance training. 

• Establishing maintenance priorities for repair and exchange of medical equipment with 
the MEDLOG company (ensuring that critical items are included on the division CSSCS/FBCB2 CTIL). 

• Ensuring that a viable preventive maintenance program is established and monitored. 

• Coordinating the evacuation and replacement of medical equipment with the MEDLOG 
company. 

• Verifying emergency supply requests for submission to the supporting MEDLOG com- 
pany and taking the necessary action to expedite shipment. 

• Analyzing Class VIII resupply operations, identifying trends in performance, and 
providing technical advice, as necessary. 

• Establishing and managing, in coordination with the division support command (DISCOM) 
medical materiel management branch (MMMB), the medical critical items list. 

• Interfacing with the DISCOM MMMB to ensure that the necessary coordination with the 
division supply and transportation system occurs. 

• Establishing transportation procedures, based on the tactical situation, with the MEDLOG 
company and DISCOM MMMB. 

• Providing technical staff assistance for the DISCOM MMMB and division medical unit/ 
elements, as required, to ensure divisionwide support for CHL and blood management. 

• Monitoring the CHL picture and reporting its status using CSSCS. 

• Establishing coordination procedures for the disposition of captured medical materiel. 

• Prioritizing Class VIII supply requests and distribution, as required. 

The CHL cell is staffed with a health service materiel officer (HSMO). The HSMO (Major, AOC 70K67) 
works closely with the DISCOM MMMB and MEDLOG company. The HSMO coordinates and oversees 
the CHL support for the division. 

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c. Patient Disposition and Reports Cell. The patient disposition and reports cell is responsible 
for coordinating patient disposition throughout the division. The branch obtains and coordinates disposition 
of patients with the medical plans and operations cell and the corps medical regulating office(r) (MRO). It 
prepares and forwards appropriate medical statistical reports as required. The patient disposition and reports 
cell is staffed with a patient administration NCO and two patient administration specialists. 

(1) Patient Administration Noncommissioned Officer. The patient administration NCO (E-5, 
MOS 71G20) assists the operations officer, medical evacuation in the coordination of patient disposition in 
the division. This NCO prepares the required patient statistical reports and coordinates their timely 
submission to higher headquarters. He also supervises the patient administration specialists. 

(2) Patient Administration Specialists. The two patient administration specialists (E-4, MOS 
71G10) assist the patient administration NCO in preparing patient statistical reports and in performing other 
patient administration functions. They also operate the Tactical Army CSS Computer System (TACCS). 

d. Preventive Medicine Cell. The division PVNTMED cell is responsible for— 

• Supervising the command PVNTMED program; see AR40-5 and FM 4-02. 17 (8-10-17). 

• Ensuring PVNTMED measures are implemented that protect division personnel against 
food-, water-, and vectorborne diseases, as well as environmental injuries (for example, heat and cold 
injuries). 

• Monitor disease trends within the division. 

The PVNTMED missions are accomplished according to the division CHS plan and coordinated by the 
PVNTMED officer through the medical plans and operations cell with the division support medical company 
and forward support medical companies (FSMCs). Division PVNTMED personnel provide advice and 
consultation in the areas of environmental sanitation, epidemiology, and entomology, as well as limited 
sanitary engineering services and pest management. Additional information pertaining to the PVNTMED 
personnel and their specific functions is discussed in FMs 8-10, 8-10-1, 8-10-3 and 4-02.17 (8-10-17). The 
PVNTMED cell is staffed with a PVNTMED officer. The PVNTMED officer (Major, AOC 60C00) is re- 
sponsible for the implementation of the command PVNTMED program. The PVNTMED officer determines 
the status of and conditions influencing the health of units located in the division AO. He formulates and 
recommends measures for health improvements. Based on command, corps, and theater Army (TA) 
guidance, he plans, directs, and prioritizes PVNTMED activities within the division. The PVNTMED 
officer serves as the principal advisor on medical threats encountered by division units. He recommends 
PVNTMED measures to minimize these threats within the division AO. He is also involved in PVNTMED 
activities that must begin prior to deployment to minimize disease and nonbattle injury (DNBI). Actions 
taken prior to deployment must include— 

• Performing medical threat analysis. 

• Ensuring command awareness of potential medical threats and that appropriate PVNTMED 
measures are being implemented. 

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• Monitoring immunization and chemoprophylaxis status of division personnel. 

• Monitoring the status of individual and small unit PVNTMED measures. 

• Monitoring PVNTMED measures against heat and cold injuries and food-, water-, and 
vectorborne diseases. 

• Preparing PVNTMED estimates. 
Planning considerations must include the following issues: 

• Water. 

• Environmental conditions. 

• Vectors. 

• Food. 

• Waste/sanitation. 

• Nuclear, biological, and chemical. 

1-5. Functions 

The staff of the DSS assists the division surgeon in planning and conducting division CHS operations. 
Specific functions of the DSS include— 

• Planning and ensuring that Echelons I and II CHS for the division is provided in a timely and 
efficient manner. 

• Developing and maintaining the medical troop basis, revising as required, to ensure task 
organization for mission accomplishment. 

• Planning and coordinating CHS operations for division and attached/OPCON corps medical 
assets. This includes reinforcement and reconstitution. 

• Preparing and presenting, as directed by the division surgeon, routine CHS portion of the 
division briefings. 

• Coordinating with the G3 for prioritizing the reallocation of organic and corps medical 
augmentation assets as required by the tactical situation. 

• Overseeing division TSOPs, plans, policies, and procedures for CHS as prescribed by the 
division surgeon. 

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• Overseeing individual and collective medical training and providing information to the division 
surgeon and division commander. 

• Coordinating and prioritizing CHL and blood management requirements for the division. 

• Coordinating with the Assistant Chief of Staff (Personnel) (Gl) for tracking critical AOC and 
MOSs. 

• Monitoring disease trends within the division. 

• Collecting and disseminating medical threat information and coordinating combat health 
intelligence requirements with the division G2 according to FM 8-10-8. 

• Facilitating functional integration between CHS and military intelligence staff elements within 
the division. This is done in support of the intelligence preparation of the battlefield. 

• Coordinating and redirecting patient evacuation within the division. 

• Coordinating patient evacuation from division-level medical treatment facilities (MTFs) to 
corps-level MTFs. 

• Coordinating with the G3, G4, and division chemical officer for nonmedical assets for assisting 
with mass casualties and patient decontamination operations. 

• Coordinating with the G3 for additional corps evacuation assets, as required. 

• Coordinating the medical evacuation of all EPW casualties. 

• Coordinating and managing the disposition of captured medical materiel. 

• Coordinating, planning, and prioritizing PVNTMED missions. 

• Coordinating corps dental support when the tactical situation permits. 



• 



Coordinating with the supporting veterinary element pertaining to subsistence and animal 



disease surveillance. 

• Developing and publishing the medical reporting schedule for FBCB2 (medical situation 
report [MEDSITREP]), CSSCS (medical unit status reporting), evacuation requests, and other reports as 
necessary. 

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FM 4-02.21 



Section III. STAFF AND COMMAND INTERFACE 



1-6. Interface with the Division Staff 

a. The Gl provides and coordinates personnel support for the division. The Gl's functions are 
listed in FM 101-5. 

( 1 ) The Gl's responsibilities include— 

(a) Tracking critical medical AOCs and MOS. 

(b) Reporting casualties. 

(c) Conducting replacement operations. 

(d) Making casualty projections for the division. 

(e) Monitoring patient evacuation and mortality. 

(2) Reports submitted from the DSS to the Gl should be identified in the division TSOP. 
These reports can vary depending on the needs of the command and are submitted using CSSCS. 

(3) The DSS and the Gl staff must work together and coordinate their staff and operational 
activities to ensure mission accomplishment. 

b. The G2 and G3 staffs are primarily involved with plans, operations, intelligence, and security. 
The functions of the G2 and G3 are listed in FM 101-5. 

c. The G4 functions are listed in FM 101-5. The G4 is primarily concerned with the logistical 
status of the division. The G4 has the responsibility for planning and supervising the supply, service, 
maintenance, and transportation activities to support the command. 

d. The Assistant Chief of Staff (Civil Affairs) (G5) functions are listed in FM 101-5. These 
functions include those actions that embrace the relationship between the command and host nation (HN), 
civil authorities and the local nationals in the AO. 

e. The DSS works with other division staff elements to inform, coordinate, and achieve 
synchronization of CHS activities for division operations. Examples of the coordination that must take 
place between the DSS and other division staff elements are shown in Table 1-1. The division surgeon, the 
DSS chief medical planner, and other DSS staff members must be informed of division staff activities and 
be involved with the decision-making process. Areas of mutual interest are shown in Table 1-2. 

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FM 4-02.21 



Table 1-1. Coordination Between Division Surgeon 's Section and Division Staff 



SUBJECT AREA 



DIVISION STAFF ELEMENT 



DSS 



PLANNING 

RELOCATING CHS ELEMENTS 
PREVENTIVE MEDICINE 

MEDICAL SUPPORT REQUEST 



MEDICAL INFORMATION OF POTENTIAL 
INTELLIGENCE VALUE 

CORPS SUPPORT MEDICAL ELEMENTS 
MEDICAL ELEMENTS 

CIVIL AFFAIRS ACTIVITIES 



CLASS VIII RESUPPLY 

NUCLEAR, BIOLOGICAL, CHEMICAL DEFENSE 
SMOKE/OBSCURATION 

ENEMY PRISONER OF WAR OPERATIONS 

MAINTENANCE 

CASUALTY ESTIMATES AND REPORTING 

A2C2 

HEALTH CARE POLICY 



G2/G3/G4 



G2/G3/G4 



G1/G2/G3/G4/G5 
DIV FOOD ADVISOR 

G3/G5 



G2 



G1/G3/G4 



G5/G3/G2 



G4/G3 

DIV MCO/DTO 

G2/G3 



G2/G3 
G4 

G1 

G3 (AIR) 
G1/G3 



MED PLANS/OPS CELL 
CHLCELL 

MED PLANS/OPS CELL 

MED PLANS/OPS CELL 
PVNTMED CELL 

MED PLANS/OPS CELL 
CHLCELL 

MED PLANS/OPS CELL 
PVNTMED CELL 

MED PLANS/OPS CELL 
CHLCELL 

MED PLANS/OPS CELL 
PVNTMED CELL 

CHLCELL 

MED PLANS/OPS CELL 

MED PLANS/OPS CELL 
PVNTMED CELL 

MED PLANS/OPS CELL 

MED PLANS/OPS CELL 
CHLCELL 

MED PLANS/OPS CELL 
PNTDISP&RPTCELL 

MED PLANS/OPS CELL 

DIV SURGEON 

MED PLANS/OPS CELL 



1-12 



FM 4-02.21 



Table 1-2. Areas of Mutual Interest for Division Surgeon 's Section and Division Staff 



SUBJECT 



DIVISION STAFF SECTION 



MEDICAL INFORMATION OF A POTENTIAL INTELLIGENCE 

VALUE OR INTELLIGENCE OF A MEDICAL NATURE 
COMBAT HEALTH SUPPORT 
CONTINGENCY OPERATIONS 

REPLACEMENT AND RECONSTITUTE OPERATIONS 
PREVENTIVE MEDICINE 
CIVIL AFFAIRS/HOST-NATION SUPPORT 
INTERNMENT/RESETTLEMENT (l/R) OPERATIONS 
MASS CASUALTY PLAN 
NUCLEAR, BIOLOGICAL, CHEMICAL DEFENSE 



G2 

G1/G3 

G3 

G1/G3/G4 

G1/G2/G3/G4/G5 

G5/G2/G3/G4 

G1/G2/G3 

G1/G2/G3/G4 

G1/G2/G3/G4 



1-7. Interface with the Major Commands of the Division 

a. Maneuver Brigades. Interface with each of the maneuver brigades is accomplished through 
the BSS and through the DISCOM support operations section, DISCOM medical operations branch, and the 
health service support officers (HSSOs) of the division support battalion (DSB) and forward support 
battalions (FSBs) and other staff elements as appropriate. This interface will focus on CHL and CHS 
requirements for the brigades. It also includes coordination for A2C2 information for air evacuation assets 
supporting maneuver elements. 

b. Aviation Brigade. Interactions between the aviation brigade and the DSS should include— 

(1) Coordination for area medical support. 

(2) Coordination for evacuation of patients using helicopters with heavy lift capabilities. 

(3) Coordination for air delivery of Class VIII emergency resupply. 

(4) Coordination for appropriate aviation plans and overlays supporting division operations. 

(5) Coordination for aviation logistics support (aviation fuel maintenance and spare parts) to 
support air ambulances, when required. 

(6) Coordination for aviation weather information from the USAF WX detachment in the 
aviation brigade. 

(7) Coordination through the division aviation support battalion (DASB) CHS requirements 
for the aviation brigade and the division cavalry squadron. For further discussion, see FM 63-23-2. 

c. Division Support Command. Interface with the DISCOM will include most of its staff elements. 



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FM 4-02.21 



(1) The Adjutant (US Army) (SI) provides and coordinates personnel support for the 
command. The DISCOM Si's responsibilities are listed in FM 63-2-2. 

(a) Some of the Si's responsibilities include— 

• Tracking critical AOCs and MOS by skill indicators. 

• Reporting casualties. 

• Conducting replacement operations. 

• Making casualty projections for the DISCOM. 

• Monitoring patient evacuation and mortality. 

(b) Reports submitted from the medical operations cell, DISCOM to the SI should 
be identified in the DISCOM TSOP. These reports can vary depending on the needs of the command. 

(c) The DSS and DISCOM medical operation branches work together and coordinate 
their staff and operational activities to ensure mission accomplishment. 

(2) The Intelligence Officer (US Army)(S2)/S3 section is primarily involved with plans, 
operations, intelligence, and security. The elements of the S2/S3 and its numerous responsibilities are listed 
in FM 63-2-2. 

(a) Elements of the DSS, DISCOM medical operations cell and elements of the S2/S3 
work together to synchronize CHS activities to division operations. The DSS will use its CSSCS to receive 
and transmit information and prepare briefings, overlays and plans with the DISCOM staff. Examples of 
the coordination that must take place between elements of the DSS, DISCOM medical operations cell and 
elements of the DISCOM S2/S3 section are shown in Table 1-3. 

(b) The DISCOM support operations officer, DISCOM S2/S3 and the DSS chief 
medical planner must be informed of staff activities and be involved with the decision-making process. 

(3) The DISCOM Supply Officer (US Army) (S4) is responsible for all logistics matters 
pertaining to DISCOM units. The DISCOM S4's responsibilities are listed in FM 63-2-2. 

(a) The DSS coordinates with the DISCOM S4 for logistical requirements, other than 
medical, that impact on CHS operations. 

(b) The DSS must coordinate with the S4 for critical supply items list (nonmedical) 
requirements. 

1-14 



FM 4-02.21 



Table 1-3. Coordination Between Division Surgeon 's Section and Division Support Command 



SUBJECT AREA 



DISCOM 



DSS 



PLANNING 



S2/S3 PLANS-INTEL BR 
DMC MED OPS BR 
DMCOPSSEC 
GSO MMMB 



MED INTEL NCO 
MED PLANS/OPS CELL 
MED PLANS/OPS CELL 
HSMO 



RELOCATING CHS ELEMENTS 



DMCOPSSEC 
DMC MED OPS BR 



MED PLANS/OPS CELL 



PREVENTIVE MEDICINE 



DMCOPSSEC 
S4DIV FOOD ADVISOR 
S2/23 PLANS-INTEL BR 
MED INTEL NCO 
PVNTMEDCELL 
MED PLANS/OPS CELL 



MED PLANS/OPS CELL 
PVNTMED CELL 
PVNTMED CELL 



MEDICAL SUPPORT REQUEST 



S2/S3 OFC 

S2/S3 PLANS-INTEL BR 

GSO MMMB 

DMCOPSSEC 



MED PLANS/OPS CELL 

MED INTEL NCO 

CHLCELL 

MED PLANS/OPS CELL 



MEDICAL INFORMATION OF POTENTIAL 
INTELLIGENCE VALUE OR 
INTELLIGENCE A MEDICAL NATURE 



S2/S3 PLANS-INTEL BR 
DMC MED OPS BR 



MED INTEL NCO 
MED PLANS/OPS CELL 
PVNTMED CELL 



CORPS SUPPORT 



DMCOPSSEC 
DMC MED OPS BR 



MED PLANS/OPS CELL 



MEDICAL ELEMENTS 

CIVIL AFFAIRS ACTIVITIES 



S2/S3 PLANS-INTEL BR 



MED PLANS/OPS CELL 
PVNTMED CELL 



CLASS VII RESUPPLY 



GSO MMMB 
DMC MED OPS BR 
DMCOPSSEC 
MCO 



CHLCELL 

MED PLANS/OPS CELL 

CHLCELL 

CHLCELL 



NUCLEAR, BIOLOGICAL, CHEMICAL DEFENSE 

SMOKE/OBSCURATION 

ENEMY PRISONER OF WAR OPERATIONS 

MAINTENANCE 



S2/S3 PLANS-INTEL BR 
S2/S3 PLANS-INTEL BR 
S2/S3 PLANS-INTEL BR 
SPT OPS SEC MAINT MGT OFC 
GSO MMMB 



PVNTMEDCELL 
MED PLANS/OPS CELL 
MED PLANS/OPS CELL 
MED PLANS/OPS CELL 
MED PLANS/OPS CELL 
CHL/PVNTMED CELL 



NUTRITION INITIATIVES AND MENU 
APPROVAL 



S4DIV FOOD ADVISOR 



DIV SURGEON 



USE OF DIGITAL SYSTEMS 



S6 



MED OPS OFFICER 



1-15 



FM 4-02.21 



1-8. Interface with the Corps Medical Units 

Interface with corps medical units is accomplished through the corps MEDCOM/brigade. Direct interface 
can occur with those medical units providing support to the division and will be coordinated by the DSS and 
the corps staff. The MEDCOM/brigade will provide subordinate units to support the division by establishing 
a command relationship of OPCON or attachment. The MEDCOM/brigade could also choose to maintain 
only a support relationship of DS or GS to support the division. The DSS interfaces with corps medical 
units according to the MEDCOM/brigade TSOP. The DSS and other division staff elements must be 
prepared to integrate corps-level medical units/elements into the medical, as well as the logistical, support 
structure. The MEDCOM/brigade will normally deploy a liaison officer to the division to coordinate and 
synchronize corps CHS. Information concerning the organization, functions, and responsibilities of the 
corps MEDCOM/brigade is found in FM 8-10. 

a. Corps Medical Command and Medical Brigade. The corps MEDCOM and medical brigade 
provide C2, including— 

• Staff planning. 

• Supervision of operations. 

• Administration of the assigned and attached units. 



elements: 



(1) The following areas are subjects of mutual concern for division and corps medical staff 

Medical regulating. 

Division CHS requirements. 

Ground and air ambulance support. 

Class VIII resupply, blood management, and medical maintenance. 

Status of corps medical elements attached, or OPCON, to the division. 

Disease surveillance. 

Medical threat and intelligence estimates. 

Captured medical supplies and equipment. 

Reinforcement and reconstitution of CHS elements. 

Civil affairs and HN support. 



1-16 



FM 4-02.21 



• Communications. 

• Locations of medical elements in support of the division. 

• Preventive medicine, mental health, dental, or veterinary assistance. 

(2) Logistical support requirements for corps medical elements operating in the division are 
identified and coordinated with the corps support battalion. When corps medical elements deploy to the 
division, logistical support is normally provided by the corps support battalion. Coordination could be 
required for— 

• Class I— Subsistence items and gratuitous issue health and welfare items. 

• Class II— Items of equipment other than principal items which are prescribed in 
authorization and allowance tables (individual equipment, clothing items, tents, tool sets, and administrative 
and housekeeping supplies). 

• Class III— Petroleum, oils, and lubricants (POL) (petroleum fuels, hydraulic and 
insulating oils, chemical products, antifreeze compounds, compressed gases, and coal). 

• Class IV— Construction and barrier materials, lumber, sandbags, and barbed wire. 

• Class V— Ammunition. 

• Class VI— Personal demand items such as health and hygiene products (soap and 
toothpaste), writing material, snack food, beverages, batteries, and cameras (nonmilitary sales items). 

• Class VII— Major end items— (final combination of items which are ready [assem- 
bled] for intended use). 

• Class VIII and Blood— Medical materiel, including repair parts peculiar to medical 
equipment, and blood products 

• Class IX— Repair parts. 

• Field services (billeting, showers, and services). 

• Personnel replacements (corps supported). 

b. Medical Logistics Battalion. The MEDLOG battalion is organic to the corps medical brigade. 
The MEDLOG battalion provides C2 for assigned MEDLOG companies and the blood support detachment. 
The MEDLOG battalion is responsible for receiving, storing, and distributing medical materiel; single and 
multivision optical fabrication and repair; medical maintenance; blood and blood product collection, 
manufacturing, and distribution; medical gas production and distribution; and building of medical 
assemblages/push packages. The MEDLOG battalion will employ standard state-of-the-art MEDLOG 

1-17 



FM 4-02.21 



information management and communications systems to include satellite links. Interface between the DSS 
and the MEDLOG battalion, MEDLOG company, or blood support detachment could be required for— 

Emergency Class VIII resupply. 

Repair of medical equipment. 

Blood management. 

Optical fabrication requirements. 

Management of captured medical materiel. 

Storage and decontamination techniques to minimize NBC contamination of Class VIII 
supplies. 

(1) Medical logistics company. The MEDLOG company provides Class VIII supplies, DS/ 
GS medical maintenance, and optical support. The MEDLOG company will use line item requisitioning to 
support customers and will have the capabilities of building and maintaining preconfigured push packages in 
support of forward deployed medical units. 

(2) Blood support detachment. The MEDLOG battalion's blood support detachment serves 
as the Army's blood supply unit (BSU). Blood and blood products will be stored and distributed under rigid 
specifications and managed by standard automated systems. Air movement will be the mode of choice for 
transporting blood and blood products. Army blood support in the AO will be the responsibility of the 
supporting MEDLOG battalion. The MEDLOG battalion's blood support detachment will collect and 
manufacture, receive, store, and distribute blood and blood products on an area basis. 

c. Medical Evacuation Battalion. The headquarters and headquarters detachment, medical 
evacuation battalion serves as the central manager of ground and air evacuation assets in the corps. Its 
mission is to provide C2 of ground and air medical evacuation units within its AO. Information pertaining 
to the organization, functions, and capabilities of this unit is discussed in FM 8-10-6. The DSS interfaces 
with the medical evacuation battalion or subordinate units concerning— 

Air and ground movement liaison within the division AO. 

Reinforcement of division CHS assets. 

Mass casualty evacuation plans. 

Evacuation of patients from division to supporting corps hospitals. 

Emergency movement of medical personnel, supplies, and blood. 

Ambulance shuttle operations, to include ambulance exchange points (AXPs) and patient 
collection points. 



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FM 4-02.21 



The status of medical evacuation battalion elements operating in the division. 

Management and decontamination of ground/air evacuation assets. 

Support requirements for forward deployed medical evacuation battalion assets. 

Location of medical evacuation battalion assets. 

Location of division medical elements. 

The tactical situation and threat updates. 

Delivery of blood and blood products. 

Reinforcement of covering force and deep operations evacuation assets. 

Road and movement clearances. 

Maintenance support, to include aviation intermediate maintenance (AVIM). 

Emergency resupply of medical and nonmedical items (if required). 

Communications requirements and signal operation instructions (SOI). 

Updated tactical maps and evacuation overlays. 

Terrain considerations and barrier plans for ambulances. 

Evacuation destinations (MRO functions). 

Division and brigade A2C2 requirements. 

Combat search and rescue missions. 

(1) Within the division area, the air ambulance company provides aeromedical evacuation on 
a DS basis. This company is normally attached for support (less OPCON) to the division aviation brigade. 
Air ambulances will operate from the division support area (DSA) and brigade support areas (BSAs) 
providing 24-hour immediate response medical evacuation capability. 

(2) Successful aeromedical evacuation support to the division requires current and accurate 
operational information. This information includes A2C2, current intelligence, friendly situation, air traffic 
service procedures, weather, combat service support (CSS), and aviation safety and standardization data. 
To enhance the safety and effectiveness of aeromedical operations, operations information should flow 
between air ambulance units and the GS aviation battalion or assault helicopter battalion of the respective 
aviation brigade. 



1-19 



FM 4-02.21 



• 



• 



(3) Information is exchanged by various methods including on-site coordination or communi- 
cations systems. The air ambulance company can obtain information through various sources such as the 
DSS and BSSs of the maneuver brigade TOCs. However, during the planning and execution phases 
of operations, the medical evacuation battalion and the aviation unit to which the air ambulance com- 
pany is attached are the primary sources for providing this information. The DSS also provides A2C2 
planning information to the air ambulance company. This information includes, but is not limited to, the 
following: 

• Location of medical units. 
Locations of forward arming and refueling points. 
Liaison requirements with supported units. 

• Evacuation corridors recommendation. 

The air ambulance company, in turn, continually provides the medical evacuation battalion, aviation brigade, 
and DSS with updated information about its current and planned operations. The company also provides 
pertinent combat information obtained during missions. This information includes threat disposition, 
downed aircraft, weather, and other factors obtained by air ambulance crews during the performance of 
their duty. All medical evacuation crews communicate directly with the division air traffic service and 
execute A2C2 while operating behind brigade boundaries. 

(4) When air ambulances operate in the DSA, they execute the A2C2 plan and communicate 
directly with the division air traffic service. Emergency requests for aeromedical evacuation is relayed as 
necessary from the DSS through the DSMC to the air ambulance elements position at their location for the 
mission. 

(5) Air ambulances deployed forward into the BSA normally collocate with the FSB or 
aviation task force. When deployed forward to the BSA, the air ambulance team's evacuation missions are 
coordinated by the FSMC commander. The FSMC assisted by the support operations section provides real- 
time tactical information to the air ambulance crew about evacuation missions from the maneuver battalion/ 
company to the brigade rear area. When air ambulances operate forward of the BSA, they will execute the 
A2C2 plan through the maneuver brigade S3. The FSB support operations section provides planning and 
coordination between aeromedical evacuation and the supported maneuver brigade. The brigade S3 provides 
the A2C2 plan which includes the air corridors, air control points, and communications checkpoints. The 
brigade S3 will provide updates as required. Air ambulances deployed to the BSA will normally provide 
medical evacuation from forward areas (battalion aid station [BAS]) back to the BSA. Air ambulance 
evacuation from the point of injury will be mission, enemy, terrain, troops, time available, and civilian 
considerations (METT-TC) dependent. Air ambulances from the corps or those positioned in the DSA will 
evacuate from the BSA to corps hospitals. 

(6) The medical evacuation battalion communications link to the air ambulance company is 
accomplished by a combination of wire, frequency modulated (FM) voice, and mobile subscriber equipment 
(MSE). To enable air-to-air communications between medical evacuation aircraft and aviation brigade 

1-20 



FM 4-02.21 



aircraft during the conduct of missions, air ambulance companies obtain aviation unit call signs, frequencies, 
and cryptonet variables. 

(7) Corps aeromedical elements will operate from the DSA and BSAs providing around the 
clock immediate response evacuation aircraft. To accomplish this, elements must maintain a close tie with 
the A2C2 system in the division. The division A2C2 element provides an airspace plan through the division 
operation order (OPORD)/OPLAN A2C2 annex. The aircrew must also be familiar with the daily airspace 
control order and the airspace control plan. These documents contain all airspace control measures (ACM), 
to include free fire areas, no-fly/fire areas, restricted operations zones, and established and standard Army 
aircraft flight routes (SAAFRs). These route and ACMs change on a daily basis and cannot be integrated 
into the division OPORD. The DSS will ensure all A2C2 information is provided to corps aeromedical 
elements. The DSS does not generate A2C2 information, but does provide A2C2 planning information to 
division A2C2 elements. This information includes, but is not limited to, the following: 

• Locations of medical aviation and medical units. 

• Locations of forward air refueling equipment. 

• Locations of supported units and liaison requirements. 

• Locations of evacuation corridors and recommendations on usage. 

(8) All medical air-flight crews will communicate directly with the division air traffic service 
and execute division A2C2 while operating behind brigade boundaries. The medical evacuation battalion 
normally deploys air ambulance elements to the division. These elements include an air ambulance 
company or a selected element of the company. When the air ambulance company deploys to the division, 
it collocates with the aviation brigade, or according to the division TSOP. Air ambulance companies will 
obtain A2C2 information from the division A2C2 section and coordinate with the DSS. Air ambulance 
teams can be deployed forward into the BSA and collocate with the FSB. When deployed forward, the air 
ambulance team is totally dependent on the FSB for communications support. When air ambulance 
elements operate forward of the BSA, they will execute the A2C2 plan through the brigade S3. The FSB's 
support operations section provides planning and coordination between air evacuation elements and the 
maneuver brigade S3. Information provided to the maneuver brigade S3 should include, but not be limited 
to, the following: 

Location of MTFs and AXPs. 

Location and number of aircraft in sections. 

Location of AMEDD forward air refueling equipment. 

Locations of supported units and liaison requirements. 

Locations of evacuation corridors and recommendations on usage. 

1-21 



FM 4-02.21 



(9) The brigade S3 provides the A2C2 plan which includes the air corridors, air control 
points, and communications checkpoints. The brigade S3 will provide updates as required. 



1-9. Interface with the Division Support Battalion 

The DSS coordinates through the DISCOM medical operations branch, and interfaces with staff elements of 
the DSB on CHS issues pertaining to the DSA, and attachment/OPCON of corps medical elements. 
Interface with the division support medical company will primarily concern area medical support activities 
for the DSA. All medical issues are coordinated with the DSB HSSO who is located in the headquarters 
section. For further discussion on the DSB, see FM 63-21-1. 



1-10. Interface with the Forward Support Battalions 

After coordination with the DISCOM medical operations branch, the DSS can interface with elements of the 
FSB through the CHS cell (HSSO) of the support operations section. This interface between the DSS and 
elements of the FSB is driven by CHS requirements in the forward areas. This information will assist the 
DSS in planning, coordinating, and managing division medical elements and resources in support of the 
battle. Communications and coordination between elements of the DSS, DISCOM support operations 
section and medical operations branch and the FSBs are essential for continuous CHS. The DSS will 
normally interface through the HSSO with the following FSB elements: 

a. S2/S3. The S2 or S3 advises and assists the FSB commander in planning, coordinating, and 
supervising the communications, operations, training, security, and intelligence functions of the battalion. 

b. Support Operations Section. The support operations section's mission includes DS supply, 
field services, DS maintenance, CHS, and limited transportation functions. The section must ensure that 
logistics and CHS to the supported units remain at a level consistent with the type of tactical operations 
being conducted. Interface between the support operations section and the DSS will be direct or indirect. 
The FSB HSSO is assigned to the support operations section. 

c. Forward Support Medical Company. The FSMC provides CHS for the brigade as well as area 
medical support for the brigade rear and BSA. Combat health support operations are coordinated by the 
DSS through the DISCOM with the BSS and the FSB (HSSO). The DSS tasks elements of the FSMC, 
through DISCOM support operations chain of command, to provide division-level CHS. The HSSO, 
FSMC commander, and brigade surgeon are the principal managers of the CHS assets assigned or attached 
to the brigade. 



1-11. Interface with the Maneuver Battalions 

Medical platoons organic to the maneuver battalion provide Echelon I CHS for the battalion and area 
medical support in forward areas. Coordination is made with the medical platoons through the BSS. 

1-22 



FM 4-02.21 



Section IV. COMMAND POST SETUP AND COMMUNICATIONS 



1-12. Command Post, Division Headquarters 

The DSS, as an element of the division sustainment cell relocates and establishes itself as part of the division 
main command post (CP). The sustainment cell consists of several 5-ton expandable vans. These expandable 
vans house the assistant division commander for support (ADCS), DISCOM headquarters, and division and 
DISCOM CSS staffs. The ADCS conducts the rear fight from the sustainment cell. For sample setup of the 
division sustainment cell, see FM 63-2-2. 

a. Command posts are organized in many different ways to accomplish their missions. There are 
several options for setting up the division CPs. The division has changed to a main CP (tactical command 
post administrative center). The main CP combines all of the functions of the old division main and division 
rear CPs. For example of division CPs, see FM 71-100. 

b. The DSS's area is setup according to division TSOPs. 

1-13. Information, Communications, and Digitization 

Effective management and control of division CHS operations are dependent on the DSS's ability to 
communicate with division and corps elements. The use of the area common-user system (ACUS), 
digitization of all echelons of CHS communications, digitization of the battlefield distribution (BD) 
transportation assets and lastly, modular medical organization structure provides the DSS information 
needed to tailor and synchronize CHS. Through real-time situational awareness, the DSS anticipates, 
coordinates, and provides CHS for the division to include all units attached, DS, and OPCON to the 
division. Information and communications assets available to the DSS include are provided in Table 1-4. 

Table 1-4. Information and Communications Assets Available to the Division Surgeon 's Section 



RADIO SETS TELEPHONES & FACSIMILE (FAX) 

AN/VRC 88F (1 EACH) DIGITAL NONSECURE VOICE TELEPHONE (4 EACH) 

AN/VRC 89F (1 EACH) DIGITAL SECURE VOICE TELEPHONE (1 EACH) 

AN/GRC213(2EACH) MSE FACSIMILE 

ROUTERS COMPUTER SYSTEMS 

TACTICAL LAND AREA NETWORKS COMBAT SERVICE SUPPORT CONTROL SYSTEM 

LOCAL AREA NETWORK ROUTER THEATER ARMY MEDICAL MANAGEMENT INFORMATION SYSTEM 

MEDICAL COMMUNICATIONS FOR COMBAT CASUALTY CARE 

OTHERS THEATER MEDICAL INFORMATION PROGRAM 

WEATHER SYSTEM FORCE XXI BATTLE COMMAND BRIGADE AND BELOW (3 EACH) 
POSITION/NAVIGATION DEVICE (1 EACH) 



1-23 



FM 4-02.21 



NOTE 

Mobile subscriber equipment support for the DSS is 
provided by elements of the division signal battalion. 

a. Army Battle Command System. The primary means of communications within the digital 
division is through the use of the Army Battle Command System (ABCS). The DSS uses CSSCS to receive 
and transmit information and prepare briefings, overlays and plans. In addition, the DSS maintains an 
updated status of the tactical and logistics situations through the use of CSSCS. The division surgeon is re- 
sponsible for establishing the CHS and CHL reporting procedures in the division using CSSCS and FBCB2. 
Complete details for use of the CSSCS at the CSSCS homepage @ http://www.lee.army.mil/CSSCS/. 

b. Radio Communications Networks and Radios used by the DSS. Radio communications 
networks and radios used by the DSS include— 

(1) The division logistics operations net (amplitude modulated [AM]— single sideband [SSB]) 
which is controlled by the DISCOM S2/S3 support operations section. The net provides the necessary long- 
range C2 link between the DISCOM, the FSBs, the DSB, the division materiel management center (DMMC) 
and the distribution management center (DMC) medical operations branch. 

(2) The DSS maintains continual communications with division and DISCOM medical ele- 
ments through its FM and AM radios. Single-Channel Ground and Airborne Radio System (SINCGARS) 
components provide the DSS with AN/VRC 89 series (FM) which has a receiver/transmitter capable of 
using two FM nets for reception and transmission. This permits the DSS to operate a medical net (FM). 
The DSS AM radio is an AN/GRC 213 radio (AM -improved high-frequency radio [IHFR]). 

c. Mobile Subscriber Equipment. Mobile subscriber equipment is a part of the ACUS, which 
goes from the corps rear boundary forward to the division maneuver battalion's rear area. This system will 
allow the DSS to communicate throughout the battlefield in either a mobile or static situation. The mobile 
subscriber system is managed by the organic MSE signal battalion. The signal support company normally 
provides subscriber services to the division/DISCOM main CP. This system integrates the functions of 
transmission, switching, control, and terminal equipment. Additional information pertaining to MSE is 
found in FM 1 1-55 and FM 63-2-2. 

(1) The MSE telephones, mobile subscriber radiotelephones (MSRTs), FAXs, data terminals, 
and computer systems, as part of the ACUS, are user-owned and operated. The DSS is responsible for 
running wire to the designated junction boxes. These boxes tie the DSS MSE telephones into the extension 
switches that access the system. The subscriber terminals used by the units are digital secure and nonsecure 
voice telephones. These provide full duplex digital, four-wire voice, as well as data ports, for interfacing 
the AN/UXC-7 FAX, the TACCS computer, and the unit-level computer (ULC). See FM 11-43 for 
information on how to connect the entry point terminal communications systems. 

(2) Wire subscriber access points provide the entry points (interface) between fixed subscriber 
terminal equipment owned and operated by users and the MSE area system operated by signal units. 

1-24 



FM 4-02.21 



See FM 63-2-2 for information pertaining to fixed subscriber terminal equipment assignments for the DSS. 
The MSE MRST terminal is the AN/VRC-97. This MSRT, which consists of a very high-frequency radio 
and a digital secure voice terminal, is a vehicle-mounted assembly. It interfaces with the MSE system 
through a radio access unit (RAU). The primary use of the MSRT terminal is to provide mobile subscribers 
access to the MSE area network. Radio access units are deployed to maximize area coverage and MSRT 
terminal concentrations. Mobile subscriber radiotelephone terminals can also operate in CPs to allow staff 
and functional personnel access. Local standing operating procedures (SOP) will determine use of MSRTs 
in CP areas based on the possibility of interference with SINCGARS radios operating in the immediate area. 
As the Army continues to digitize the battlefield and modernize the force, the use of automation continues 
to develop. 

(3) Mobile subscriber equipment Packet Switching Network gives units the ability to connect to 
division and corps tactical local area network (TACLAN). This allows units/CPs to connect computer 
systems such as the CSSCS and the maneuver control system, (MCS) to an ethernet cable (coaxial) and send 
and receive information in an extremely efficient manner. Packet switching does not utilize or take up 
existing telephone lines. Instead, telephone lines are freed up even more because information is being sent 
over a network on appliques. Using ABCS, common hardware/software facilitates the interface and 
exchange of information between the DSS, corps elements, and division medical elements. See FM 63-2-2 
for information concerning automatic data processing (ADP) continuity of the OPLAN. 



Section V. COMBAT HEALTH LOGISTICS AND BLOOD MANAGEMENT 



1-14. Class VIII Resupply 

a. Management. Class VIII resupply management in the Army XXI division is accomplished by 
medical units/elements through the use of a functional business system called Medical Logistics-Division 
(MEDLOG-D). Currently the functional business system for Class VIII wholesale/retail management at 
echelons above division (EAD) is the Theater Army Medical Management Information System (TAMMIS), 
which is a legacy system. This system will be replaced in the future by the Defense Medical Logistics 
Standard Support (DMLSS) System. Medical Logistics-Division is a module of DMLSS and is scheduled 
for fielding to division and corps medical units/elements. This system provides division and corps medical 
units/elements a direct link with the supporting MEDLOG battalion's units. The HSMO of the DSS and the 
DISCOM MMMB in the division support operations section coordinates Class VIII resupply for division 
medical units/elements. Each medical unit maintains its own basic load of 3 days of medical supplies. The 
MEDLOG battalion assigns one MEDLOG company in DS of each division. Once established, it provides 
Class VIII resupply for the division and corps medical elements operating in the division AO. 

b. Resupply during {Employment and Initial) Employment. 

(1) During deployment, lodgment, and early buildup phases, medical units operate from 
planned, prescribed loads and from existing pre-positioned war reserve stockpiles identified in applicable 
contingency plans. 

1-25 



FM 4-02.21 



(2) During the initial employment phase, each FSMC will receive a preconfigured medical 
resupply push-package every 48 hours from pre-positioned stock or the continental United States (CONUS) 
base. Preconfigured medical resupply push-packages will continue until appropriate units of the corps 
MEDLOG battalion are established. 

(3) Initial resupply efforts will consist of preconfigured medical supply packages tailored to 
meet specific mission requirements. Preconfigured push-packages will normally be shipped directly to the 
division support medical company (DSMC) and FSMCs until replenishment line item requisitioning is 
established with the supporting MEDLOG company. During this time, medical company treatment and 
ambulance teams deployed with maneuver or other division elements are resupplied from their medical 
company. Maneuver battalion medical platoons/BAS will receive standard push-packages every 12 to 24 
hours. Contents of push-packages can be adjusted as the battle changes. Line item requisitioning will be by 
exception only during this time. While resupply by preconfigured packages is intended to provide support 
during the initial phase, continuation on an exception only basis will be dictated by operational needs. 
Planning for such a contingency must be directly coordinated with the DSS. Other than line item 
requisitioning from the FSMCs and DSMC, the HSMO of the DSS and the DISCOM MMMB will 
coordinate all Class VIII requirements for the division with the supporting MEDLOG battalion and/or 
MEDLOG company, as appropriate. 

c. Medical Logistics -Division. Divisional medical elements use MEDLOG-D to requisition Class 
VIII supplies. Users of this system in the division include maneuver battalion medical platoons, FSMCs, 
the DSMC, and the DISCOM MMMB. The MEDLOG-D system is the primary source for Class VIII line 
item requisitions from the FSMCs and DSMC. Forward support medical companies and the DSMC request 
Class VIII resupply from the supporting MEDLOG company. 

d. Routine Requisitions. Routine requisitions from maneuver battalion medical platoons for 
Class VIII resupply from their supporting FSMC will be via a digital request. An information copy of all 
requisitions within the brigade will be forwarded by the FSMC on-line to the DISCOM MMMB and off-line 
to the BSS. Routine requisitions submitted by FSMCs, division or corps medical elements operating in the 
BSAs are forwarded directly to the supporting MEDLOG company. An information copy goes to the 
DISCOM MMMB. The MMMB coordinates shortfalls in throughput distribution with the DSS and divisions 
support operations branch. The MMMB updates priorities with the MEDLOG company to correct 
deficiencies in the delivery system. If the requested items are available for issue, a materiel release order is 
printed and the requested supplies are prepared for shipment. For items not available for issue, the requests 
are passed to the MEDLOG battalion's logistics support company. Using TAMMIS, the MEDLOG 
company forwards information to the unit on items shipped and on those requests which were not filled. An 
information copy is forwarded to the MMMB. 

e. Emergency Requisitions. Emergency requisitions from maneuver battalion medical platoons 
are submitted to the supporting FSMC. When the supporting FSMC is unable to fill the request, the 
requisition is forwarded to the DISCOM MMMB. The DISCOM MMMB will expedite handling of this 
request to ensure tracking of critical Class VIII items and timely delivery. Cross-leveling in the division 
should be accomplished if it is the most expedient method of obtaining and shipping required items to the 
requesting unit/element. If the DISCOM MMMB is unable to locate requested item(s) in the division, the 
request is forwarded to the supporting MEDLOG company. Emergency requisitions from FSMCs are sent 

1-26 



FM 4-02.21 



through the DISCOM MMMB for management and to ensure visibility of the requisitions. The DISCOM 
MMMB maintains a record of the requisition until it is filled. All emergency requests received by the 
MEDLOG company are processed for shipment by the most expedient transportation available. When 
feasible delivery of these emergency supplies are accomplished using air ambulances which is coordination 
with the medical evacuation battalion. The MEDLOG company immediately forwards all emergency 
requests not filled to the MEDLOG battalion logistics support company located in the corps rear. The 
DISCOM MMMB has the responsibility of monitoring all emergency requisitions not filled by the MEDLOG 
company. The DISCOM MMMB reports all emergency Class VIII requests to the DSS/CHS cell. 

/ Delivery of Class VIII Supplies. Delivery of throughput Class VIII supplies to the requesting 
medical units in the division is accomplished by logistical packages (LOGPACs) and nonmedical transports. 
Shipment of these Class VIII LOGPACs from the MEDLOG company is coordinated with the corps support 
battalion and the corps MCO. The management and in-transit visibility of Class VIII delivery is 
accomplished through document number and transportation number tracking. The systems that work 
together to provide this management and coordination are TAMMIS, Transportation Coordinator's 
Automated Information for Movement System (TCAIMS), Movement Tracking System (MTS), and Global 
Traffic Network (GTN). These systems are located in the MEDLOG company and the DISCOM MMMB. 
In some cases, delivery of medical materiel into the division AO is achieved through use of the directed 
Class VIII resupply using medical evacuation resources that are returning to the division medical units. 
From the FSMCs, delivery of Class VIII supplies to maneuver battalion medical platoons via LOGPAC or 
nonmedical transports is coordinated by the FSMC with the FSB support operations section. For directed 
Class VIII resupply, medical transports can be used. Emergency Class VIII resupply will be processed for 
shipment by the most expedient means available. Based on casualty estimates, medical push-packages 
should be pre-positioned with maneuver battalion medical platoons or with the FSMC. Figure 1-2 provides 
an overview of Class VIII requisitions and resupply flow at Echelon I. Figure 1-3 provides an overview of 
Class VIII requisitions and resupply flow at Echelon II. 

1-15. Assemblage Management Reporting Under Unit Status Reporting 

a. Unit Status Reporting. With the fielding of MEDLOG-D, unit status reporting (USR) of 
medical equipment sets (MES) in the division will be created using the MEDLOG-D USR feeder report. It 
calculates percentage fill of sets according to AR 220-1 and AR 40-61 and does not create a roll-up of 
equipment on-hand calculations. Minus the potency or dated items while units are not deployed, 70 percent 
fill of the combined expendable, durable, and nonexpendable items within a set constitute an on-hand set for 
accountability purposes. Medical equipment must be maintained at an acceptable degree of readiness to the 
level above 70 percent as determined by the division surgeon and unit commander. Division medical units/ 
elements will prepare a requisition plan to immediately replenish all potency, dated, and other items that are 
not being maintained and missing items from sets. Units will coordinate with the supporting MEDLOG 
company prior to implementation of the plan. 

b. Transmission of Requisitions and Status Reports Data. Transmission of Class VIII requisitions 
and status reports data will be accomplished by one of a number of ways. The baseline method will always 
be by disk and hard copy. The preferred method will be by radio or MSE transmission if signal capabilities 
allow. At the battalion level, units will attempt to transmit requisition and report data using SINCGARS 

1-27 



FM 4-02.21 



Systems Improvement Program (SIP) or Enhanced Position Location Reporting System (EPLRS) linked to 
the hyperlink or modem capability of DMLSS-AM. Given the line of site limitations of FM radio, this 
attempt is best accomplished in synchronization with previously coordinated retransmission. Within the 
BSA and higher, transmission of data will be by either MSE or Harris radio (FM) if allowed. Note that if 
MSE is used, the unit must accomplish prior coordination with the division Assistant Chief of Staff (Signal) 
(G6) to obtain a net encryption system or other encryption hardware system in order to send data. 





MEDLOG 
(LOCATED IN CORPS) 



THE MEDICAL PLATOONS 
WILL DIGITALLY REQUEST 
SUPPLIES FROM FSMC. 



BAS 



BAS/MED PLT 
3 X TRMT TM 



'V ; 



PNT COLL POINT X 
CO MEDIC 





IdS 


* 


+ iM 


< v::: 

T- 


— Js* 


T *,.. 


-~ £3 




" M 



PLT MEDIC/ 
CBT LIFESAVER 



CLASS VIII FLOW/ 
BACKHAUL 



REQUISITION 



INFORMATION 
COPY 



THE AMBULANCE CREW 
CAN ALSO RESUPPLYTHE 
MEDIC FROM SUPPLIES ON 
THE AMBULANCE. THE 
CREW CAN THEN 
REPLENISH ITS STOCK AT 
THE BAS. (MEDLOG-D/ 
APPLIQUE SHOULD BE 
USED TO PASS REQUESTS 
FOR RESUPPLY.) 



THE MED PLT LEADER 
CAN ENHANCE SUPPLY 
TO THE COMBAT MEDICS 
BY FORWARD LOCATING 
PRECONFIGURED 
MATERIEL AT THE 
PATIENT COLLECTING 
POINTS. (CO MEDIC 
SHOULD USE 1SG 
APPLIQUE TO REQUEST 
RESUPPLY.) 



THE COMBAT MEDIC AND THE 
COMBAT LIFESAVER 
REQUEST SUPPLIES FROM 
THE BAS. THIS IS USUALLY 
DONE BY THE MEDIC IN THE 
AMBULANCE RETURNING TO 
THE BAS WITH PATIENTS. 
AMBULANCES MAY BE USED 
TO DELIVER SUPPLIES 
FORWARD FROM THE BAS AS 
THE AMBULANCE RETURNS 
TO THE MANEUVER UNIT. 



Figure 1-2. Overview of Class VIII resupply at Echelon I. 



1-28 



FM 4-02.21 



THE MEDLOG CO 
THROUGHPUTS CLASS VIII 
RESUPPLY TO DIVISION 
MEDICAL COMPANIES USING 
CORPS TRANSPORTATION 
ASSETS AND AMBULANCE 
BACKHAUL. 



CLASS VIII FLOW/ 
BACKHAUL 



REQUISITION 



INFORMATION 
COPY 




Figure 1-3. Overview of Class VIII resupply at Echelon II. 

1-16. Medical Equipment Maintenance 

The CHL Cell of the DSS will establish a list of critical medical equipment for the division. Units are to 
report the status of items on this list to the CHL cell. 

a. Medical Equipment Repairer. The medical equipment repairer provides operational and unit- 
level medical equipment maintenance for the FSMC and the brigade. He exercises his responsibilities by— 

• Scheduling and performing preventive maintenance checks and services (PMCS). 

• Performing electrical safety inspections and tests. 

• Accomplishing calibration, verification, and certification services. 

• Performing unscheduled maintenance functions with emphasis upon the replacement of 
assemblies, modules, and printed circuit boards. 



1-29 



FM 4-02.21 



• Operating a medical equipment repair parts program, to include Class VIII supplies as 
well as other commodity class parts. 

• Maintaining a technical library of operator and maintenance technical manuals (TMs) 
and/or associated manufacturers' manuals (printed and/or digital). 

• Conducting inspections for new or transferred equipment. 

• Maintaining documentation of maintenance functions according to the provisions of 
Technical Bulletin (TB) 38-750-2 or DA standard automated system. 

• Collecting and reporting data for readiness reportable medical equipment in accordance 
with AR 700-138. 

• Requesting through the DISCOM, MMMB for maintenance support services, repairable 
exchange, or replacement from the Medical Standby Equipment Program (MEDSTEP), see AR 40-61. 

b. Mandatory Parts and Prescribed Load Lists. Mandatory parts lists (MPLs) and prescribed 
load lists (PLLs) need to be monitored routinely. An MPL to support medical equipment is published 
annually in the Supply Bulletin (SB) 8-75 Series. Most medical equipment repair parts can be requisitioned 
through the Class VIII supply system; however, some repair parts are needed to repair medical equipment 
that falls in the category of Class IX repair parts (that is, common fasteners, electrical components, and 
others). Requisitions for Class IX repair parts are sent through the organization's supporting motor pool 
and require stringent monitoring and follow-up efforts. Special considerations for medical repair parts are 
explained in AR 40-61. 

1-17. Division Blood Management 

Blood requirements for the division are determined by the division surgeon. Only packed liquid red blood 
cells are expected to be available to the division. Blood products are shipped to Army MTFs in the division 
by the blood support detachment of the MEDLOG battalion. The DSS (HSMO) coordinates with the blood 
support detachment for division blood requirements. 

a. Blood Shipment. Shipment of blood from the corps to the division is coordinated by the blood 
support detachment with the corps movement control center (CMCC). It is then transported to the requesting 
MTF by dedicated medical vehicles (air and ground). The blood support detachment notifies the DISCOM 
MMMB when blood is shipped. Emergency resupply can be accomplished by air ambulances from the 
medical battalion, evacuation or by medical personnel on nonstandard medical transports. 

b. Blood Support System. Blood support is a combination of four systems (medical, technical, 
operational, and logistical). Blood support must be considered separate from laboratory support. In the 
long term, theater blood management is based on resupply from the CONUS donor bases (Armed Services 
Whole Blood Processing Laboratories [ASWBPLs]). At the corps level, storage and transportation 
refrigerators allow the blood support detachment to provide blood as far forward as the FSMCs of the 
division. See FMs 8-10, 8-10-9, 8-55, and TM 8-227-12 for definitive information on blood management. 

1-30 



FM 4-02.21 
CHAPTER 2 
BRIGADE MEDICAL STAFF 

Section I. BRIGADE SURGEON 

2-1. Duties of the Brigade Surgeon 

The brigade surgeon is an MC officer (Major, AOC 62BOO). He is a special staff officer who plans with 
and coordinates brigade CHS activities with the brigade SI. The brigade surgeon is assigned to the 
headquarters and headquarters company (HHC) of the maneuver brigade. The surgeon is responsible for 
the technical control of all medical activities in the command. The brigade surgeon oversees and coordinates 
CHS activities through the BSS and the brigade S3. The brigade surgeon keeps the brigade commander 
informed on the status of CHS for brigade operations and the health of the command. He provides input 
and obtains information to facilitate medical planning. His specific duties in this area include— 

• Ensuring implementation of the CHS section of the brigade TSOP. 

• Determining the allocation of medical resources within the brigade. 

• Supervising technical training of medical personnel and the combat lifesaver program within 
the brigade. 

• Determining procedures, techniques, and limitations in the conduct of routine medical care, 
emergency medical treatment (EMT), and advanced trauma management (ATM). 

• Monitoring aeromedical and ground ambulance evacuation. 

• Monitoring the implementation of automated medical systems. 

• Informing the division surgeon on the brigade's CHS situation. 

• Monitoring the health of the command and advising the commander on measures to counter 
disease and injury threats. 

• Exercising technical supervision of subordinate battalion surgeons and PAs. 

• Providing consultation and mentoring for subordinate battalion surgeon, physicians, and PAs. 



• 



Providing the medical estimate and medical threat for inclusion in the commander's estimate. 



2-2. Responsibilities of the Brigade Surgeon 

The brigade surgeon, assisted by the BSS, is responsible for— 

• Planning and coordinating the following CHS operations: 

• The system of treatment and medical evacuation (MEDEVAC), including aeromedical 
evacuation. 

2-1 



FM 4-02.21 



status reports 
requirements) 



Dental services. 

Preventive medicine services. 

Combat stress control. 

Medical supply and medical maintenance support, including technical inspection and 

Medical humanitarian assistance (see FM 8-42 pertaining to Title 10, United States Code 

Combat health support within the command. 

Preparation of reports regarding medical administrative records of injured, sick, and 
wounded personnel. 

• Advising on health status of the command and of the occupied or friendly territory within the 
commander's area of responsibility. 

• Reviewing all brigade OPLANs and contingency plans to identify potential medical hazards 
associated with geographical locations and climatic conditions. 

• Advising on the medical effects of the environment, NBC, and directed-energy devices on 
personnel, rations, and water. 

• Identifying and tracking critical Class VIII items and establishing priorities for procurement. 

• Determining requirements for medical personnel and making recommendations concerning 
their assignments. 

• Coordinating with the FSB HSSO and maneuver battalion staff elements for continuous CHS. 

• Submitting to higher headquarters those recommendations on professional medical problems 
that require research and development. 

• Providing recommendations on allocation and redistribution of AMEDD personnel, CHL, and 
CHS during the reconstitution process. 

• Advising commanders about the PVNTMED aspects of all operations and the availability and 
use of CSC teams. 

• Advising commanders on the effects of accumulated fatigue, radiation exposure, possible 
delayed effects from exposure to chemical or biological agents, and use of countermeasures and 
pretreatments. 



2-2 



FM 4-02.21 



• Advising commanders on policy for personnel exposed to lethal but not immediately life- 
threatening doses of radiation or chemical and biological agents. 

• Ensuring that clear and accurate patient records are maintained of all clinical encounters for 
supported deployed personnel through the use of a DA Form 8007-R or through the use of digital patient 
records, as they become available. See AR 40-66 and FM 8-10-1 for management of individual health 
records in the field. Also, digital patient records at the division and brigade level will be available through 
the fielding of MC4 and the TMIP. 

Section II. ORGANIZATION AND FUNCTIONS OF THE BRIGADE 

SURGEON'S SECTION 



2-3. Mission of the Brigade Surgeon's Section 

The mission of the BSS is to plan, coordinate, and synchronize the brigade's CHS under the supervision of 
the brigade surgeon. An overview of the process for developing the OPLAN/OPORD is provided in 
Chapter 3. For definitive information on developing the OPLAN/OPORD, see FM 101-5. 

2-4. Responsibilities and Functions of the Brigade Surgeon's Section 

a. The BSS is assigned to the HHC of the brigade and operates out of the brigade TOC. The 
section, in coordination with the HSSO of the FSB support operations section and the FSMC commander, is 
responsible for the development of the medical portion of the brigade OPLAN/OPORD and takes part in the 
brigade planning process. The BSS staff is responsible to the brigade commander for staff supervision of 
CHS within the brigade. The BSS is also responsible for coordinating GS and DS relationships of organic 
medical units and medical units/elements whether under OPCON or attached to the brigade. The brigade 
commander is updated as required on the status of CHS in the brigade. 



b. Figure 2-1 shows the typical organization and staffing of the BSS. 
plans and operations cell and a patient disposition and reports cell. 



It consists of a medical 



BRIGADE 

SURGEON'S 

SECTION 



MED PLANS/ 
OPS CELL 



PNT DISP 
RPTS CELL 



Figure 2-1. Brigade surgeon 's section. 



2-3 



FM 4-02.21 



The staff of the BSS assists the brigade surgeon in planning and conducting brigade CHS operations. 
Specific functions of the BSS include— 

• Planning and ensuring that Echelons I and II CHS for the brigade are provided in a 
timely and efficient manner. 

• Planning and coordinating CHS operations for brigade medical assets, attached, or 
OPCON corps assets. This includes reinforcement and reconstitution. 

• Coordinating with the DISCOM support operations section, the DISCOM medical 
operations branch, and the FSB support operations CHS cell (HSSO) for prioritizing the reallocation of 
organic and corps medical augmentation assets as required by the tactical situation. 

• Ensuring that the medical annex of the brigade TSOPs, plans, policies, and procedures 
for CHS, prescribed by the brigade surgeon, are prepared and executed. 

• Overseeing medical training and providing information to the brigade surgeon and brigade 
commander. 

• Coordinating and prioritizing CHL and blood management requirements for the brigade. 

• Collecting medical threat information and coordinating combat health intelligence 
requirements with the brigade S2 according to FM 8-10-8. 

• Coordinating and directing patient evacuation from forward areas to supporting MTFs. 

• Coordinating the MEDEVAC of all EPW casualties from the brigade AO. 

• Coordinating the disposition of captured medical materiel. 

• Coordinating, planning, and prioritizing PVNTMED missions. 

• Coordinating with the supporting veterinary element for subsistence and animal disease 
surveillance. 

2-5. Medical Plans and Operations Cell 

The medical plans and operations cell is typically staffed with a— 

• Medical plans officer. 

• Medical operations sergeant. 

• Medical operations/intelligence NCO. 

2-4 



FM 4-02.21 



This cell is responsible for— 

• Developing CHS staff estimates for supporting brigade operations. 

• Developing and coordinating the medical brigade CHS plan with the brigade staff, FSB, 
FSMC, and maneuver battalion medical platoons. 

• Developing the CHS annex of the brigade OPLAN/OPORD. 

• Overseeing and synchronizing brigade CHS operations. 

• Monitoring medical troop strength to determine task organization for mission accomplishment. 
Forwarding all medical information of potential intelligence value to the brigade S2 and S3 



sections. 



• Obtaining updated medical threat and intelligence information through the brigade S2 and S3 
sections and from the DSS for evaluation and applicability. 



required. 



operations. 



Coordinating the disposition of captured medical materiels according to the TSOPs. 
Coordinating through the DSS for corps medical support reinforcement/augmentation, as 

Verifying emergency supply requests and taking the necessary action to expedite delivery. 
Monitoring Class VIII resupply levels to ensure adequate stockage for support of brigade 



• Tracking and managing critical Class VIII items in coordination with the maneuver battalion 
medical platoons, FSMC, DSS and brigade surgeons. 

2-6. Patient Disposition and Reports Cell 

The patient disposition and reports cell assists the operations officer with tracking patient disposition of 
brigade personnel. This cell prepares and forwards appropriate patient statistical reports to the division 
headquarters according to the division TSOP. 

2-7. Information and Communications 

a. The Brigade Surgeon's Section Communications and Information Systems. Information and 
communications assets available to the BSS include radio sets (AN/VRC 89 series [FM]); digital nonsecure 
voice telephone (1 each); MSE FAX; TACLAN work station (WS); local area network (LAN) router; 

2-5 



FM 4-02.21 



MCS; CSSCS ; and FBCB2/position/navigation (1 each). The BSS has a CSSCS that aids the BSS with 
maintaining real-time situational awareness and understanding of what is happening on the battlefield. This 
system tracks unit information down to the company level. Included in the classes of supplies tracked by the 
CSSCS is Class VIII. Using the CSSCS to track Class VIII will enhance the BSS's ability to identify critical 
Class VIII items. The BSS will exchange information with the FSMC, the DSMC, and the DSS, using the 
CSSCS. For definitive information on the CSSCS, see FMs 63-20-1, 63-21-1, and 63-23-2. 

b. Combat Health Support Functions on Force XXI Battle Command Brigade and Below System. 
The FBCB2 is a hardware/software suite that digitizes C2 at brigade and below level. The FBCB2 system 
provides a seamless battle command capability for performance of missions throughout the operational 
continuum at the tactical level. The FBCB2 system is the implementation of information technology to 
provide increased battlefield operational capabilities. The system is positioned on specified platforms and 
will perform combat, combat support (CS) and CSS functions for the planning and execution of operations. 
This system gives the BSS a common relevant picture of the current CHS situation at BAS, AXPs, and the 
FSMC. For the first time, the medical organizations and elements are digitally linked to the platforms and 
organizations they support. The current CSS functionality on FBCB2 gives the combatant a common 
relevant picture of the current CSS situation at his echelon of command and at subordinate levels. It also 
provides the personnel and logistics leaders CSS situational awareness and understanding throughout their 
battle space. It also provides enhanced capability to synchronize support to customer units. Combat service 
support functionally on FBCB2 includes the following: 

Logistics situation report (LOGSITREP). 

Personnel situation report (PERSITREP). 

Medical situation report. 

Situation awareness. 

Logistics call for support. 

Logistics task order. 

Currently the FBCB2 also permits information to be entered using free text such as comments and other 
pertinent CSS information. This common battle space picture will enable CHS providers to maintain the 
operational tempo set by the maneuver commander. There are three medical screens incorporated into the 
CSS applique function. They are the medical functionality in the LOGSITREP, the MEDSITREP, and the 
MEDEVAC request. It is important that units use standard message and reports formats to eliminate 
confusion. As the system is further developed and additional CHS screens are added, there will be less 
space for using free text. Figure 2-2 is the medical screen as seen on the CSS function of FBCB2. 
Descriptions of each screen are provided below. 

(1) Medical functionality in the logistics situation report. This message provides visibility of 
selected Class VIII items at the BAS and FSMC levels, date-time group (DTG) of the most recent 
report, and location of medical units. Recipients of the report are the forward support company (FSC), the 

2-6 



FM 4-02.21 



051709ZMAR99 



UNCLASSIFIED 



MAP:NI1113 



TOP PRECEDENCE MSG 



NEXT PRECEDENCE MSG 



DDDDD 
□□□□□ 



0:00:00N 



REPORTING 




REPORTING UNIT 





















CRITICAL SHORTAGES 



PERSONNEL 



EQUIPMENT 



COMMENT 



MEDICAL COMPANY SITREP 



LOCATION 


CURRENT 


NEXT ETA 


PATIENTS 


WIA 


DNBI 


DENTAL 


CBT 
STRESS 


EVAC 


RTD/ 
/HOLD 


RTD/ 
/EVAC 


rtd/ 
/evac 


RTD-/ 
/EVAC 


RTD / 

/evac 






PATIENTS 
AWAITING 
EVAC 


URGENT 


PRIORITY 


ROUTINE 


URGENT 


CLVIII 
STATUS 


RED 

<65% 


AMBER 
65-80% 


GREEN 
>80% 


AMBULANCES 


M113 


M997 


BLOOD 


UNITS ON HAND 


PATIENT 
ESTIMATE 


CURRENT 


NEXT 24 HOURS 



Figure 2-2. Sample of medical screen incorporated into the combat service support Force XXI Battle 

Command Brigade and Below function. 

FSB support operations (HSSO), the BSS, and the DSS. This report does not replace TAMMIS; however, 
it is entered into CSSCS by the BSS. 

(2) Medical situation report. The FSMC and BAS prepare and submit this report. The 
recipients of the report are maneuver commanders and their SI, the FSCs, the FSB support operations 
(HSSO), the FSMC, the BSS, and the DSS. The BSS and FSMC receive roll up from the BAS. The DSS 
receives a roll up of the FSMC reports. Adjacent units can receive information copies of the MEDSITREP. 
This message reports the following information: 

(a) Current location and proposed next location with estimated time of arrival (ETA). 

(b) Number of patients seen and classified as wounded in action (WIA), DNBI, dental, 
and combat stress. The field will also show the number of patients evacuated and the number returned to 
duty (RTD). 



2-7 



FM 4-02.21 



(c) Patient(s) awaiting MEDEV AC. 

(d) The Class VIII status of the element/unit, the number of ambulances that are 
mission capable, and the number of units of blood and type on hand. 

(e) Free text field for critical Class VIII or other supply shortages and commander's 
comments. 

(3) Medical evacuation request. This request is currently embedded into the FBCB2 and is a 
digitized standard 9-line MEDEV AC request. The current messaging is from the requestor to the medical 
platoon leader (with an information copy to the maneuver battalion commander). The medical platoon 
leader either responds or forwards the request to the FSMC commander who dispatches the appropriate 
MEDEV AC asset. Information copies of all MEDEV AC requests are sent to the BSS so they can maintain 
real-time situation awareness on the volume of requests. The FSMC commander sends an information copy 
to the BSS with after-action information that includes destination of evacuated patient(s). 

c. Radio Nets. Radio nets used by the BSS include— 

(1) The division logistics operations net (AM-SSB), which is controlled by the DISCOM S2/ 
S3 support operations section. The net provides the necessary long-range C2 link between the DISCOM, 
the FSBs, the DSB, and the DMMC. 

(2) The BSS maintains communication with medical elements supporting the brigade through 
its FM medical net. Single-channel ground and airborne radio system components provide the BSS with an 
AN/VRC 89 series (FM) which has a receiver/transmitter (R/T) capable of using two FM nets for reception 
and transmission. This permits the BSS to communicate with CHS elements via the administrative/logistic 
net (FM). The AN/VRC-89 series has two R/Ts (and one power amplifier). The two R/Ts allow the BSS to 
participate in two FM nets. These nets include the brigade administrative/logistics net and one of the three 
medical platoons operations nets. The BSS also communicates using AM-IHFR with its AN/GRC 213 
or AN/GRC 193 A radio. Another technique is to use the FSMC command net for brigadewide medical 
communications while using the administrative/logistics net for other CSS integration. Situation awareness 
is monitored using FBCB2 and by face-to-face contact with other brigade staff members in the brigade 
TOC. 

d. Mobile Subscriber Equipment. Mobile subscriber equipment will allow the BSS to com- 
municate throughout the battlefield in either a mobile or static situation. As the Army continues to digitize 
the battlefield and modernize the force, the use of automation continues to develop. Mobile subscriber 
equipment packet switching network gives units the ability to connect to division and corps LANs or wide 
area network (WAN). A WAN is similar to the LAN but covers a larger distance. This allows units/CPs to 
connect computer systems such as the CSSCS, MCS, and FBCB2 to an ethernet cable (coaxial) and send 
and receive information in an extremely efficient manner. Because of the limitations of a network 
constructed with coaxial cable, a WAN uses a combination of the MSE packet switch network and radio 
networks to distribute the data where necessary through the system. Packet switching does not use or take 
up existing telephone lines. Instead, telephone lines are freed up even more because information is being 
sent over a network on computers and related equipment. Using the common hardware/software facilitates 

2-8 



FM 4-02.21 



the interface and exchange of information between the BSS, medical platoons operating BAS, FSMCs, 
DSS, corps, and division medical elements. See FM 63-2-2 for information concerning ADP continuity of 
the operations plan. 

e. Combat Service Support Control System. The CSSCS is the CSS component of ABCS. This 
is the primary CSS information tool used within the DISCOM. The CSSCS provides a concise picture of 
unit requirements and support capabilities by collecting, processing, and displaying information on key 
items of supplies, services, and personnel that the commanders deem crucial to the success of an operation. 
The CSSCS does not duplicate Standard Army Management Information System (STAMIS) functions. The 
management of all items within a class of supply or support functions remains STAMIS functions. Items 
tracked in CSSCS represent a small, but critical portion of the items managed by STAMIS. The CSSCS 
also supports the decision-making process with course of action (CO A) analysis. Staffs can analyze up to 
three COA for a 4-day period. Variables include combat intensity, combat posture, unit task organization, 
miles traveled, and geographical region. This system maintains a database of unit personnel and equipment 
authorizations by standard requirements code (SRC) (similar to table of organization and equipment [TOE]) 
and unit and equipment planning factors. It includes a database of equipment and personnel called a 
baseline resource item list (BRIL). The items that a commander identifies as critical to the operation can be 
selected from the BRIL to establish the CTIL. The CSSCS currently provides situation awareness of critical 
elements within supply Classes I, II/IV, IIIB, HIP, V, VII, and VIII, and personnel strength management. 
Maintenance, transportation, and medical functionality are a few features to be added as the system 
matures. 

(1) Data collection on the combat service support control system. Unit supply status and 
requirements can be entered manually using standard input forms (screens) at the brigade S4, DSB, DASB, 
or FSB CSSCS terminal. Electronic interfaces to systems such as the FBCB2 will greatly enhance the entry 
of unit data. The CSSCS tracks unit information down to the company level. Battle loss spot reports can be 
inputted to the CSSCS node at any level (brigade, division, or corps). Information is entered either 
manually, as in the case of Class III, or by electronic transfer as when a STAMIS disk is downloaded into 
the CSSCS terminal. The CSSCS automatically updates the database. The data is then distributed to other 
CSSCS nodes. The primary means of communication is MSE. The CSSCS nodes then manipulate the data 
through a series of algorithms that are based on Army planning factors, the specified task organization, and 
the established support relationships. This way, large quantities of data are presented in comprehensive, but 
usable, decision support information formats. This information is graphically portrayed to the commander 
through green, amber, red, and black bubble charts; situational awareness; subordinate unit locations; and 
supply point status. Status can be projected out to 4 days using a combination of planning factors and 
manually generated estimates. The commander and his staff can further evaluate simplified color status by 
accessing more detailed numerical data that supports the color status displayed. At the divisional brigade 
level, two CSSCS devices (or nodes) will exist. One is located in the brigade SI and S4 operational facility 
and the other in the FSB support operations section. The brigade node is the point of entry into the CSSCS 
for all organizational-level CSS status and requirements of the brigade and its subordinate units. The 
brigade S1/S4 can also view the status of its supporting FSB/DASB and higher echelon supply points. 
Through interfaces to the other Army Tactical Command and Control System (ATCCS), a CSSCS node 
provides the brigade S1/S4 with the battlefield common picture. The FSB, DASB, and DSB CSSCS node 
serves as the entry point for some supply point data that is not supported by a STAMIS and all organizational 
status of their elements. The FSB, DASB, and DSB use CSSCS to— 

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FM 4-02.21 



• Track and anticipate customer logistic status and requirements. 

• Track supply point status, issues, receipts, and due-ins of CTIL items. 

(2) Combat service support control system interfaces. All CSSCS nodes will be able to 
interface with all other CSSCS devices and are also able to interface with other ATCCS such as air missile 
defense workstations (AMDWS), MCS, all source analysis system, and Advanced Field Artillery Tactical 
Data System (AFATDS). The CSSCS connects to the FBCB2 at the brigade S1/S4 level. The FBCB2 will 
serve as a data source for CSSCS by passing aggregate data (MEDSITREP, LOGSITREP, and PERSITREP) 
that has been rolled up from squad/section, platoon, company, and battalion. The LOGSITREP includes 
roll-ups of Classes I, HIP, IIIB, IV, V, VII, and VIII. Class VII data also includes nonmission capable 
information. The CSSCS consolidates battalion data selected by the commander on the CTIL, up to 120 
items. The CSSCS reports to higher headquarters and then provides the lower echelons with the location of 
supply points via FBCB2. Force XXI Battle Command Brigade and Below transmits personnel strength 
information by officer/warrant officer/enlisted through the PERSITREP. This information is rolled up from 
platform through battalion to brigade SI where it is entered directly into CSSCS or the Army XXI manning 
system resident on the CSSCS. The CSSCS uses this information to update its database on those personnel 
categories listed on the CTIL. The CSSCS updates supply point locations whenever supply points moves an 
electronic map overlay format and passes it down to platform level via FBCB2. 

2-8. Medical Standard Army Management Information System 

The MC4 system will be a theater automated CHS system, which links commanders, health care providers, 
and supporting elements, at all echelons, with integrated medical information. The system provides digital 
enablers to connect, both vertically and horizontally, all ten CHS functional business systems. The MC4 
system receives, stores, processes, transmits, and reports medical C2, medical surveillance, casualty 
movement/tracking, medical treatment, medical situational awareness, and MED LOG data across all levels 
of care. This will be achieved through the integration of a suite of medical information systems linked 
through the Army data telecommunications architecture. The MC4 system begins with the individual 
soldier and continues throughout the health care continuum. The best way to visualize the MC4 system 
capability is as a piece of the Army digital computer network where all ten CHS functional areas have been 
digitized and the CHS information made available to specified commands, supported units, and their 
personnel. Not only will the MC4 system provide the Army commanders with CHS information, but will 
provide him with a seamless transition to the joint CHS environment. 

a. Components of Medical Communications for Combat Casualty Care System. The MC4 system 
will consist of three basic components: software, hardware, and telecommunications capabilities. 

(1) Software capability. 

(a) The joint TMIP will provide government off-the-shelf (GOTS)/commercial off-the- 
shelf (COTS) software and interoperability standards to support joint theater operations. The software 
provides an integrated medical information capability that will support all levels of care in a TO with links 
to the sustaining base. Medical capabilities provided by the software to support commanders in the theater 

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FM 4-02.21 



will address medical C2 (including medical capability assessment, sustainability analysis, and medical 
intelligence); MED LOG (including blood product management and medical maintenance management); 
casualty evacuation; and health care delivery. 

(b) The MC4 system will support Army-unique requirements and any software needed 
to interface with Army information systems such as CSSCS, Global Command and Control System-Army 
(GCCS-A), FBCB2, Warrior Programs, and the MTS. 

(2) Hardware capability. The hardware capability will consist of COTS automation 
equipment supporting the above software capabilities. Examples include, but are not limited to, computers, 
printers, networking devices, and the personal information carrier (PIC). 

(3) Telecommunications capability. The MC4 capability will rely on current and proposed 
Army solutions for tactical, operational, and strategic telecommunications systems to transmit and receive 
digitized medical information throughout the theater and back to the sustaining base. There will be no 
separate AMEDD communication system. Telecommunications at brigade and below will be accomplished 
through the tactical internet; above brigade level, telecommunications will be accomplished through the 
warfighter information network (WIN) architecture. The MC4 system will include hardware or software 
required to interface with current and emerging technologies supporting manual, wired, and wireless data 
transmission. At end-state, the MC4 system users will exchange data electronically via the WIN architecture. 
In the interim, commercial satellite and/or high-frequency radios will be fielded to selected medical units 
(for example, medical detachment-telemedicine [MDT]) receiving the MC4 system to support high band- 
width requirements until the WIN architecture is fully fielded. Personnel operating satellite assets are 
resourced in the MDT TOE and will be located with the MDT. 

b. Patient Treatment Recording System. Under the MC4 system, medical information about each 
soldier will be entered into a local database maintained at the supporting BAS or troop medical clinic. This 
information will include the soldier's immunization status, medical deployability status, and dental 
deployability status. A commander, faced with a deployment, will be able to simply query the database to 
gain the deployability status of the entire command. Time previously spent on physically searching paper 
records will be available for other tasks. Under the MC4 system each soldier will be issued a PIC. The 
PIC is an electronic device that will store personal information about the individual soldier. The PIC 
specifications are addressed in a separate DOD requirements document, which incorporates Army 
operational requirements into this standard joint device. The PIC will be used to record all of the soldier's 
health care events and the soldier's readiness status. Each time a soldier receives medical care or 
immunizations, the medical history on the PIC will be updated. When a soldier is deployed, his PIC will 
contain baseline clinical data. During processing for deployment, the medical staff will be able to read all 
immunizations, medical and dental patient history data directly from the PIC, speeding up the process. Once 
in an operational theater, the soldier's PIC will continue to provide a backup record of all medical events 
that occur during the deployment. Any medical data generated by a medical event will be entered onto the 
PIC as well as being entered into the MC4 information system. The preservation of medical data will no 
longer rely on safeguarding and transporting stacks of paper records. 



2-11 



FM 4-02.21 

CHAPTER 3 

DIVISION AND BRIGADE COMBAT HEALTH 
SUPPORT OPERATIONS 

Section I. PLANNING COMBAT HEALTH SUPPORT FOR 
DIVISION AND BRIGADE OPERATIONS 

3-1. Division Combat Health Support Planning 

a. Division CHS operations involve all of the factors that must be considered in the initial 
developmental stages of the division CHS plan. The CHS plan is updated to meet tactical or CHS 
operations requirements. The following factors should be considered: 

• Information requirements (current task organization structure, medical troop strengths, 
projected weather and environmental factors, and maintenance status of medical equipment). 

• Results of the mission analysis. 

• Commander's intent. 

• Planning guidance. 

• Courses of actions. 

• Tactical plan. 

• Enemy. 

• Terrain. 

• Troops. 

• Weather. 

• Threat (including medical threat). 

• Operational conditions and constraints. 

• Military population supported. 

• Civilian populace in the AO. 

• Medical personnel status. 

• Equipment status of medical units and elements. 

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FM 4-02.21 



Supply status including Class VIII. 

Wartime HN support. 

Indigenous medical services. 

Communications capability. 

Nuclear, biological, and chemical defense including OEG. 

Nuclear, biological, and chemical casualty considerations. 

Training status. 

Casualty estimates. 

Medical evacuation requirements and capabilities. 

Corps CHS status. 

Nonmedical support requirements from division. 

Area support requirements. 

Special operations support requirements. 

Army airspace command and control. 

Medical records and reports requirements. 

Phases of operations. 

Allied/coalition health assets requirements. 

Policy and procedure updates. 

b. The division CHS plan is developed by the DSS staff with assistance from the DISCOM 
medical staff. See FMs 8-10, 8-10-6, 8-10-8, 8-10-9, 8-42, 8-55, 63-2-2, 63-20-1, 63-21-1, 63-23-2, 100-5 
and 101-5 for doctrinal guidance on CHS operations. After the CHS plan is completed, it is incorporated 
into the CSS plan. After the CSS and other areas of the division plan are approved by the division 
commander, it is incorporated into the division OPORD. 



3-2. Division Operation Plan and Operation Order 

The G3 section, using input from each of the staff elements of the division headquarters, develops the 
division OPLAN and OPORD. 



3-2 



FM 4-02.21 



NOTE 

An approved plan becomes an order. 

a. The division surgeon is responsible for supervision and development of CHS input for the 
division OPORD. The division CHS plan serves as the base document for this input. The division CHS 
plan is revised or updated based on mission analysis or changes in CHS requirements. The division surgeon 
is tasked by the G3 for CHS input to the division OPORD for support of division operations. The G3 
indicates time-line requirements. The division surgeon is involved in all stages of the planning process. He 
and his staff participate in all phases of the planning process. This allows them to identify all CHS 
requirements. Information for development of staff estimates and the OPLAN /OPORD are discussed 
below. 

b. The medical plan/operations cell develops a CHS plan based on guidance received from the 
division commander and the division surgeon. The DSS provides CHS operational planning updates to the 
division surgeon. The CHS plan is briefed to the division commander for approval, as required. The CHS 
plan is provided to the G3 according to the format of the CHS outline in FM 8-55. 

c. The DSS has a primary responsibility for the coordination of division and corps medical assets 
in support of the division. Supporting medical elements should be pre-positioned according to the CHS plan 
and anticipated requirements. Division and corps evacuation assets should be task-organized to support the 
area of greatest casualty density. All supporting medical elements should be issued the maximum allowable 
levels of Class VIII and other required supplies. The DSS must establish and maintain continuous 
communications with the DISCOM medical operations branch and the BSS. The DISCOM medical 
operations branch and the BSS maintain continuous communication with the DSB and FSB HSSOs. The 
medical plan/operations cell maintains a situational map that includes overlays with friendly, as well as 
threat information. The cell should use charts to monitor functional areas. Subject areas that could enhance 
situational awareness or mission areas that are critical to CHS operations should be tracked. In digitized 
units, situational awareness will be maintained using the CSSCS modules for locations of friendly units, 
corps ground and air ambulance assets, and all other areas listed below which are normally maintained on a 
situational map. For digitized units the traditional situational map is only maintained as a back up to the 
ATCCS and programs. The subject areas that are to be tracked should be identified by the division surgeon 
and/or the chief medical planner and may include— 

• Corps ground and air ambulance assets. 

• Army airspace command and control overlays. 



• 



Threat picture (includes tracking reports and posting updates so that the threat is portrayed 



on the situational map). 

• Current routes and their status. 

• Maintenance status of evacuation platforms. 



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FM 4-02.21 



• Status of units operating in high-risk environments or with threat/enemy contact. 

• Division to corps evacuation schedule and evacuation delays. 

• Supply status including critical Class VIII shortages. 

• Critical medical personnel and equipment shortages. 

• Pending resupply missions from corps. 

• Medical maintenance backlog. 

• Patient status board (for example, awaiting evacuation from division to corps). 

• Hospitals supporting the division with latest bed spaces available, additional/shortages of 
specialties, and locations (this is a division-level requirement, except for some stability operations or 
support operations). 

• Blood status. 

• Dirty routes and patient decontamination sites. 

• Brigade operations and CSS overlays. 

3-3. Brigade Combat Health Support Planning 

Brigade CHS planning is accomplished based on the same factors found in division CHS planning. The 
brigade surgeon is responsible for development of the brigade CHS plan. He tasks the BSS with development 
of the brigade CHS plan. The brigade plan/operations cell has the primary responsible for developing and 
coordinating the brigade CHS plan. The foundation of the brigade CHS plan is the brigade commander's 
guidance and the division CHS plan. 



3-4. Brigade Operation Plan and Operation Order 

Planning starts with mission analysis. The brigade begins mission analysis when the division provides 
enough information for the brigade staff to analyze. Mission analysis is done by the entire brigade staff and 
is an integral part of the planning for an operation. Information that the brigade staff analyzes will normally 
be provided with a well-written warning order (WARNO) or after receiving several WARNOs from the 
division. The first WARNO from the brigade should be issued as soon as possible after receiving the 
division WARNO for a new operation. The mission analysis (see Table 3-1) is Step 1 of the military 
decision-making process (MDMP). See FM 101-5 for further discussion on the MDMP. For guidance on 
military decision making in abbreviated planning for a time-constrained situation, see Center for Army 

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FM 4-02.21 



Lessons Learned Newsletter, Number 99-12 Update, located at http://call.army.mil/call/liomepage/ 
newsltr.htm. The BSS must ensure all available CHS information is included in the brigade WARNO. The 
BSS could also forward additional coordinating instructions down to the medical platoon level. These 
coordinating instructions are normally transmitted in a force text E-mail message via the TACLAN. As part 
of the mission analysis and based on the brigade commander's intent and guidance, the BSS develops CHS 
staff estimates for supporting brigade operations. An understanding of the brigade combat teams (BCT) 
time lines or battle rhythm will assist the medical planner in developing the CHS input to the brigade 
OPLAN/OPORD. Bear in mind that parallel planning is occurring at different levels of command; for 
example, the brigade WARNO allows the subordinate unit to begin their planning process, allowing 
maximum use of the available time for planning. Timely WARNOs are the key to effective parallel 
planning. When decisions are made or pertinent information becomes available, the brigade staff issues 
WARNOs as a part of the planning process. See Chapter 5 and Appendix H of FM 101-5 for additional 
information on WARNOs. Mission analysis includes— 

• Assessing CHS capabilities (organic and attached assets with current status and location). 

• Assessing limitations for CHS assets that are not available, specify reason. 

• Identifying specified, implied, and essential CHS tasks in the division OPORD. 
The following is an example of subject areas that should be addressed during mission analysis: 

• Treatment (to include surgical requirements). 

• Emergency and sustaining dental treatment. 

• Patient holding. 

• Combat stress control. 

• Preventive medicine. 



• 



Medical evacuation support by air and ground ambulances (and nonmedical evacuation 



platforms, if necessary). 

• Class VIII resupply and blood support. 

• Medical maintenance. 

• Nuclear, biological, and chemical operations. 

• The threat to treatment and evacuation assets capable of causing CHS failure. 

• Likely targeted area of threat chemical weapons strike and types of agents (the S2 and the 
chemical officer should brief the BSS on the effects possible requirement). 

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FM 4-02.21 



• Casualty estimates (number and types of casualties). 

• Terrain effects on evacuation. 

• Current medical status of brigade personnel. 

Table 3-1. Mission Analysis of the Situation 



1. MISSION ANALYSIS 

A. MISSION AND INTENT OF COMMANDER TWO LEVELS UP. 

B. MISSION AND INTENT OF IMMEDIATE COMMANDER. 
C ASSIGNED TASKS (SPECIFIED AND IMPLIED). 

D. CONSTRAINTS AND LIMITATIONS. 

E. MISSION-ESSENTIAL TASKS. 

F. RESTATED MISSION. 

G. TENTATIVE TIME SCHEDULE. 

2. ESTIMATE THE SITUATION AND DETERMINE COURSES OF ACTION 

A. TERRAIN AND WEATHER. 

(1) TERRAIN— OBSERVATION AND FIELDS OF FIRE, CONCEALMENT AND COVER, OBSTACLES, KEY 
TERRAIN, AND AVENUES OF APPROACH (OCOKA). 

(2) WEATHER— VISIBILITY, MOBILITY, SURVIVABILITY. 

B. ENEMY SITUATION AND COA. 

(1) COMPOSITION. 

(2) DISPOSITION. 

(3) RECENT ACTIVITIES. 

(4) CAPABILITIES. 

(5) WEAKNESS. 

(6) MOST PROBABLE COA (ENEMY USE OF METT-TC) 

(7) MOST DANGEROUS COA. 

C. FRIENDLY SITUATION— METT-TC. 

D. FRIENDLY COA. DEVELOP A MINIMUM OF TWO. 

3. ANALYSIS OF COURSES OF ACTION 

A. SIGNIFICANT FACTORS. 

B. WARGAME. 

4. COMPARISON OF COURSES OF ACTION. 

5. DECISION. 



a. The restated mission (Step F of mission analysis) goes directly into paragraph 2 of the brigade 
OPORD after approved by the commander (S3 responsibility). 

b. Brigade COA development/analysis and wargaming are accomplished after mission analysis. 
Course of action development and wargaming result in the production of the OPORD and the CHS annex. 
During wargaming, the evacuation and treatment facets of the medical plan are synchronized with the 
maneuver plan. Also, during wargaming, the questions of how many casualties; at what point in the fight 



3-6 



FM 4-02.21 



(when); where they will occur; and how they are produced (direct fire, artillery, chemical, and so forth) can 
be forecasted based on input from the SI. This information allows the CHS planner options to select 
preplanned locations. It also provides the triggers that will allow medical elements to occupy these 
positions at appropriate times and in a manner that reduces the risk from threat actions. This information 
becomes the CHS plan and is published in the brigade order. The following is an example of key areas that 
will be analyzed during this process; they include— 

• Casualty estimates broken down to the lowest level possible, by task force, by phase line, 
and so forth. 

• Task organizations established (attachment/ detachment or OPCON relationships in 
division order). Do they adequately support the brigade mission? If not, recommend changes to the 
brigade commander. 

• Division-directed actions as part of the division CHS plan. 

• Current CHS unit status (maintenance status on all brigade key items of equipment, both 
medical and nonmedical, and recommendations of the BSS). 

c. Once the task force or maneuver battalions receive the brigade WARNO, they conduct mission 
analysis and determine their tactical plan. Part of determining their plan is the emplacement of medical 
treatment elements (BAS or treatment teams). This information is provided to the medical plan/operations 
officer in the BSS, so he can review the plans from the brigade-level perspective. Time permitting, the BSS 
plan/operations officer, the FSMC commander, and the HSSO should meet with the medical platoon leaders 
to synchronize the brigade plan prior to the brigade combined arms rehearsal. Provided below in Table 3-2 
is an example of an OPORD format. When the commander approves the OPLAN, it becomes the OPORD. 
The BSS staff is responsible to the brigade commander for staff supervision of CHS within the brigade. The 
BSS is also responsible for coordinating DS relationships of organic medical units and medical elements 
OPCON or attached to the brigade. The brigade commander is updated as required on the status of CHS in 
the brigade. The brigade OPLAN and OPORD are developed by the S3 section using input from each of 
the staff elements of the brigade headquarters. The brigade CHS plan is revised or updated based on 
mission analysis or changes in CHS requirements. 

d. The BSS has a primary responsibility for the coordination of corps medical assets in support of 
the brigade, both OPCON and attached, and for supporting corps MEDEVAC assets positioned forward in 
the brigade AO. Brigade and corps evacuation assets should be task-organized to support the area of 
greatest casualty density. All supporting medical elements should be issued the maximum allowable levels 
of Class VIII and other required supplies. The BSS must establish and maintain continuous communications 
with the HSSO, the FSMC commander, and the DSS. The medical plan/operations cell maintains a 
situational map and should use charts to monitor functional areas that will include— 

• Units in contact or in high-risk environments. 

• Threat situation. 

3-7 



FM 4-02.21 

Table 3-2. Operation Order or Plan Outline Format 

REFERENCES: 

TIME ZONE USED THROUGHOUT THE PLAN (ORDER): 

TASK ORGANIZATION: 

1. SITUATION. 

A. ENEMY FORCE 

B. FRIENDLY FORCE 

C. ATTACHMENT AND DETACHMENTS 

D. ASSUMPTION (OPLAN ONLY) 

2. MISSION. 

3. EXECUTION. 
INTENT: 

A. CONCEPT OF OPERATION 

(1) MANEUVERS 

(2) FIRES 

(3) RECONNAISSANCE AND SURVEILLANCE 

(4) INTELLIGENCE 

(5) ENGINEER 

(6) AIR DEFENSE 

(7) INFORMATION OPERATIONS 

B. TASKTO MANEUVER UNITS 

(1) ENGINEER 

(2) AIR DEFENSE 

(3) FIELD ARTILLERY 

C. TASKS TO COMBAT SUPPORT UNITS 

(1) INTELLIGENCE 

(2) FIRE SUPPORT 

(3) SIGNAL 

(4) NBC 

(5) PROVOST MARSHAL 

(6) PSYCHOLOGICAL OPERATIONS 

(7) CIVIL MILITARY 

(8) AS REQUIRED 

D. COORDINATING INSTRUCTIONS 

(1) TIME OR CONDITION WHEN A PLAN OR ORDER BECOMES EFFECTIVE 

(2) COMMANDER'S CRITICAL INFORMATION 

(3) RISK REDUCTION CONTROL MEASURES 

(4) RULES OF ENGAGEMENT 

(5) ENVIRONMENTAL CONSIDERATIONS 

(6) FORCE PROTECTION, AS REQUIRED 

(7) AS REQUIRED 

4. SERVICE SUPPORT. 

A. SUPPORT CONCEPT 

B. MATERIEL AND SERVICE 

C. MEDICAL EVACUATION AND HOSPITALIZATION 

D. PERSONNEL 

E. CIVIL MILITARY, AS REQUIRED 

F. AS REQUIRED 

5. COMMAND AND SIGNAL. 

A. COMMAND 

B. SIGNAL 

ACKNOWLEDGE: 

NAME (COMMANDER'S LAST NAME) 

RANK (COMMANDER'S RANK) 

OFFICIAL: NAME AND POSITION 

ANNEXES: 



(CLASSIFICATION) 
SEE FM 101-5 FOR DEFINITIVE INFORMATION ON OPERATION PLANS/ORDERS. 



3-8 



FM 4-02.21 



Evacuation routes and/or main supply route status. 

Supporting corps ground and air ambulance assets. 

Army airspace command and control overlays. 

Status of evacuation platforms (all assets under the brigade's control). 

Supply status, to include critical Class VIII shortages. 

Pending resupply missions from corps. 

Critical medical personnel and equipment shortages. 

Medical maintenance backlog. 

Patient status board (for example, awaiting evacuation). 

Blood status. 

Dirty routes/patient decontamination sites. 

Location of BAS (current/projected). 

Area medical support responsibilities. 



3-5. 



Rehearsal 



Developing a good brigade CHS plan is not an easy process. It requires a major coordinated effort with 
sound preparation, discipline, and significant amounts of the precious commodity— leader time. Properly 
rehearsing the plan is a critical step in achieving synchronized execution with the brigade commander's 
plan. The brigade rehearsal provides an excellent opportunity to practice C2 and integrate the CHS 
operations. For successful implementation of the CHS annex of the brigade plan, the CHS plan must be 
coordinated and synchronized with the maneuver plan so that CHS requirements are met. The BSS 
provides coordinating instruction to the brigade medical elements as the plan is developed. This permits 
informed development and affords the time to better develop the initial plans. To achieve optimal 
synchronization, the CHS plan is rehearsed as an integral part of the combined arms plan at the combined 
arms rehearsal. The CHS rehearsal by itself as a technique will increase understanding and synchronization, 
but is not as effective as when it is integrated into the combined arms rehearsal. The rehearsal of the CHS 
plan will allow subordinate medical elements and leaders to analyze the tactical CHS plan to ascertain its 
feasibility, its common sense, and the adequacy of its C2 measures prior to execution. 

a. Medical platoon leaders of the maneuver battalions also provide input to the task force CHS plan. 
In the digitized brigade, the BSS develops the concept for the CHS plan. During the decision-making/ 



3-9 



FM 4-02.21 



orders process, the CHS planners identify critical events and synchronize their plans. In addition to medical 
locations on the CSS overlay, these plans indicate the triggers for CHS events. At the brigade rehearsal, the 
brigade leaders practice their synchronized plans that include CHS. The sequence of events for the CHS 
portion of the brigade rehearsal includes— 

• The FSMC commander and ambulance platoon leader practicing execution of triggers 
for AXP movement. 

• The FSMC commanders detailing the concept and procedures for MEDEVAC (both 
ground and air ambulances) in the brigade. 

• The battalion/task force executive officer (XO) or S4 explains triggers for BAS and 
combat trains command post (CTCP) movement and ensures that brigade level and adjacent units understand 
their internal plan. 

The BCT medical elements with area support missions indicate which units are supported and the areas they 
cover. They will also provide projected triggers and times they will be at projected locations. 

b. The CSS/CHS annex of the brigade OPORD that includes map overlays is the culmination of 
the medical planning efforts and the CHS rehearsal is the culmination of the preparation phase for an 
operation. In the digitized division, the brigade medical planner has the responsibility for rehearsing CHS 
operations. Rehearsals are done to achieve a common understanding and a picture of how the plan will be 
implemented. 

• All plans must be complete prior to the CHS rehearsal. 

• The brigade OPORD is then issued through effective troop leading procedures. 

• The CHS rehearsals should focus on the events that are critical to mission accomplish- 
ment. A successful rehearsal ensures explicit understanding by subordinate medical leaders of their 
individual missions, how their missions relate to each other, and how each mission relates to the maneuver 
commander's plan. It is important for all medical echelons to see the total CHS concept. 

• Rehearsing key CHS actions allows participants to become familiar with the operation 
and to visualize the "triggers" which identify the circumstances and timing for friendly actions. This visual 
impression helps them understand both their environment and their relationship to other units during the 
operation. The repetition of critical medical tasks during the rehearsal helps leaders remember the sequence 
of key actions within the operation and when they are executed. 

NOTE 

To achieve the last two bullets above, the CHS rehearsal needs to be a 
part of the Brigade combined arms rehearsal along with all the 
battlefield operating systems. It is just as important for the supported 
units to understand the CHS plan as it is for the medical unit to 
understand the maneuver plan. 

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FM 4-02.21 



c. Planning and rehearsing CSS is the responsibility of the brigade S4. His responsibilities 
include— 

• Deciding what events must be rehearsed in coordination with the medical planner and/or 
brigade surgeon. 

• Determining all the CHS activities on the CSS synchronization matrix to be rehearsed. 

• Focusing on key events that must be carried out from just prior to line of departure (LD) 
time, through reorganization and consolidation. 

• Deciding on the participants and observers for the rehearsal. 

• Participants providing information or performing actions that cause triggered events to 
occur. Observers do not have a direct impact on triggered events, but gather information and answer 
questions as required. 

• The FSB support operations officer representing CSS elements of the FSB along with 
FSB company commanders. The CHS activities may include the brigade surgeon, the brigade medical 
planner, the FSB HSSO, and the FSMC commander, his ambulance and treatment platoon leaders, and the 
forward support MEDEVAC team (FSMT). 

NOTE 

As many executors of the plan as possible should be included in the 
rehearsal. The FSMC commander and the ambulance platoon leader 
as a minimum are participants for the FSB. The task force medical 
platoon leaders should also be active participants. 

• All task force medical platoon leaders participating. The reserve task force will rehearse 
the conditions under which the commander expects to employ them; this medical platoon leader should 
participate as well. If the medical platoon leader cannot participate, the medical platoon sergeant should 
represent that task force. 

• Allow adequate time between the end of planning and the beginning of the CHS rehearsal 
for subordinates to develop their plans and synchronize them with the brigade (this is normally accomplished 
using the % — 2 h rule). 

• Holding the CHS rehearsal on the same terrain model as the combined arms rehearsal. 
(Ideally it should be part of the combined arms rehearsal.) 

The BSS must inform all CHS personnel about the CHS rehearsal. This may be SOP or issued as part of the 
CHS annex in the brigade order. If not, then send a fragmentary order to all medical elements with time, 
place, and required participants. 

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Section II. CONDUCTING COMBAT HEALTH SUPPORT 
FOR MILITARY ACTIONS 



3-6. Force Projection 

a. The force projection process includes eight related activities. These activities include— 
mobilization; predeployment; deployment (including basing); entry (including reception, staging, onward 
movement, and integration) and force buildup; decisive operations; postconflict and postcrisis actions; 
redeployment; and demobilization. For detailed information on the force projection process, see FMs 
100-7 and 100-17. 

b. The first rule of anticipation for the staff of the BSS in a force projection era is to expect to be 
alerted and deployed. A high level of anticipation causes military forces to mentally and physically prepare 
for force projection. If the brigade has been assigned a region of focus in peacetime, planning can occur 
long before alert and deployment. Appropriate actions include ordering and posting maps, studying 
available infrastructures, familiarizing soldiers with language, training soldiers for deployment, and 
sensitizing soldiers to a particular culture. Key to successful anticipation is continuous force tracking, total 
asset visibility during deployment, and continuous intelligence preparation of the battlefield (IPB) of the 
contingency area. 

c. Many of the missions assigned to US Army forces will be received as short-notice deployments 
(such as deployments in support of contingency operations). The advance preparation time will be limited. 
Normally, due to the sensitivity of the operations security (OPSEC) level of the operation, the number of 
individuals that engaged in the planning process could be restricted. It is, therefore, necessary that the BSS 
ensure that the medical platoons organic to the brigade's maneuver battalion are administratively ready for 
short-notice deployment. For definitive information on the CHS aspects of short-notice deployments for 
stability operations and support operations, see FMs 8-42 and 100-5. 



3-7. Combat Health Support for the Offense and the Defense 

a. Support to the Offense. 

(1) The offense is the decisive form of war, the commander's only means of attaining a 
positive goal, or of completely destroying an enemy force (FM 100-5). Rapid movement, deep penetrations, 
aggressive action, and the ability to sustain momentum regardless of counterfires and countermeasures 
characterize the offense. 

(2) When developing the CHS plan to support the offense, the CHS planner must consider 
many factors (FM 8-55). The forms of maneuver, as well as the threat's capabilities, influence the 
character of the patient workload and its time and space distribution. The analysis of this workload 
determines the allocation of CHS resources and the location or relocation of MTFs. 

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(3) Combat health support for offensive operations must be responsive to several essential 
characteristics. As operations achieve success, the areas of casualty density move away from the supporting 
MTF. This causes the routes of MEDEVAC to lengthen. Heaviest patient workloads occur during 
disruption of the threat's main defenses, at terrain or tactical barriers, during the assault on final objectives, 
and during threat counterattacks. The accurate prediction of these workload points by the CHS planner is 
essential if MEDEVAC operations are to be successful. 

(4) As advancing combat formations extend control of the battle area, supporting medical 
elements have the opportunity to clear the battlefield. This facilitates the acquisition of the battle wounded 
and reduces the vital time elapsed between wounding and treatment. There are two basic problems 
confronting the supporting medical units and MEDEVAC elements. First, contact with the supported units 
must be maintained. Responsibility for the contact follows the normal CHS pattern— higher echelon 
evacuates from lower echelon. Contact is maintained by forward deployed air and ground evacuation 
resources. Secondly, the mobility of the MTFs supporting the combat formations must be maintained. The 
requirement for prompt MEDEVAC of patients from forward MTFs requires available ambulances to be 
echeloned well forward from the outset. Air ambulance and ground ambulance support beyond the 
capabilities of the FSMC is requested from the supporting corps MEDEVAC battalion. The requirement for 
periodic movement of large numbers of patients from divisional and corps facilities further stresses the 
MEDEVAC system. 

(5) In traditional combat operations, the major casualty area of the operation is normally the 
zone of the main attack. As the main attack accomplishes the primary task of the tactical combat force, it 
receives first priority in the allocation of combat power. The allocation of combat forces dictates roughly 
the areas that are likely to have the greatest casualty density. In the division, CHS (Echelon I) for the 
brigade is provided by the maneuver battalion medical platoons. Each platoon consists of three treatment 
teams, an ambulance section, and a combat medic's section. The medical platoon operates the BAS, places 
combat medics in DS of the maneuver companies, provides patient evacuation from forward areas, and 
deploys treatment teams in DS of the maneuver battalion elements for up to 48 hours without resupply. The 
FSMC (Echelon II) located in the BSA provides MEDEVAC support from the BAS back to the BSA and 
reinforces treatment capabilities at BASs for limited periods of time. When combat operations commence, 
the medical platoon normally locates its BAS as far forward as combat operations permit. As the battle 
moves from the original area of contact, coordinated movement of the three treatment teams are able to 
provide continuous CHS. Once patients are received, a treatment team from the BAS will care for and treat 
these patients until their MEDEVAC or appropriate disposition. The remaining teams of the BAS move 
with the battle and provide CHS to the maneuver elements according to the task force order or current 
execution conditions. If patients are received, one of the other treatment teams performs its treatment and 
evacuation mission. After MEDEVAC or appropriate disposition of their patients, the treatment team 
prepares for its next move. This "leap frog" technique provides for maximum utilization of medical platoon 
treatment teams and permits continuous uninterrupted CHS to maneuver battalions on the move. Each of 
the above actions must be coordinated with the CTCP and the supporting FSMC. 

(6) In operations that feature deep battles with weapons of mass destruction targeted at 
supporting logistical bases, mass casualty operations could be conducted in rear areas. 

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(7) Types of operations in the offense include— 

(a) Movement to contact. Medical evacuation support in movement to contact is keyed 
to the tactical plan. Prior deployment of FSMC ground ambulances with the maneuver battalion's organic 
medical platoons permits uninterrupted and effective MEDEVAC support from the BAS to the FSMC 
located in the BSA. Movement to contact operations are executed when there is little or no threat 
information. The FSMC and treatment teams from maneuver BAS in support of these operations must 
maintain their flexibility and be prepared to adjust CHS support once contact is established. 

(b) Exploitation and pursuit. Medical evacuation support of exploitation and pursuit 
operations resemble those discussed for the envelopment (paragraph 3-8a[2]). Since exploitation and 
pursuit operations can rarely be planned in detail, evacuation operations must adhere to TSOPs and 
innovative C2. These actions are often characterized by- 
Fewer casualties. 
Decentralized operations. 
Unsecured ground evacuation routes. 
Exceptionally long distances for evacuation. 
Increased reliance on convoys and air ambulances. 
More difficult communications (maximum radio range). 

(c) Deliberate attack. The deliberate attack is based on a more detailed knowledge of 
the threat disposition and likely actions. The brigade's actions in contact will be more predictable than the 
fluid situation found in the movement to contact, or exploitation and pursuit. Specific terrain and routes/ 
avenues of approach can be selected. Units can conduct at least a map reconnaissance of their planned 
locations. While there may be CHS requirements during the approach, the assault on the objective will 
produce the greatest number of casualties. Some of the CHS considerations for the deliberate attack 
include— 

• Higher percentage of casualties. 

• Casualties will be more concentrated in time and space. 

• Treatment teams moving to the objective instead of evacuating patients from 
the objective to the treatment teams once the objective is secured. 

• Use of air ambulance to overcome some obstacles may be required. 

b. Support to the Defense. There are three forms of the defense: area defense, mobile defense, 
and retrograde. The area defense concentrates on denying threat access to designated terrain for a specific 

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period of time, rather than on the outright destruction of the threat. The mobile defense focuses on denying 
the threat force by allowing him to advance to a point where he is exposed to a decisive counterattack by the 
striking force. The primary defeat mechanism, the counterattack, is supplemented by the fires of the fixing 
force. The third form of defense is the retrograde. The retrograde is an organized movement to the rear 
and away from the threat. The threat could force these operations or a commander can execute them 
voluntarily. Delay, withdrawal, and retirement are the three forms of retrograde operation. 

(1) Combat health support is generally more difficult to provide in the defense. The patient 
load reflects lower casualty rates, but threat actions and the maneuver of combat forces complicate forward 
area patient acquisition. Medical personnel are permitted much less time to reach the patient, complete vital 
EMT, and remove him from the battle site. Increased casualties among exposed medical personnel further 
reduce the medical treatment and evacuation capabilities. Heaviest patient workloads, including those 
produced by threat artillery and NBC weapons, can be expected during the preparation or initial phase of 
the threat attack and in the counterattack phase. The threat attack can disrupt ground and air routes and 
delay evacuation of patients to and from treatment elements. The depth and dispersion of the defense create 
significant time and distance problems for evacuation assets. Combat elements could be forced to withdraw 
while carrying their remaining patients to the rear. The threat exercises the initiative early in the operation, 
which could preclude accurate prediction of initial areas of casualty density. This makes the effective 
integration of air assets into the MEDEVAC plan essential. The use of air ambulances must be coordinated 
with the FSMT, normally positioned in the BSA. The utilization of corps air ambulances must be integrated 
into the CHS annex to the OPORD and also into the brigade's A2C2 annex. In addition, frequent 
coordination with the corps MEDEVAC team is essential. 

(2) The CHS requirements for retrograde operations can vary widely depending upon the 
tactical plan, the threat reaction, and the METT-TC factors. Firm rules that apply equally to all types of 
retrograde operations are not feasible, but considerations include— 

A requirement for maximum security and secrecy in movement. 

The influence of refugee movement conducted in friendly territory, which could 
impede MEDEVAC missions. 

The integration of evacuation routes and obstacle plans. 

Difficulties in controlling and coordinating movements of the force, that could 
produce lucrative targets for the threat. 

Movements at night or during periods of limited visibility. 

Time and means available to remove patients from the battlefield. In stable 
situations and in the advance, time is important only as it affects the physical well-being of the wounded. In 
retrograde operations, time is more important. As available time decreases, CHS managers at all echelons 
closely evaluate the capability to collect, treat, and evacuate all patients. 

• Medical evacuation routes required for the movement of troops and materiel. This 
causes patient evacuation in retrograde movements to be more difficult than in any other type of operation. 

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The threat could disrupt C2 and communications. Successful MEDEVAC requires including ambulances 
on the priority list for movement; providing for the transportation of the slightly wounded in cargo vehicles; 
and providing guidance to subordinate commanders defining their responsibilities in collecting and evacuating 
patients. Special emphasis must be placed on the triage of patients and consideration given to the type of 
transportation assets available for evacuation. 

• Decisions concerning patients left behind. When the patient load exceeds the 
means to move them, the tactical commander must make the decision as to whether patients are to be left 
behind. The medical staff officer keeps the tactical commander informed so that he can make timely 
decisions. Medical personnel and supplies must be left with patients who cannot be evacuated. (Refer to 
FM 8-10 for additional information.) 

3-8. Combat Health Support for Maneuver and Enabling Operations 

a. Choices of Maneuver. 

(1) Penetration. In this tactic, the attack passes through the threat's principal defensive 
position, ruptures it, and neutralizes or destroys the threat forces. Of all forms of offensive maneuver, the 
penetration of main threat defenses normally produces the heaviest patient workload. Patient acquisition 
starts slowly, but becomes more rapid as the attack progresses. The evacuation routes lengthen as the 
operation progresses. Heavy preparatory fires which can evoke heavy return fire often precede the 
penetration maneuver. These threat fires could modify the decision to place evacuation assets as far 
forward as possible. The FSMC can reinforce the penetration force medical elements. Patient evacuation 
could be slow and difficult due to bottleneck at the penetration. Medical evacuation support problems 
multiply when some combat units remain near the point of original penetration. This is done to hold or 
widen the gap in threat defenses while the bulk of tactical combat forces exploit or pursue the threat. 
Treatment elements are placed near each shoulder of the penetration; ground evacuation cannot take place 
across an avenue of heavy combat traffic. Because of the heavy traffic, the area of the penetration is 
normally a target for both conventional and NBC weapons. The trigger to push treatment team/BASs 
through the penetration and where they will go must be identified in the OPORD. 

(2) Envelopment. In the envelopment, the main or enveloping attack passes around or over 
the threat's principal defensive positions. The purpose is to seize objectives that cut the threat's escape 
routes and subject him to destruction in place from flank to rear. Since the envelopment maneuver involves 
no direct breach of the threat's principal defensive positions, the MEDEVAC system is not confronted with 
a heavy workload in the opening phase. However, ambulances are positioned well forward in all echelons 
of CHS to quickly evacuate the patients generated by suddenly occurring contact. Medical treatment 
facilities moving with their respective formations assist with clearing the battlefield to reduce delays in 
treatment. After triage and treatment, the patients are evacuated to MTFs in the rear by supporting ground 
ambulances from the FSMC. When the isolated nature of the envelopment maneuver precludes prompt 
evacuation, the patients are carried forward with the treatment element. This must be planned for in detail 
and is an extreme measure when no other option is feasible. Expect an increase in mortality from wounds. 
Again, nonmedical vehicles could be pressed into emergency use for this purpose. When patients must be 
carried forward with the enveloping forces, CHS commanders use halts at assembly areas and phase lines to 

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FM 4-02.21 



arrange combat protection for ground ambulance convoys through unsecured areas. Further, the commander 
should take advantage of friendly fires and suppression of threat air defenses to call for prearranged air 
ambulance support missions, or emergency use of medium-lift helicopter backhaul capabilities. 

(3) Infiltration. 

(a) Infiltration is a choice of maneuver used during offensive operations. The division 
can attack after infiltration or use it as a means of obtaining intelligence and harassing the threat. Though it 
is not restricted to small units or dismounted actions, the division employs these techniques with a portion of 
its units, in conjunction with offensive operations conducted by the remainder of its units. 

(b) Combat health support of infiltration is restricted by the amount of medical 
equipment, supplies, and transportation assets that can be introduced into the attack area. No deployment of 
BAS treatment teams without their organic transportation should be attempted. Elements of unit-level CHS 
should be accompanied by their organic vehicles, and ambulances should receive priority for deployment. 
It could be necessary to man-carry enough BAS equipment into the attack area to provide EMT and ATM; 
this, however, results in degrading mobility. When the element is committed without its ambulances, 
patients are evacuated to the BAS by litter bearer teams. These litter teams must be designated and 
equipped by the commanders in their orders. Noise, light, and litter discipline during evacuation in an 
infiltration depends on how the casualty was wounded. Disease and nonbattle-injured soldiers may not have 
been noticed by the enemy. If the casualty is a battle injury, the enemy has already detected that element. 
Once the enemy has detected and engaged the force, causing casualties, maximum allowable use of standard 
and nonstandard MEDEVAC platforms should be used. This will increase lift capabilities and save time 
and soldier's lives. Patient evacuation from the BAS and medical resupply of the force could be provided 
by litter bearers, depending upon distances and degree of secrecy required. 

(c) When airborne and air assault forces are used, infiltrating elements can land at 
various points within the threat's rear area and proceed on foot to designated attack positions. As in surface 
movement, the amount of medical equipment taken could be limited. In airborne operations, the evacuation 
of patients will be by litter bearers or frontline ambulances to collecting points or the BAS and then by 
FSMC ambulances to the clearing station operated by the FSMC treatment platoon. In air assault operations, 
the evacuation is by litter bearers to collecting points or the BAS and then by air ambulances to a clearing 
station. Once the combat element begins the assault on the objective, secrecy is no longer important and its 
isolated location requires CHS characteristic to airborne and air assault operations until ground linkup. 

(4) Turning movement. A turning movement is a variation of the envelopment in which the 
attacking force passes around or over the threat's principal defense positions to secure objectives deep in the 
threat's rear and force the threat to abandon his position, or to divert major forces to meet the threat. As 
stated above, the turning movement is a variant to the envelopment in which the attacker attempts to avoid 
the defense entirely; rather, the attacker seeks to secure key terrain deep in the threat's rear and along his 
lines of communication (LOC). Faced with a major threat to his rear, the threat is thus "turned" out of his 
defensive positions and forced to attack rearward at a disadvantage. Medical evacuation support to the 
turning movement is provided basically in the same manner as to the envelopment. As the operation is 
conducted in the threat's rear area, LOC and evacuation routes could be unsecured, resulting in delays in 
resupply and evacuation. 

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b. Enabling Operations. 

(1) Passage of lines. This situation presents a challenge for the CHS planner. There will be 
a number of MEDEVAC units using the same air and road networks. Coordination and synchronization are 
essential if confusion and overevacuation are to be avoided. The medical units of the force manning the line 
should provide area support to the force passing through. This allows continued mobility for the moving 
force. The below information facilitates this coordination. 

Radio frequencies and call signs. 

Operation plans and TSOPs. 

Location of MTFs. 

Location of patient collecting points and AXPs. 

Main supply route, forward arming and refueling points, and A2C2 data. 

(2) Security operations. Security operations obtain information about the enemy and provide 
reaction time, maneuver space, and protection to the main body. Security operations are characterized by 
aggressive reconnaissance to reduce terrain and enemy unknowns, gaining and maintaining contact with the 
enemy to ensure continuous information and provide early and accurate reporting of information to 
the protected force. See FM 17-95 for definitive information on security operations. The discussion 
below focuses on how CHS is provided for security operations. Security operations include the following 
missions: 

• Cover. 

• Screen. 

• Guard. 

• Area security. 

(a) Cover. The covering forces are dependent upon organic resources found in the 
maneuver battalion medical platoon for initial support. The level of command for the covering force 
determines the responsibility for the subsequent evacuation plan. In a corps covering force, for example, 
the corps CHS structure has the responsibility for establishing and operating the MEDEVAC system to 
support the forward deployed corps forces. This is done to prevent the tactical combat force following the 
covering forces from becoming overloaded with patients prior to the hand off and passage of lines. The use 
of patient collecting points, AXPs, and nonmedical transportation assets (casualty evacuation) to move the 
wounded is essential. The covering force battle could be extremely violent. Patient loads will be high and 
the distance to MTFs can be much longer than usual. The effectiveness of the MEDEVAC system depends 
upon the forward positioning of a number of ground ambulances and the effective integration of corps air 
ambulances into the evacuation plan. 

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(b) Screen. The primary purpose of a screen is to provide early warning to the main 
body. Screen missions are defensive in nature and largely accomplished by establishing a series of 
observation posts and conducting patrols to ensure adequate surveillance of the assigned sector. The screen 
provides the protected force with the least protection of any security mission. Combat health support will 
be provided by organic medical elements and ambulances teams deployed from the supporting medical 
company. 

(c) Advance, flank, and rear guards. A guard force accomplishes all the task of a 
screening force. Additionally, a guard force prevents enemy ground observation of and direct fire against 
the main body. A guard force reconnoiters, attacks, defends, and delays as necessary to accomplish its 
mission. A guard force normally operates within the range of the main body's indirect fire weapons. A 
guard force is deployed over a narrower front, then a screen to permit concentration of combat power. 
These forces normally receive MEDEVAC support through the attachment of evacuation teams. The 
teams evacuate patients to predesignated patient collecting points along a main axis of advance or to the 
nearest treatment element providing area support. Employment of air ambulances provide a measure of 
agility and flexibility. 

(d) Area security. Area security is a form of security that includes reconnaissance and 
security by designated personnel of airfields, unit convoys, facilities, main supply routes, LOCs, equipment, 
and critical points. Area security operations are conducted to deny the enemy the ability to influence 
actions in a specific area or to deny the enemy use of an area for his own purpose. This may entail 
occupying and establishing a 360-degree perimeter around the area being secured, or taking actions to 
destroy enemy forces already present. The area to be secured may range from specific points (bridges, 
defiles) to areas such as terrain features (ridgelines, hills) to large population centers and adjacent areas. 
Combat health support will be provided by organic and attached medical elements. In area security, 
Echelon I CHS is provided by organic or attached treatment teams. Echelon II CHS is provided by the 
supporting medical company via DS and on an area support basis. Depending on the type of area security 
operations being conducted, both air and ground ambulances may be employed. 

(3) River crossing operations. The river barrier itself exerts decisive influence on the use of 
medical units. An attack across a river line creates a CHS delivery problem comparable to that of the 
amphibious assault. Combat health support elements cross as soon as combat operations permit. Early 
crossing of treatment elements reduces turnaround time for all crossing equipment that is used to load 
patients on the far shore. Maximum use of air ambulance assets is made to prevent excessive patient 
buildup in far shore treatment facilities. Near-shore MTFs are placed as far forward as assault operations 
and protective considerations permit to reduce ambulance shuttle distances from off-loading points. For 
detailed information on river-crossing operations, refer to FM 90-13. Rescuing casualties in the water must 
be considered by the task force medical planner. 

(4) Reconnaissance operations. The reconnaissance in force is an attack to discover and test 
the threat's position and strength or to develop other intelligence. The tactical combat force usually probes 
with multiple combat units of limited size, retaining sufficient reserves to quickly exploit known threat 
weaknesses. Combat health support techniques follow those discussed above for a movement to contact. 
Ambulances are positioned well forward and moved at night to enhance secrecy. The echeloning of 
ambulances is an indication to the threat that an attack is imminent due to the forward placement of CHS. 

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Clearing stations are not established until a significant patient workload develops. Patients received at BAS 
of reconnoitering units are evacuated to clearing stations as early as practical, or are carried forward with 
the force until a suitable opportunity for evacuation presents itself. The maximum possible use of air 
ambulance assets is made to cover extended distances and to overcome potentially unsecured ground 
evacuation routes. 

(5) Unified action. The majority of the operations occurring at the present time are joint, 
interagency, or multinational operations. The CHS planner must determine in the initial planning stages of 
these operations whose responsibility it is to provide MEDEVAC support to the force. The CHS planner 
must also ensure that duplications in support do not exist, that guidelines are established as to eligible 
beneficiaries, when individuals are to be returned to their own nation's health care delivery system, and 
what mechanisms exist for reimbursement of services. For additional information, refer to FM 8-42 and 
JP 4-02. 

(6) Integrated warfare operations. Medical evacuation in an NBC environment is discussed 
in FMs 8-10-4, 8-10-6, and 8-10-7. 



3-9. Combat Health Support During Night Operations 

The BSS must anticipate that the brigade does a substantial amount of its work at night or in limited 
visibility. For night operations to be successful, they require tactics, techniques, and procedures that 
maximize the night-fighting technological advantages. Command and control is one of the most important 
factors in conducting night operations. The mission of maneuver forces is to destroy the enemy without 
committing fratricide. To achieve this end state, all soldiers must operate as efficiently at night as during 
the day. Moreover, leaders must master night C2. 

a. General Considerations. 

(1) The DSS and BSS, along with medical company commanders, must anticipate that 
supported maneuver brigades and division units do a substantial amount of their work at night or in limited 
visibility. They must ensure that TSOPs are available and used throughout the division and brigade for 
providing MEDEVAC and treatment at night. Real-life trauma care at night will be enhanced by the ability 
to use white light (visible light) at the earliest opportunity. Therefore, medical units/elements must establish 
standard procedures to use white light without compromising the tactical environment. This means training 
to erect shelters as soon as possible and routinely during hours of darkness. Personnel must understand that 
some shelters block visible light but those same shelters glow when viewed through night vision goggles 
(NVGs). In some extremely mobile situation ambulance/vehicles could be used to enclose patients and care 
providers thus allowing treatment to proceed under white-light conditions. The DSS and BSS, along with 
medical company commanders, must understand the technology and their capabilities for conducting night 
operations. The brigade surgeons and medical company commanders should know how to use both far 
infrared devices (and how their capabilities can enhance CHS operations at night) such as the combat 
identification panel (CIP) and near infrared devices such as the BUD light and Phoenix light. See the 
discussion below on infrared and night vision devices. They need to know status and amount of equipment 
on-hand and to identify equipment needed. The BSS must plan the SOPs and METT-TC specific techniques 

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necessary to perform the CHS mission. For these types of operations, the commander should be advised to 
consider— 



• 



• 



• 



• 



Appropriating civilian buildings to reduce light and thermal signatures. 
Lightproofing shelters. 

Using nonvisible spectrum light in conjunction with night vision devices. 
Reducing noise signature to a minimum. 



(2) In addition, divisional units, the DSA, and BSAs are susceptible to a night attack. This 
further slows logistics and CHS activities. Use of chemical lights may be applicable. However, overuse of 
chemical lights degrades light discipline and security. Chemical lights are visible from a distance of a 
kilometer or more. Possible techniques for medical units/elements to use include— 

• Chemical lights to light CP areas, thus eliminating generator noise and thermal 
signature. 

• Magnetic holders to allow placement of color chemical lights on vehicles. 

• Chemical lights to illuminate vehicle engine compartment areas for night repairs. 

• Chemical light holders to regulate the amount and direction of light. 

b. Combat Health Support Considerations. 

(1) Light discipline requirements affect CHS operations much as they do supply and 
maintenance operations. Medical units/elements will use additional fuel to operate power generation 
equipment. Treatment operations require lightproof shelters. Patient acquisition is more difficult. Units 
should employ some sort of casualty-marking system such as luminous tape. 

(2) Limited visibility slows MEDEVAC. This requires additional ground ambulances to 
compensate. In the offense, ambulances move forward with BASs. However, personnel have to accomplish 
this movement carefully to avoid signaling the threat. Personnel use predesignated AXPs. Medical 
evacuation by air ambulance is difficult and requires precise grid coordinates as well as prearranged signals 
and frequencies. As in daylight, CHS operations conducted at night require active participation of all 
involved units. Operational procedures must include near and far recognition, signaling, predetermined 
marking of patient collection points, routes, and MTFs. Maximum use of modern navigation tools such as 
the Global Positioning System (GPS), infrared, and night visions devices will enhance the ability of medical 
units/personnel to carry out CHS in support of night missions. Night operating procedures must be routine 
and practiced as a part of routine operating procedures. This is especially true for medical units/personnel 
since they have a 24-hour responsibility under all conditions, not just combat operations. 

c. Infrared and Night Vision Devices. 

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(1) Far-infrared device, such as the CIP, is a QUICK FIX device for friendly identification. 
The thermal taped-covered CIP provides an aid in distinguishing friendly from threat vehicles when thermal 
sights are used. Combat identification panels do not replace current acquisition, identification, or 
engagement procedures. They provide a device visible through thermal sights to increase situational 
awareness and provide a safety net at normal engagement range. For additional information on the CIP go 
to http://call.army.mil/call/user-gui/95-3/chapter2.htm. These devices can be used to further identify 
medical vehicle and units. 

(2) Near-infrared devices that aid in C2 may be used for signaling and marking devices. 
The infrared beam is an effective means to increase situational awareness, improve identification, and 
increase combat effectiveness. These devices reduce fratricide risk when used for marking obstacles, 
seized terrain, and breached sites. Additionally, these lights are super signaling devices (that is, configuring 
of certain patterns to indicate unit identification, turning on/off to signal accomplishment of a task, crossing 
a phase line, signaling from one ground position to another specific position, or from ground to air). They 
are also useful in specialized units such as pathfinders for marking pickup, drop, or landing zones (LZs). 
These are excellent devices for near recognition signaling to guide incoming evacuation vehicles. 

(a) BUD light. The BUD light operates using active near-infrared light viewed through 
image-intensifying devices. These image-intensifying devices are only effective during nighttime conditions. 
Near-infrared devices can be directional or omnidirectional and emit a steady pulse or a codable pulse. The 
BUD light is a compact near-infrared source using a standard 9-volt (BA-3090) battery as its power source. 
Both the BUD light and its power source will fit in the palm of the hand. The average life span of the battery 
power for a BUD light is 8 hours of continuous use. The near infrared pulse emitted by the BUD light is 
similar to a strobe light, and pulses every 2 seconds. It is invisible to the naked eye and thermal imagers. 
The pulse is clearly visible out to 4 kilometers under optimal conditions when pointing the beam directly at 
the viewer. The directional characteristic of the beam makes it possible to limit observation by an enemy. 
If used to mark vehicles, care should be taken to minimize the light illuminating the vehicle's surface. The 
enemy has to have image intensifying devices to see the lights directly; however, they may see the light 
being reflected off of vehicles when the lights are employed in a directional mode. This device is most 
effective for C2 purposes. The BUD light is also very useful for dismounted operations at night. 

(b) Phoenix light. The Phoenix light operates using active near-infrared light viewed 
through image intensifying devices. The Phoenix light can be used as a codable infrared beacon. The light 
is powered by a standard 9-volt (BA-3090) battery. The Phoenix light is ideal for use when positive 
identification at night must be made out to 4 kilometers under optimal conditions. The infrared beacon has 
a range equal to the BUD light. One advantage is the ability to code many beacons with different codes 
(sequence of flashes— including Morse code— up to 4 seconds) enabling anyone to be distinguished in a 
group. A programmed sequence will repeat until canceled or when the battery expires (same as BUD 
light). Operating instructions include connecting the battery to the Phoenix light. Using a metal object— a 
coin is best— make connection across the two pins on top of the light. A microminiature red indicator 
flashes the sequence as the code is entered. At the end of the 4-second memory, a green microminiature 
indicator will flash, indicating the end of the input sequence. The Phoenix light is now emitting the desired 
code. To check the code, make a connection across the pins. The green microminiature indicator will flash 
the code. To change the code, disconnect the battery and repeat the instructions. The Phoenix light also can 
be used during dismounted operations. The programming of a code can assist in distinguishing one unit 

3-22 



FM 4-02.21 



from another. An active Phoenix light or BUD light can be covered or uncovered as necessary to ensure the 
light is visible only when necessary. 

(c) Night vision devices. There are numerous types of night vision devices in the Army 
inventory but this subparagraph will focus on what the FSMC has on its TOE. Each vehicle in the FSMC 
will have two night vision devices. The wheeled vehicle driver will use either the AN/PVS-7B (discussed 
below) or the driver's vision enhancer (DVE). The DVE is a thermal imaging system capable of operating 
in degraded visibility conditions such as fog, dust, smoke, and darkness. In conditions of reduced visibility, 
the DVE allows a vehicle to maintain speeds up to 55 to 60 percent of those attained during normal daylight 
operations. Unlike traditional night vision devices that magnify ambient light, the DVE generates a picture 
based on very minute variances in temperature in the surrounding environment. It gives the operator 
visibility to the horizon in total darkness and the ability to recognize a 22-inch object at a distance of 360 
feet. It can elevate 35 degrees, depress 5 degrees, and rotate 170 degrees in either direction. The DVE 
consists of a sensor module, display control module, positioning module, wiring harness, and mounting 
equipment. A combat DVE and a tactical wheeled vehicle DVE will be available. The tracked ambulances 
(Ml 13) and M577 tracked treatment vehicle drivers will use DVE if available, or will continue to wear 
NVGs. The NVGs (AN/PVS-7B) is a hand-held, head-mounted, or helmet-mounted night vision system 
that enables walking, driving, weapons firing, short-range surveillance, map reading, treatment of patients, 
vehicle maintenance in both moonlight and starlight. It has an infrared projector that provides illumination 
at close ranges and that can be used for signaling. There is a high-light level shutoff if the device is exposed 
to damaging levels of bright light. There is a compass that attaches to the device that allows for reading an 
azimuth through the goggles. This device has a weight of 1.5 pounds and operates on two AA batteries. 
Armored medical vehicles (M577, treatment vehicle, Ml 13, armored ambulance, and the new armored 
evacuation vehicle [AEV] when fielded) have infrared headlights. These infrared headlights can be used for 
assisting drivers who wear NVGs and can be used for signaling. As with all lights, extreme caution must be 
taken in tactical situations. The infrared headlights are typically very bright to personnel wearing NVGs. 

d. Example Techniques for Using Chemical Lights for Marking and Signaling. 

NOTE 

Techniques are only limited to available equipment and imagination. 
The METT-TC should always take precedence. 

(1) For marking, chemical lights can be placed inside standard military short or long tent 
stakes/pickets to mark routes and positions. The concave side of the tent stake contains the chemical light 
and the convex side faces the most likely direction of enemy observation. This techniques controls the 
direction of the light while assisting with such things as a MEDEVAC route, supported unit collection point, 
AXP, or link up point identification. 

(2) For signaling, tying a chemical light to a length of cord or string and slinging it in a 
circle overhead is an unmistakable signal. This only needs to be use once for recognition (radio) to be 
established and is ended once the signal is seen. This technique makes use of widely available common 
supplies. It is especially useful for a unit guiding an incoming ground or air ambulance. 

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FM 4-02.21 



3-10. Combat Health Support for Stability Operations 

a . Overview of Stability Operations . 

(1) Stability operations apply military power to influence the political environment, facilitate 
diplomacy, and interrupt specified illegal activities. Stability operations include both developmental and 
coercive actions. Developmental actions enhance a government's willingness and ability to care for its 
people. Coercive actions apply carefully prescribed limited force and/or the threat of force to achieve 
objectives. The types of activities conducted in stability operations include— 

Peace operations. 

Operations in support of diplomatic efforts. 

Combatting terrorism operations. 

Counterdrug operations. 

Noncombatant evacuation operations (NEO). 

Arms control. 

Nation assistance and foreign internal defense. 

Support to insurgencies and counterinsurgencies. 

Shows of force. 

Civil disturbance operations. 

(2) While each operation in this environment is unique, there are seven broad imperatives 
that enhance the deployed forces' ability to develop concepts and schemes for executing stability operations. 
These imperatives are- 
Stressing force protection. 
Emphasizing information operations. 

Maximizing interagency, joint, and multinational cooperation. 
Displaying the capability to apply force without threatening. 

Understanding the potential for disproportionate consequences to individual and 
small-unit actions. 



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FM 4-02.21 



• Applying force selectively and discriminatingly. 

• Acting decisively to prevent escalation. 
b. Combat Health Support for Stability Operations. 

(1) Combat health support to forces deployed for stability operations is dependent upon the 
specific type of operation, anticipated duration of the operation, number of forces deployed, theater 
evacuation policy, medical troop ceiling, and anticipated level of violence. In most situations, CHS follows 
the traditional support provided to combat forces. If there is a shortened theater evacuation policy, a limited 
medical troop ceiling, and limited hospitalization assets within the AO, organic and DS ambulance support 
is provided from the point of injury to the supporting Echelons I or II MTF. The patient is stabilized at the 
MTF, then evacuated from the treatment element to an airfield for evacuation out of the theater. 

(2) During NEO, those persons who are injured, wounded, or ill are treated and stabilized 
by the medical element accompanying the NEO force. Once stabilized, the NEO force evacuates them. In 
NEO conducted in a permissive environment (no apparent physical threat to the evacuees), sick, injured, or 
wounded persons should be evacuated on dedicated MEDEVAC platforms, if at all possible. In an 
uncertain or hostile environment, the transportation assets used to insert and extract the NEO force are 
normally used to evacuate the patients. The medical personnel accompanying the force provide en route 
medical care until the NEO force reaches an intermediate staging base (ISB) or safe haven. Those evacuees 
requiring medical care are then transferred to dedicated MEDEVAC platforms for further evacuation to 
MTFs capable of providing the required care. 

(3) During combatting terrorism operations, planning considerations for CHS include— 

• Using medical and nonmedical transportation assets to evacuate casualties in mass 
casualty situations. If nonmedical assets are used, planning should include augmenting these assets with 
medical personnel, adequate litters, and medical supplies to provide en route medical care. 

• Applying techniques for acquiring and evacuating patients under hostile fire or on 
adverse terrain (from rubble or from above or below ground level). (Refer to FM 8-10-6 for additional 
information.) 

• Ensuring security measures (such as establishing checkpoints, screening personnel 
and vehicles, and limiting access to the MTF area) are implemented. 

(4) Medical personnel in nation assistance, support to insurgencies, and support to counter- 
insurgencies could be called upon to assist in the development of a MEDEVAC system. This system would 
provide for the supported nation/group; teach civilian, military, or paramilitary personnel basic evacuation 
techniques and the treatment protocols for providing en route medical care. It could also provide the more 
traditional support from the point of injury to the supporting treatment element. 

(5) For additional information, refer to FM 8-42. 

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FM 4-02.21 



3-11. Combat Health Support for Support Operations 

a. Support operations provide essential supplies and services to assist designated groups. They 
are conducted mainly to relieve suffering and help civil authorities respond to crises. In most cases, Army 
forces achieve success by overcoming conditions created by man-made or natural disasters. The ultimate 
goal of support operations is to meet the immediate needs of designated groups and transfer responsibility 
quickly and efficiently to appropriate civilian authorities. Support operations, which consist of humanitarian 
assistance and environmental assistance, accomplish one or more of the following: save lives; reduce 
suffering; recover essential infrastructure; improve quality of life; and restore situations to normal. The 
seven broad support imperatives are- 
Secure the force. 

Provide essential support to the largest number of people. 

Coordinate actions with other agencies. 

Hand over to civilian agencies as soon as feasible. 

Establish measures of success. 

Conduct robust information operations. 

Ensure operations conform to legal requirements. 

b. Humanitarian assistance operations can include a number of activities such as disaster relief, 
domestic support, refugee assistance, the provision of medical care to isolated populations, and refeeding 
programs resulting from natural or human-related disasters. Medical evacuation assets could be used to 
evacuate the injured from disaster sites, to provide the emergency transport of critically needed medical 
supplies and personnel to remote locations, or to perform emergency rescues during times of flooding, wild 
fires, or other natural disasters. 

c. Further, medical personnel may perform community assistance missions such as the Military 
Assistance to Safety and Traffic Program, where an air ambulance unit provides evacuation support to the 
nearby civilian community. See FM 8-42 for definitive information. 

3-12. Mass Casualty Operations 

Mass casualty situations occur when casualties exceed CHS capabilities. Procedures for mass casualty 
operations should be contained in the TSOP of each unit. Tactical standing operating procedures for mass 
casualty operations are coordinated through the principal staff, approved by the command, and coordinated 
with subordinate and higher commands. If mass casualty operations are viewed as part of area damage 
control missions, then the medical requirements will be integrated into the overall plan. See FMs 8-10 and 
8-10-6 for definitive information. 

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FM 4-02.21 



3-13. Combat Health Support in Nuclear, Biological, and Chemical Defensive Operations 

Nuclear, biological and chemical weapons of mass destruction and strategic delivery systems exist throughout 
the world. Delivery systems once limited to the superpowers are now available to third world nations. The 
corps' and division's sustainment and support capabilities are prime target for the threat's NBC weapons. 
The division and brigade medical units/elements can expect to conduct operations in an NBC environment. 
Although medical companies, platoons, or teams cannot be specifically targeted, locating close to supported 
CS and CSS units and near road junctions make them vulnerable to NBC weapons. Prompt notification of, 
and reaction to, downwind messages in the event of NBC employment will enhance both unit and individual 
NBC defensive measures. Defensive measures include all measures necessary to increase the effectiveness 
of operations, reduce the degradation to the operational tempo, and to minimize casualties. To successfully 
operate in a NBC environment, the DSS must focus on pre-and postdeployment training and realistic 
operational plans. Realistic training, SOPs considering NBC, and appropriate anticipation and preparation 
will greatly increase medical capability. This includes contamination avoidance and control, protection, 
and decontamination. Field Manuals 3-3, 3-3-1, 3-4, and 3-5 provide specific guidance for NBC avoidance 
and protection. For information on NBC casualty estimates, see NATO Pub AMED P-8. For definitive 
information on CHS in an NBC environment, see FMs 8-10-7 and 8-9. For information on NBC patient 
treatment, see FMs 8-9, 8-284, and 8-285. 

a. Combat health support planning factors for NBC defensive operations include— 

Increased casualties. 

Increased MEDEVAC requirements with compromised MEDEVAC capabilities. 

Supply and resupply disruptions. 

Contamination of unit equipment, supplies, and personnel. 

Mission performance degradation due to individual protective postures. 

Prolonged treatment procedures due to decontamination. 

Increased medical treatment requirements. 

Disruption of LOC. 

Equipment damage (chemical corrosion and nuclear electromagnetic pulse). 

Select sites for medical units that are away from likely targeted areas. 

The need to adjust CHS to meet the complexities generated. 

Increased number of battle fatigue (BF) and stress-related casualties. 



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FM 4-02.21 



b. The battlefield operations under NBC conditions can present mass casualty situations that will 
develop quickly and have long-lasting residual effects. The range of threat weapons, NBC weapons/agents, 
directed-energy weapons, and weapon delivery systems could cause high casualty rates, especially in poorly 
trained and improperly equipped troops and units. Medical treatment facilities could be in target areas; this 
will compromise medical treatment and other CHS services. 

c. The flexibility of Echelons I and II medical units and their modular design allows reconstitution 
of other Echelons I and II units, or the ability to task-organize to meet the CHS requirements of the 
supported units. 

d. The requirement for patient sorting (RTD and non-RTD [NRTD]) is of extreme importance. 
Many of the patients, particularly those with mild symptoms or combat stress, have excellent RTD potential. 
These individuals, if promptly and properly treated, could RTD within hours or a couple of days which 
can significantly influence the outcome of the battle. Additionally, many of these soldiers who only have 
BF will present physical signs and symptoms which resemble true exposure. It is important not to evacuate 
soldiers with minimal or no exposure to NBC hazards to hospitals. Putting BF soldiers in hospitals could 
reinforce their perceptions or beliefs that there is something wrong with them, other than simple fatigue 
and stress. It could influence their thinking and cause them to exaggerate the severity of their conditions. 
Also, hospitalization could slow BF soldiers' recovery and possibly result in their developing a chronic 
disability. 

e. Those potential RTD patients with biological or chemical effects and those with radiation 
exposure requiring hospitalization will be evacuated to combat support hospitals (CSHs). Restoration 
programs will be conducted for BF and stress-related casualties within the division. See FMs 22-51 and 
8-51 for definitive information on the prevention, control, and treatment of BF and other stress-related 
casualties. 

/. In decontamination of NBC environments, immediate operational (individual and buddy) 
decontamination is absolutely critical for soldier survival. It is then essential the surgeon inform supported 
commanders that delaying decontamination of casualties will greatly increase their mortality and morbidity. 
Establishing decontamination sites, coordinating manning and training is a time-consuming task and needs 
to be part of the pre-operation preparation. Decontamination is the responsibility of the unit and not the 
medical unit. The medical unit is responsible for ensuring that the few casualties which bypass the 
decontamination sites are decontaminated before admission to the MTF, protecting the medical unit from 
contamination (verifying casualties are clean), and individual decontamination. Under medical supervision, 
patient decontamination is performed by nonmedical personnel from supported units. Decontamination can 
be greatly reduced by protecting supplies and equipment prior to attack. Surgeons can train troops to 
support this by integrating the training into their Combat Lifesaver Program. 

3-14. Force Protection and Security Measures 

a. Force protection is a complex process in which each action impacts upon many others. 
Planning for force protection is a continuous process. Force protection in stability operations and support 
operations scenarios can pose significant challenges. 

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FM 4-02.21 



b. The commander is responsible for providing security for his unit and the patients under his 
care. In some scenarios, a combat or CS unit can provide security forces to assist in the defense of medical 
units/elements. In other situations, the medical units/elements may not be collocated with other types of 
CSS units and the medical commander/leader must then provide completely for his own security. In the 
division, the DSMC and FSMCs are located in the DSA and BSAs with their respective battalions. The 
DSB and FSB commanders have the overall responsibility for the security of their battalions. 

c. In stability operations and support operations, medical units could be deployed into a given 
geographical area prior to the deployment of combat and CS forces. During humanitarian assistance and 
disaster relief operations, the perceived threat may be low, but the commander must ensure that his security 
measures are adequate for the appropriate threat level. Further, he must ensure he has the capability to 
increase these protective measures should the operational scenario change and mission creep occur. If the 
political, social, or economic status of the HN or region deteriorates, an increase in the potential for local 
inhabitants to raid convoys, steal from base camps, or attack the base camp is possible. The commander 
must continuously evaluate the potential threat activity and adjust his force protection plan accordingly. 

d. Unit and individual protective measures are discussed in detail in Joint Pub 3-07.3. 

3-15. Combat Health Support Tactical Standing Operating Procedures 

The DSS and the BSS are responsible for the development of the CHS annexes for the division and brigade 
TSOPs. The purpose of a TSOP is to establish routine protocols. The procedures in the TSOP should not 
be dependent upon the METT-TC factors. If a specific decision is required each time, it should not be 
included in the TSOP. The division and brigade surgeons assists in development of the TSOPs by their 
staffs and by division and brigade medical activities that include medical cells, medical platoons, and 
medical companies. The division and brigade TSOPs are based on the corps TSOPs and serve as the 
foundation for subordinate units to develop their TSOPs. The division and brigade CHS annexes to the 
TSOPs should be clear and concise, yet provide sufficient detail of procedural requirements. The CHS 
annexes to the TSOPs must reflect procedural guidance that supports current mission and doctrinal 
requirements. The CHS annexes to the division and brigade TSOPs should be maintained and reviewed at 
least every 6 months and revised as required. Most importantly, the TSOP must be trained and understood 
at all levels prior to deployment or it has no real value. 



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FM 4-02.21 
APPENDIX A 
GUIDE FOR GENEVA CONVENTIONS COMPLIANCE 



A-l. General 

a. Sources for the law of war obligations of the US are customary international law and treaties 
ratified by the US. As such, they are part of the supreme law of the land. 

b. The US is obligated to adhere to these obligations even when an opponent does not. 
Department of Defense and Army policy is to conduct military operations in a manner consistent with 
customary international law and treaty obligations. 

c. An in-depth discussion of the provisions applicable to medical units and personnel is provided 
in FM 8-10 and FM 27-10. 



A-2. Distinctive Markings and Camouflage of Medical Facilities and Evacuation Platforms 



This paragraph implements STANAG 2027 and QSTAG 512. 



a. All US medical facilities and units, except veterinary, display the distinctive flag of the 
Geneva Conventions. This flag consists of a red cross on a white background. It is displayed over the unit 
or facility and in other places as necessary to adequately identify the unit or facility as medical. 



This paragraph implements STANAG 2931. 



b. Camouflage of medical facilities (medical units, medical vehicles, and medical aircraft on the 
ground) is authorized when the lack of camouflage might compromise the tactical operation. If the failure 
to camouflage endangers or compromises tactical operations, the camouflage of medical facilities could be 
ordered by a NATO commander of at least brigade level or equivalent. Such an order is to be temporary 
and local in nature and is rescinded as soon as circumstances permit. It is not envisioned that large, fixed 
medical facilities will be camouflaged. 



NOTE 

As used in this context, camouflage means to cover up or remove 
the emblem. The black cross on an olive background is not a 
recognized emblem of the Geneva Conventions and is not authorized 
for use. 



A-1 



FM 4-02.21 



A-3. Self-Defense and Defense of Patients 

Medical personnel may carry small arms for personal defense of themselves and defense of their patients. 
Self-defense of medical personnel or defense by medical personnel of their patients is always permitted. 
This does not mean that they may resist capture or otherwise fire on the advancing enemy. It means that, if 
civilian or enemy military personnel are attacking and ignoring the marked medical status of medical 
personnel, medical transportation, or the medical unit, the medical personnel may provide self-protection. 
If an enemy military force merely seeks to assume control of a military medical facility or a vehicle for the 
purpose of inspection and without firing on it, the facility or vehicle may not resist. 

A-4. Enemy Prisoners of War 

a. Sick, injured, or wounded EPW are treated and evacuated through medical channels, but are 
physically segregated from US or allied patients. The EPW patient is evacuated from the combat zone as 
soon as his medical condition permits. 

b. Personnel resources to guard EPW patients are provided by the echelon commander. Medical 
personnel DO NOT guard EPW patients. 

A-5. Compliance with the Geneva Conventions 

a. As the US is a signatory to the Geneva Conventions, all medical personnel should thoroughly 
understand the provisions that apply to CHS activities. Violation of these Conventions can result in the loss 
of the protection afforded by them or prosecution. Medical personnel should inform the tactical commander 
of the consequences of violating the provisions of these Conventions. 

b. The following acts are inconsistent with an individual or facility claiming protected status 
under the Geneva Conventions: 

• Medical personnel are used to man or help man the perimeter of nonmedical facilities, 
such as unit trains, logistics areas, or base clusters. 

• Medical personnel are used to man any offensive-type weapons or weapons systems. 

• Medical personnel are ordered to engage enemy forces other than in self-defense or in 
the defense of patients and MTFs. 

• Crew-served weapons are mounted on a medical vehicle. 

• Mines or booby traps are placed in and around medical units and facilities. 

• Hand grenades, light antitank weapons, grenade launchers, or any weapons other than 
rifles and pistols are issued to a medical unit or its personnel. 

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FM 4-02.21 



• The site of a medical unit is used as an observation post, a fuel dump, or an ammunition 
storage site. 

c. Possible consequences of violations described in b above are— 

• Loss of protected status for the medical unit and personnel. 

• Medical facilities attacked and destroyed by the enemy. 

• Medical personnel being considered prisoners of war rather than retained persons when 
captured. 

• Combat health support capabilities decremented. 

• Prosecution for violations of the law of war. 

d. Other examples of violations of the Geneva Conventions include— 

• Making medical treatment decisions for the wounded and sick on any basis other than 
medical priority, urgency, or severity of wounds. 

• Allowing the interrogation of enemy wounded or sick even though medically not 
recommended. 

• Allowing anyone to kill, torture, mistreat, or in any way harm a wounded or sick enemy 
soldier. 

• Marking nonmedical unit facilities and vehicles with the distinctive emblem, or making 
any other unlawful use of this emblem. 

• Using medical vehicles marked with distinctive Geneva Conventions emblem for 
transporting nonmedical troops, equipment, and supplies. 

• Using a medical vehicle as a TOC. 

e. Possible consequences of violations described in d above are— 

• Criminal prosecution for war crimes. 

• Medical personnel being considered prisoners of war rather than retained persons when 
captured. 

NOTE 

The use of smoke and obscurants by medical personnel is not a 
violation of the Geneva Conventions (see FMs 8-10-6 and 3-50 for 
information on the use of smoke). 



A-3 



FM 4-02.21 
APPENDIX B 
TACTICAL STANDING OPERATING PROCEDURE 



B-l. General 

All DSS and BSS must establish TSOPs. These TSOPs should be detailed and cover all aspects of division 
or brigade CHS operations. This is an example TSOP which can be used by both the DSS and the BSS to 
guide them in the development of their TSOPs. 

B-2. Sample Tactical Standing Operating Procedure 

The sample shown is an annex from a division service support SOP (wartime and other operations). There 
is not a standard format for all TSOPs; however, it is recommended that the annex follow the format used 
by its higher headquarters. 

Volume II of Division Service Support Standing Operating 

Procedure (WAR AND OTHER OPERATIONS) 

ANNEX T (MEDICAL), INFANTRY DIVISION SUPPORT COMMAND 

TACTICAL STANDING OPERATING PROCEDURES 

I. PURPOSE 

This annex has been prepared to standardize operations and CHS procedures for the division in time of war 
and other operations. 

II. GENERAL 

A. The division surgeon is normally located at the division main CP. 

B. The DSS will be located with the division main CP and a DSS element deploys with the 
division forward TOC. 



III. ORGANIZATION AND MISSION 

A. Medical Plans and Operations Cell. The medical plan and operations cell is responsible for— 

1. Developing and coordinating patient evacuation support plans among the division and 
corps MEDEVAC elements. 

2. Coordinating corps-level CHS for the division with the corps medical brigade/group. 

3. Submitting A2C2 requirements for aeromedical evacuation elements to the division G3 
and aviation brigade. 

B-1 



FM 4-02.21 



4. Ensuring A2C2 information is provided to supporting corps air ambulance assets. The 
A2C2 information is normally provided by G3 Air at division and by the brigade S3 Air in the maneuver 
brigades. 

5. Coordinating aviation weather information from USAF WX detachment in the aviation 
brigade. 

6. Ensuring that the road clearance information provided to and received from the division 
MCO is disseminated to all ground ambulance assets. This information should include— 

a. Nuclear, biological, and chemical threat. 

b. Priorities for use of evacuation routes. 

c. Information reported by MEDEVAC assets. 

7. Monitoring medical troop strength to determine task organization for mission accomplish- 



ment. 



8. Forwarding all medical information of potential intelligence value to the division G2 and 



G3 sections. 

9. Obtaining updated medical threat and intelligence information through the G2 and G3 
sections for evaluation and applicability. 

10. Managing the disposition of captured medical materiels according to TSOPs. 

11. Coordinating corps CSC support to forward areas, as required. 

12. Monitoring optometry services. 

B. Combat Health Logistics Cell. The CHL cell is responsible for planning, coordinating, and 
prioritizing CHL and medical equipment maintenance programs for the division. The specific responsibilities 
of CHL cell include the following: 

1 . Providing the division CHL input to the CHS plan in coordination with the DMSO. 

2. Coordinating medical maintenance training with the DMSO and supporting the MED LOG 
battalion, as required. 

3. Establishing maintenance priorities for repair and exchange of medical equipment (this is 
coordinated by the MMMB). 

4. Ensuring that a viable preventive maintenance program is established and monitored. 
B-2 



FM 4-02.21 



5. Coordinating the evacuation and replacement of medical equipment with the supporting 
MEDLOG company. 

6. Verifying emergency supply requests for submission to the corps MEDLOG company 
and taking the necessary action to expedite shipment. 

7. Analyzing Class VIII resupply operations, identifying trends in performance, and 
coordinating with the MEDLOG company /battalion any changes that would enhance the Class VIII delivery 
system. 

8. Establishing and managing, in coordination with the division and brigade surgeons, the 
medical critical items list. 

9. Interfacing with the MCO to ensure necessary coordination with the division supply and 
transportation system occurs. 

10. Establishing transportation procedures, based on the tactical situation, with the MMMB 
and MEDLOG company /battalion. 

11. Providing technical staff assistance for the MMMB, as required, to ensure divisionwide 
support for CHL and blood management. 

12. Establishing coordination procedures for the disposition of captured medical materiel. 

C. Responsibilities of the Patient Disposition and Reports Cell. The patient disposition and 
reports cell is responsible for coordinating patient disposition throughout the division. The branch obtains 
and coordinates disposition of patients with the medical plans and operations cell and the corps MRO. It 
prepares and forwards appropriate medical statistical reports as required. 

D. Preventive Medicine Cell. The division PVNTMED cell is responsible for supervising the 
command PVNTMED program according to the division CHS plan and AR 40-5. The PVNTMED cell is 
staffed to provide advice and consultation in the areas of environmental sanitation, epidemiology 
environmental surveillance, entomology, and sanitary engineering services. The primary mission of the 
PVNTMED cell is to protect division personnel against food-, water-, vectorborne diseases, as well as 
environmental injuries by implementing preventive measures. All PVNTMED missions are coordinated by 
the PVNTMED officer through the medical plan/operations cell. Additional information pertaining to the 
PVNTMED cell and its specific functions is discussed in FMs 8-10, 8-10-1, 8-10-3, and 4-02.17 (8-10-17). 

IV. ECHELON II COMBAT HEALTH SUPPORT 

A. The division provides Echelon II medical treatment, and evacuation. Class VIII resupply for 
the division medical elements is supported by the MEDLOG company using throughput resupply system to 
the FSMCs and the DSMC. One FSMC operates in DS of each maneuver brigade and locates an MTF in 
the BSA of the supported brigade. The DSMC locates and establishes an MTF in the DSA. 

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FM 4-02.21 



B. Combat health support is provided on an area support basis to nondivisional units operating 
within the division AO. 



V. MEDICAL EVACUATION 

A. General. 

1 . Evacuation is based on the principle that rear higher echelon medical units are responsible 
for evacuating patients from supported units. Lower echelon supported and supporting units must ensure 
evacuation support plans are complete and current by close, direct coordination. See FM 8-
…[truncated]