two casualties from a Stryker vehicle accident onto
a UH–60 Black Hawk helicopter for evacuation
to the 67th Combat Support Hospital in Tikrit, Iraq.
Logistics doctrine is taught as a rigid standard—the
right way to conduct support operations—during field
exercises, training center rotations, and
real-world missions. I concede that doctrine is a good starting
point for training, but I believe that the Army must be flexible
to win today’s Global War on Terrorism. Further, I believe
that, on the battlefield, nondoctrinal methods are often key
to maintaining flexibility.
Lessons learned during Operation Iraqi Freedom (OIF) have shown that the current
battlefield is nonlinear, the enemy is unconventional, and the battlespace is
nondoctrinal. As we modify our tactics to combat the enemy, the enemy likewise
changes his approach, rendering massive conventional campaigns ineffective. The
reason is simple: No force can match the U.S. military head-to-head in conventional
warfare. Because of OIF experience, an evolution from current doctrine is occurring
combat health support (CHS). While being mindful that some tenets of support
must not change, those of us who provide CHS often have to resort to innovative
methods in order to provide quality, far-forward medical care. No unit has illustrated
this concept better than the Brigade Support Medical Company (BSMC) of the 296th
Brigade Support Battalion (BSB), 3d Brigade, 2d Infantry Division (3–2
BCT), or “Arrowhead Brigade,” from Fort Lewis, Washington, in support
of OIF from November 2003 to November 2004.
At first glance, the 296th BSB’s BSMC looked much like a forward support
medical company and had the same capabilities: level II medical care; emergency
dental, limited x-ray, and laboratory services; evacuation and support elements;
and a few medical operating systems that focus treatment far forward to soldiers
in the brigade sector. The unique assets of the BSMC were the Medical Logistics,
Mental Health, and Preventive Medicine (PVNTMED) Sections and two personnel not
typically seen in a medical unit below corps level—a medical-surgical nurse,
who was the officer in charge of the Patient Holding Section, and a physical
therapist (not yet on the 3–2 BCT’s modification table of organization
Flexibility was essential during the BSMC’s OIF deployment. Unlike what
is taught during training rotations to the National Training Center at Fort
Irwin, California, and the Joint Readiness Training Center at Fort Polk, Louisiana,
the BSMC healthcare providers (physicians and physician assistants) in Iraq augmented
battalion aid stations (BASs) for extended periods of time.
Split-based operations were common throughout the BSMC, greatly facilitating
the company’s area support mission. For most of the deployment, the company
was spread over six different forward operating bases (FOBs). While only one
FOB had a complete level II capability, another FOB, with area support augmentation
from corps-level units, maintained a level II capability minus laboratory and
x-ray functions. By adding more lightweight field laboratory and field x-ray
medical equipment, a level II care capability was established later in a split-based
scenario without increasing the number of authorized personnel. Ultimately, this
meant that level II care (minus dental) could be provided in two locations with
a minimal increase in the logistics footprint.
To conduct split-based operations, the BSMC’s five healthcare providers
were divided according to the company’s area support mission, risk, number
of traumas, and proximity to a combat support hospital (CSH).
Bridges (named for a 3–2 BCT soldier killed
in action) in Samarra, Iraq, an ambulance is loaded
with medical supplies and equipment.
This departure from the traditional, centrally located level
II care meant a heavy reliance on CSH support. For example,
soldiers requiring nonemergency diagnostic studies for moderate
trauma or potentially serious illnesses routinely were sent
to a CSH for laboratory or x-ray services. Soldiers needing
24 to 72 hours of observation or intravenous antibiotics had
to tolerate interrupted bed rest and frequent trips to the
One of the most significant decisions that had to be made was where and how to
locate the level II medical facility in the mature theater. The primary mission
of a BSMC is to provide immediate lifesaving care to stabilize casualties for
transport. In planning the CHS battlefield layout, this mission is paramount.
Also to be considered are demands for area support and augmentation, which are
determined by looking at areas that have little to no coverage and on the population
of each area. In other words, coverage is based on trauma first and sick call
Mental Health Section
The Mental Health Section, which was staffed by a behavioral science officer
(a captain) and a mental health specialist (a specialist), was responsible for
the well-being of over 5,000 soldiers in 13 different locations. To cover this
large population, the 785th Medical Company (Combat Stress Control) provided
augmentation in the form of four mental health specialists (two sergeants and
two specialists) and a behavioral science officer (a captain). The support concept
focused on far-forward care at various locations to expedite treatment and minimize
both lost time and evacuation of soldiers to the rear of the brigade sector and
out of theater. This battlefield coverage closely resembled the doctrinal allocation
of one licensed behavioral healthcare provider for the first 2,500 soldiers,
one additional provider for every 2,000 soldiers, and one mental health technician
for every 1,000 soldiers.
Preventive Medicine Section
The Preventive Medicine (PVNTMED) Section was staffed by two personnel—an
environmental science officer (a first lieutenant) and a preventive medicine
specialist (a specialist). The mission of the PVNTMED Section was to conduct
environmental health surveillance, inspection, and consultation services for
the brigade. In other words, its mission was to protect soldiers proactively
from disease, illness, and sickness caused by poor sanitation, bugs, animals,
and other organisms.
During the first 5 months in Iraq, the PVNTMED Section supported 13 different
locations, including logistics support areas, FOBs, camps, and ammunition supply
points. During the sixth month, the 224th Medical Detachment (PVNTMED) at Fort
Hood, Texas, provided two PVNTMED specialists and a team that consisted of a
sergeant and a specialist. The team was split—the sergeant was positioned
at an FOB with five outlying sites, and the specialist was responsible for an
FOB with two outlying sites.
The remaining three FOBs and two outlying sites remained the responsibility of
the BSMC’s PVNTMED Section. Monthly quality assurance inspections and assessments
were made of dining facilities, water-production sites, ice plants, detention
cells, barbershops, and base camps. The PVNTMED Section also assisted with soldier
awareness through classes, information boards, and fragmentary orders that kept
soldiers informed about mission changes.
Patient Holding Section
A medical-surgical nurse (a captain) was responsible for the operation of the
40-bed Patient Holding Section. There, casualties expected to return to duty
within 72 hours were cared for and monitored. The medical-surgical nurse was
responsible for the training of four trauma specialists (military occupational
specialty 91W), two of whom were sergeants, one a specialist, and one a private
first class. In addition, the medical-surgical nurse coordinated and supported
the certification and testing of fundamental 91W competencies, such as the semiannual
combat medic skills verification and cardiopulmonary resuscitation training.
During the BSMC’s deployment, the medical-surgical nurse was extremely
beneficial, especially during hospital assessments and monthly regional meetings
and in coordinating and resolving medical issues. For future deployments, the
brigade surgeon, the BSMC commander, and the medical-surgical nurse concur in
the need for an additional Nurse Corps officer authorization for a brigade nurse
in the Brigade Surgeon Section. That nurse would be responsible for medical trends
analysis, patient tracking, outreach programs, limited specialty training, 91W
certification tracking, and continuing education of medical personnel. Having
both a medical-surgical nurse and a brigade nurse in the brigade would permit
the Patient Holding Section to operate successfully while effectively exploiting
the skills and experience of a senior, clinically proficient Nurse Corps officer
to monitor, track, and enhance the medical capabilities of the 3–2 BCT.
The 3–2 BCT deployment to Iraq included the first physical therapist (a
major) deployed at the brigade level. During deployment, the therapist traveled
to five remote FOBs to evaluate and treat soldiers. As the deployment progressed,
the therapist instituted a number of practices that significantly enhanced his
efficiency. For example, he carried an aid bag stocked with physical therapy
supplies so physical therapy services would be immediately available during convoys
or at remote FOBs. Collocating physical therapy services with sick-call services
enabled the therapist to provide immediate care to patients with orthopedic complaints
and allowed easier consultation between the primary healthcare providers and
the physical therapist.
Six months into the deployment, the physical therapist had seen 841 patients
and had made 6 trips to remote FOBs to see an additional 85 patients.
Other BSMC Capabilities
The Dental Section of the BSMC supported all
organic units, attached Army National Guard and Army Reserve elements, and numerous
other personnel during the OIF deployment. The dental clinic provided many services,
including oral surgery, endodontics (root canals), operative and esthetic dentistry,
annual exams, and dental hygiene. Many improvements have been made in transitioning
the dental component into a lighter and more mobile asset. The Dental Section
examined and treated over 750 patients and performed more than 1,400 procedures
in the first 7 months of the deployment. More than 100 dental cleanings also
were provided during this time, which were critical to preventing dental disease
while in the theater of operations.
The BSMC’s digital x-ray capability made it possible to diagnose fractures
and shrapnel wounds accurately and transport the x rays electronically. Over
the first 6 months, the digital x-ray system failed only twice, once because
of a mechanical problem and once because of a software problem. Both issues accounted
for less than 2 weeks of not-mission-capable time, most of which was spent waiting
for the parts or software.
The BSMC’s clinical analyzer, known by its trade name i-STAT, provided
point-of-care blood analysis with minimal wait time for results. In future deployments,
an electrical centrifuge, which separates blood components at a speed of 5,200
or more revolutions per minute, would increase the BSMC’s blood analysis
capability significantly with little or no impact on the company’s logistics
Medical Reporting, Tracking, and Management
To help track care and medical logistics on the battlefield efficiently, several
automated systems were fielded to the BSMC during its train-up and certification.
Some of these systems were implemented successfully, and others are still works
in progress that had significant operational shortfalls.
The Medical Communications for Combat Casualty Care (MC4) system is the hardware
that supports automated medical reporting, tracking, and management functions
for deployed medical units. This “system
of systems” supports complete clinical care documentation, medical supply
and equipment, and patient movement and in-transit visibility.
The MC4 system captures medical treatment information in an austere environment
through either manual media transfer or a “store and forward” capability.
This is accomplished through the interaction
receives dental care at Forward
Operating Base Pacesetter.
of the handheld Battlefield Medical Information
System-Tactical (BMIST) data-recording system and the Composite
Health Care System II (CHCS II).
Although the BMIST required minimal user training, its performance was limited
by the requirement that a user have a legible personal identification card, or
PIC. The PIC is designed to hold a soldier’s personal data and complete
medical record and is intended to be worn with his identification tags. However,
factors such as heat, perspiration, and constant impact often rendered the cards
unreadable. Therefore, all information had to be entered into the handheld device
manually. This factor alone made the system unwieldy to use. A field medical
card would have been more expeditious.
CHCS II generates and maintains a comprehensive, lifelong computer-based patient
record (CPR) for beneficiaries of the military healthcare system. Although this
second generation system is more robust than its predecessor, it had some significant
shortcomings during deployment to OIF. The most significant failure was its inability
to “reach back” and retrieve a soldier’s CPR. This prevented
the review of medical history that assists in more responsive care and diagnosis.
Another notable CHCS II deficiency was the lack of a theater or brigade data
repository. If a soldier changed locations, the only way he could maintain his
in-theater medical history was by taking a hard copy with him. Healthcare providers
could not access any other unit’s database unless directly connected. In
addition, the system did not provide reliable documentation required
The Theater Army Medical Management Information System (TAMMIS) Customer Assistance
Module (TCAM) is a Windows-based medical logistics ordering and inventory tool
used to order medical supplies; review catalogs; and check order status, on-hand
balances, and available substitutes that are used by medical
units. Designed with flexibility in mind, TCAM is customer-friendly, automated
ordering software that has minimal systems requirements and can be used with
very little training. However, in a deployed environment,
its use is, in most cases, limited to ordering because of poor or unreliable
connectivity. As the theater develops, connectivity should improve and other
functions of the TCAM should be more readily available.
For forward units, one of the most critical capabilities is determining order
status. For a unit to order the correct quantity of items needed for a specific
period of time, it must know the anticipated customer wait time. This allows
accurate forecasting without over ordering, which results in retrograding excess
items or “dumping” them on the battlefield as the operation progresses.
More importantly, the ordering function of TCAM notifies the unit that the items
it requested have been shipped and will require pickup, which helps to ensure
that the unit gets the supplies it
ordered on time.
The Defense Medical Logistics Standard Support Assemblage Management (DMLSS–AM)
system is a medical set management tool that assists the user in creating, ordering,
and tracking shortages by set. Although intensive training is needed to use it,
DMLSS–AM is a very powerful program that has great potential. Based on
feedback from the noncommissioned officer who was in charge of the 3–2
Supply Office, some improvements are being made to the program. These improvements
include incorporating cataloging and automatic substitution functions, which
will assist in forecasting stock listings at the supply support activity
(SSA). Customers will be given a limited list of alternates when their first
choice is not available or suitable. Because the SSA is more likely to have items
in stock and can ship more quickly, customers will be more satisfied.
During operations in and around Samarra, Iraq, the 3–2 BCT was located
on the Samarra East Airfield at FOB Pacesetter. Initially, with medical facilities
in such close proximity, the maneuver battalions conducted operations in Ad Duluiyah,
just outside of the FOB, using their organic Stryker medical evacuation vehicles
(MEVs) as the primary means of evacuation from point of injury back to the BSMC.
As operations progressed, the maneuver battalions moved to the outskirts of the
city to initiate Operation Ivy Blizzard with forces from Fort Hood’s 4th
Infantry Division (Mechanized). The BSMC remained at FOB Pacesetter while level
I assets, augmented with two evacuation platforms, moved with their battalions.
When the BSMC was required to evacuate from the BAS, the maneuver units provided
security. The primary means of evacuation from level II care to level III was
by UH–60 Black Hawk MEDEVAC (medical evacuation) helicopters.
As the threat of attacks with improvised explosive devices (IEDs), small arms
fire, grenades, and rocket-propelled grenades increased, so did evacuation support.
The greatest change in evacuation procedures was the prohibition of “soft-skin” vehicles
on the main supply routes. A “soft-skin” vehicle is one that does
not have sufficient armor to protect the driver and passengers during attacks.
Consequently, the primary means of evacuation was by air, and on-the-ground MEV
evacuation was the alternate means. The frontline ambulances were used only for
patient evacuations at the FOB. With few exceptions, evacuations from the BAS
directly to the BSMC were by MEV or MEDEVAC helicopter. As the battlefield transformed
into a battlespace, the dependence on UH–60 helicopters for casualty evacuation
increased because of the long distances involved, the speed required, and the
need to protect soldiers and assets.
Support Medical Company medic (right) prepares to
stitch a laceration on the head of an Iraqi soldier.
At left is a contracted translator.
The doctrine used to prepare and certify the
Army’s first Stryker Brigade for its deployment to OIF
was tested and modified to meet the evolving tactics and techniques
of its enemies. The continuing evolution requires change and
flexibility, not only within the standing operating procedures
of the combat arms, but also of combat service support and
As the Iraqi people struggle to restructure their country and effectively exercise
their sovereignty amid constant threats from insurgents, the transformation of
the battlefield requires a flexible, agile CHS system to support every soldier
Throughout a year of deployment, the 3–2 BCT medical community met the
challenges of a nonlinear battlefield and provided superior care to the casualties
inflicted by an unconventional enemy. Although the flexibility required stretched
the medical support system to its limit, coordination among medical assets accomplished
the mission and provided the best care possible to soldiers despite such limiting
factors as time and distance to the next level of care, obsolete evacuation platforms,
and greatly dispersed providers.
Physical therapy and mental health assets unique to the brigade, along with the
traditional medical assets, minimized the time soldiers requiring care spent
away from their units. The PVNTMED Section ensured that the entire force stayed “fit
to fight” by monitoring food and water sources and mitigating the threat
Although the deployment was not without trauma and critical injury to soldiers
from hostile fire and accidents, the superior medical training that the 3–2
BCT healthcare providers received before deployment, their ability to maintain
a 95-percent equipment operational readiness rate, the timely distribution of
medical materiel, and the flexibility of both treatment and evacuation contributed
to exceptional care and the best possible chance of survival for the brigade’s
Major Scot A. Doboszenski is the Commander of the Brigade
Support Medical Company, 296th Brigade Support Battalion, 3d
Brigade Combat Team (the Army’s
first Stryker Brigade), 2d Infantry Division, at Fort Lewis, Washington.
He has a master’s degree in psychology from Saint John’s University
in Minnesota and a master’s degree in management of information systems
and sciences from Bowie State University in Maryland. He is a graduate of
the Army Medical Department Officer Basic Course, the Medical Logistics Management
Course, the Combined Logistics Officers Advanced Course, and the U.S. Army
Medical Materiel Agency Medical Logistics Management Intern Program.