Combat health support in the Army's first Stryker Brigade.

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, non-doctrinal methods are often key to maintaining flexibility.

Lessons learned during Operation Iraqi Freedom (OIF) have shown that the current battlefield is non-linear, 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 in 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.

BSMC Assets

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 and equipment).

Split-Based Operations

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). 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 closest BAS.

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 second.

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 education and 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.

Physical Therapy

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 footprint.

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 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 for redeployment.

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 BCT's Medical 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.

Evacuation Operations

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.

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 CHS.

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 and civilian.

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 of disease.

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 soldiers.

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), 20 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 DECREE IN MANAGEMENT OF INFORMATION 5YSTEMS 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.