FM 4–02 Army Health System MEDCoE Review
Written by Julius W. Chan and Chad E. Nelson
Field Manual (FM) 4–02 provides doctrine for the Army Health System (AHS) in support of the modular force. The AHS is the overarching concept of support for providing timely AHS support to the tactical commander. It discusses the current AHS force structure which was modernized under the Department of the Army approved Medical Reengineering Initiative and the Modular Medical Force. These modernization efforts were designed to support the brigade combat teams and echelons above brigade units.
As the Army’s AHS capstone doctrine publication, FM 4–02 identifies medical functions and procedures essential for operations covered in other Army Operational Medicine proponent manuals. This publication depicts AHS operations from the point of injury or wounding, through successive roles of care within the area of operations, and evacuation to the continental United States (U.S.)-support base. It presents a stable body of operational doctrine rooted in actual military experience and serves as a foundation for the development of the rest of the Army Medicine proponent manuals on how the AHS supports unified land operations. FM 4–02 is currently being revised and is projected to be published 2nd Quarter Fiscal Year 2020.
Summary of changes from the 2013 published version include —
· Aligning this publication with Army hierarchy publications including FM 3–0 and FM 4–0.
· Aligning this publication with Joint Publication 4–02, Joint Health Services’ Force Health Protection (FHP) and Health Service Support (HSS) definitions and descriptions.
· Reorganizing the order of the publication; FHP is now Part Two while HSS is Part Three.
· Revising the definitions of the following terms — AHS, FHP, HSS, definitive care, essential care, and triage.
· Replacing the mission command medical function with medical command and control; this is in line with ADP 6–0.
· Moving proponent terms from this publication to other publications that are best suited for the terms and definitions. See Introductory Table-1.
· Adding Global Health Engagement information.
· Adding hospital center information.
· Adding an appendix derived from FM 3–0 discussing command and support relationships.
· Adding an appendix discussing AHS support to the Army’s strategic roles (shape operational environments, prevent conflict, prevail in large-scale ground combat (LSGCO), and consolidate gains).
The AHS is a component of the Military Health System (MHS) responsible for operational management of the HSS and FHP missions for training, pre-deployment, deployment, and post-deployment operations. The AHS includes all mission support services performed, provided, or arranged by Army Medicine to support FHP and HSS mission requirements for the Army and as directed, for joint, intergovernmental agencies, coalition, and multinational forces. The AHS is a complex system of systems that is interdependent and interrelated and requires continual planning, coordination, and synchronization to effectively and efficiently clear the battlefield of casualties and to provide the highest standard of care to our wounded or ill Soldiers.
AHS Medical Capabilities
The AHS medical capabilities (ten medical functions) are grouped under two Army warfighting functions- FHP under the protection warfighting function and HSS under the sustainment warfighting function. These interrelated and interdependent medical functions are complex in nature and require medical command and control for synchronization. This ensures the interrelationships and interoperability of all medical assets and optimizes the effective functioning of the entire system. The ten medical functions are —
· Medical command and control.
· Medical treatment (organic and area support).
· Hospitalization.
· Medical logistics (to include blood management).
· Medical evacuation (MEDEVAC) (to include medical regulating).
· Dental services.
· Preventive medicine services.
· Combat and operational stress control.
· Veterinary services.
· Medical laboratory services (to include both clinical laboratories and environmental laboratories).
Figure 1–1 above depicts the ten medical functions-
· FHP (five yellow colored wheels) is under the protection warfighting function.
· HSS (four red colored wheels) is under the sustainment warfighting function.
· All functions (all wheels) are interlinked, interdependent, and interrelated and require continuous planning, coordination, and synchronization. In the center of this complex system (black colored wheel) is the medical command and control function, which is responsible for the integration, synchronization, and command and control of the execution of all AHS support, both FHP and HSS.
The principles of the AHS are the foundation — enduring fundamentals — upon which the delivery of health care in a field environment is founded. The principles guide medical planners in developing operation plans (OPLANs) which are effective, efficient, flexible, and executable. AHS plans are designed to support the operational commander’s scheme of maneuver while still retaining a focus on the delivery of Army medicine.
AHS Principles
The AHS principles apply across all medical functions and are synchronized through medical command and control and close coordination and synchronization of all deployed medical assets through medical technical channels. The six AHS principles are:
· Conformity- the most basic element for effectively providing AHS support is conforming to the operation order. AHS planners must be involved early in the planning process to ensure there is continued provision of AHS support in support of the Army’s strategic roles of shape operational environments, prevent conflict, prevail in large-scale ground combat, and consolidate gains, and once the plan is established, it must be rehearsed with the forces it supports.
· Proximity- is to provide AHS support to sick, injured, and wounded Soldiers at the right time and the right place and to keep morbidity and mortality to a minimum. AHS support assets are placed within supporting distance of the maneuver forces, which they are supporting, but not close enough to impede ongoing operations.
· Flexibility- is being prepared to, and empowered to, shift AHS resources to meet changing requirements. Changes in plans or operations make flexibility in AHS planning and execution essential.
· Mobility- is the principle that ensures that AHS assets remain in supporting distance to support maneuvering forces. The mobility, survivability (such as armor plating), and sustainability of AHS units organic to maneuver elements must be equal to the forces being supported. In LSCO, the use of ground ambulances may be limited depending on the security threat in unassigned areas and air ambulance use may be limited by environmental conditions and enemy air defense threat. Therefore, to facilitate a continuous evacuation flow, MEDEVAC and casualty evacuation (CASEVAC) must be a synchronized effort to ensure timely, responsive, and effective support is provided to the tactical commander.
· Continuity- the continuous medical care and treatment is achieved by moving the patient through progressive, phased roles of care, extending from the point of injury (POI) or wounding to the supporting hospital center or combat support hospital (CSH) to the Defense Health Agency (DHA) Role 4 CONUS-support base Medical Treatment Facility (MTF). A major consideration and an emerging concern in future conflicts is providing prolonged care at the point of need when evacuation is delayed. The Army’s future operating environment (OE) is likely to be complex and challenging and widely differs from previous conflicts. Operational factors will require the provision of medical care to a wide range of combat and noncombat casualties for prolonged periods that exceed current evacuation planning factors.
· Control- is required to ensure that scarce AHS resources are efficiently employed and support the operational and strategic plan. As Army Medicine is comprised of 10 medical functions which are interdependent and interrelated, control of AHS support operations requires synchronization to ensure the complex interrelationships and interoperability of all medical assets remain in balance to optimize the effective functioning of the entire system.
Army Health System Logic Chart Explained
According to FM 3–0, the future OE and our forces’ challenges to operate across the range of military operations represents the most significant readiness requirement. Refer to the logic chart below depicted in Figure 1–2 regarding how AHS supports the operating forces:
- It begins with an anticipated OE that includes considerations during LSCO against a peer threat.
- Next, it depicts the Army’s contribution to joint operations through the Army’s strategic roles.
- Within each phase of a joint operation, the Army’s operational concept of unified land operations guides how Army forces conduct operations.
- In LSGCO, Army forces combine offensive, defensive, and stability tasks to seize, retain, and exploit the initiative in order to shape OEs, prevent conflict, conduct LSGCO, and consolidate gains.
- The command and control warfighting function (ADP 6–0) designates commanders over assigned and attached forces in their approach to operations and the accomplishment of their mission. Command and control enables commanders and staffs of theater armies, corps, divisions, and brigade combat teams to synchronize and integrate combat power across multiple domains and the information environment.
- Throughout operations, Army forces maneuver to achieve and exploit positions of relative advantage across all domains to achieve objectives and accomplish missions. Throughout operations, Army forces maneuver to achieve and exploit positions of relative advantage across all domains to achieve objectives and accomplish missions.
- Most importantly, the logic chart depicts how the AHS supports the operating force to support FHP and HSS mission requirements for the Army and as directed, for joint, intergovernmental agencies, coalition, and multinational forces during LSCO.
Army command and support relationships are similar but not identical to joint command authorities and relationships. Differences stem from the way Army forces task-organize internally and the need for a system of support relationships between Army forces. Another important difference is the requirement for Army commanders to handle the administrative support requirements that meet the needs of Soldiers. These differences allow for flexible allocation of Army capabilities within various Army echelons. Army command and support relationships are the basis for building Army task organizations. Certain responsibilities are inherent in the Army’s command and support relationships.
The complexities of the range of military operations, the myriad of medical functions and assets, and the requirement to provide health care across unified land operations to diverse populations (U.S., joint, multinational, host nation, and civilian) necessitate a medical command authority that is regionally focused and capable of utilizing the scarce medical resources available to their full potential and capacity. Each of the medical command organizations (medical command [deployment support] [MEDCOM (DS)], medical brigade [support] [MEDBDE (SPT)], and medical battalion [multifunctional] [MMB]) is designed to provide scalable and tailorable command posts for early entry and expeditionary operations which could be expanded and augmented as the area of operations (AO) matures and an Army and joint integrated health care infrastructure is established. Figure 1–3 depicts AHS organizations’ command and support relationships during an operation or when deployed.
Framing Theater Sustainment Support and Command Relationships
The theater army always maintains an area of responsibility (AOR)-wide focus, providing support to Army and joint forces across the AOR, in accordance with the geographical combatant command (GCC) commander’s priorities of support. For example, the theater Army continues to shape operational environments and prevent conflict activities in various operational areas at the same time it is supporting large-scale ground combat operations. The theater army serves as the Army service combatant commander (ASCC) of the GCC. It is organized, manned, and equipped to perform that role. The ASCC is the command responsible for recommendations to the joint force commander (JFC) on the allocation and employment of Army forces within a combatant commander’s (CCDR) AOR. For additional information refer to FM 3–94, Theater, Army Corps, and Division Operations.
According to ATP 4–93, Sustainment Brigade, theater armies are assigned or provided access to five enabling capabilities (sustainment, signal, medical, military intelligence, and civil affairs), and an assortment of functional and multifunctional units, based on specific requirements for the area of responsibility.
According to FM 4–02, The MEDCOM (DS) is assigned to the ASCC. As one of the theater enabling commands, the MEDCOM (DS) is the theater medical command responsible for integration, synchronization, and command and control for the execution of all AHS support operations within the AOR. The MEDCOM (DS) may have a direct support or general support relationship with the corps or the division. The MEDCOM (DS) has a general support relationship with the theater sustainment command (TSC) or expeditionary sustainment command (ESC). A high level of coordination between the medical command and staff channels develops the situational understanding necessary to recommend priorities and courses of action to echelon commanders.
The surgeon and the surgeon cells at each echelon identify, assess, counter and/or mitigate health threats across the range of military operations. They advise commanders on medical capabilities and capacities necessary to support plans, and interface with sustainment cells (logistical, financial management, and personnel elements), protection cells, intelligence, operations, civil affairs and other command staffs to coordinate AHS support across the warfighting functions. The surgeon and the surgeon cells at each echelon including the (TSC, ESC, and sustainment brigade surgeon cells) work with their staff to conduct planning, coordination, synchronization, and integration of AHS support to plans to ensure that all 10 medical functions are considered and included in running estimates, operations plans (OPLANS), and operation orders (OPORD) in coordination with the MEDCOM (DS). Refer to Figure 1–4.
Logistics, financial management, personnel services, and HSS require coordination and synchronization at every stage of the planning process. This synchronization is crucial during LSCO with its inherently distributed nature. Only by integrating and synchronizing sustainment functions can the sustainment system achieve required effects at the speed, volume, velocity, and lethality of LSCO.
According to FM 4–0, Sustainment Operations, the TSC is the Army’s command for the integration and synchronization of sustainment in the AOR. The TSC connects strategic enablers to the tactical formations. It is a theater-committed asset to each ASCC and focuses on Title 10 support of Army forces for theater security cooperation and the CCDR’s daily operational requirements. The TSC commands assigned human resources sustainment centers and financial management support centers. The TSC commander also commands and task organizes attached ESCs, sustainment brigades, and additional sustainment units. The TSC executes the sustainment concept of support for planning and executing sustainment-related support to the AOR for all the Army strategic roles (shape OEs, prevent conflict, prevail in large-scale ground combat, and consolidate gains).
A number of high level table top exercises between the Medical Center of Excellence (MEDCoE) and the Sustainment Center of Excellence (SCoE) (CASCOM) conducted last year and early this year validated that TSCs execute sustainment operations through their assigned and attached units. The TSC integrates and synchronizes sustainment operations across an AOR from a home station command and control center or through a deployed command post (CP). The TSC has four operational responsibilities to forces in theater: theater opening, theater distribution, sustainment, and theater closing. The task-organized TSC is tailored to provide operational-level sustainment support within an assigned AOR. It integrates and synchronizes sustainment operations for an ASCC including all Army forces forward-stationed, transiting, or operating within the AOR. The TSC coordinates Title 10, Army support to other Services, DOD Executive Agent, and lead service responsibilities across the entire theater. The TSC organizes forces, establishes command relationships and allocates resources as necessary to support mission requirements, and exercises command and control over attached sustainment forces. The TSC supports the ASCC sustainment cells with planning and coordinating theater-wide sustainment. The execution of sustainment is decentralized, performed by the human resources sustainment centers, financial management support centers, ESCs, sustainment brigades, and other sustainment organizations.
The MEDCOM (DS) commander is responsible for maintaining a regional focus in support of the GCC and ASCC theater engagement plan, while providing effective and timely direct FHP and HSS to tactical commanders and general support (on an area basis) to theater forces at echelons above brigade.
Defining Roles and Responsibilities within the Sustainment Warfighting Function
These high level table top exercises between MEDCoE and CASCOM also validated that the MEDCOM (DS) commander is responsible for maintaining a regional focus in support of the GCC and ASCC theater engagement plan, while providing effective and timely direct FHP and HSS to tactical commanders and general support (on an area basis) to theater forces at echelons above brigade. The enduring regional focus of the ASCC drives organizational specialization in supporting the MEDCOM (DS) to address unique health threats, specific needs of the local populace, availability of other Service medical capabilities, and geographic factors that are distinctly related to a particular region. The MEDCOM (DS) coordinates with the ASCC surgeon (as the staff proponent with execution through G-3 channels under the authority of the ASCC commander) to provide AHS support within the AOR.
As the theater medical command, the MEDCOM (DS) integrates, synchronizes, and provides command and control of medical brigades (support), medical battalions (multifunctional), and other AHS units providing FHP and HSS to tactical commanders. The MEDCOM (DS) employs an operational CP and a main CP that can deploy autonomously into an operational area and is employed based on the size and complexity of operations or the support required. Refer to Figure 1–5 for an overview of a theater medical structure.
Key tasks of a MEDCOM (DS) in support of the ASCC include —
· Providing command and control of MEDBDE (SPT) and subordinate medical units assigned and attached.
· Task-organizing medical elements based on specific medical requirements.
· Monitoring health threats within each operational area and ensuring the availability of required medical capabilities to mitigate those threats.
Summary
Myriad doctrinal updates have recently been published to prepare the Army for the potential of LSCO. Revisions to FM 4–0 nest within changes to ADP/FM 3–0 to support the Army’s efforts to shape operational environments, prevent conflict, prevail in LSGCO, and consolidate gains in support of the joint force. The forthcoming FM 4–02 provides a doctrinal foundation to ensure leaders at echelon understand the complex system of medical functions required to maintain the health of the unit by promoting health and fitness, preventing casualties from DNBI, and promptly treating and evacuating those injured in the OE. Only a focused, responsive, dedicated medical effort can reduce morbidity and mortality and provide the best medical support to the maneuver commander’s concept of the operation.
Julius W. Chan
Chief, Doctrine Literature Division
US Army Medical Center of Excellence (MEDCoE)
Chad E. Nelson
Chief, Army Doctrine Branch
Doctrine Literature Division
U.S. Army Medical Center of Excellence (MEDCoE)
The views expressed in this article are the authors’ alone and do not reflect the official position of the Medical Service Corps, the Department of Defense, or the US Government.
