Forward Medical Service Support

System (FMSSS)

Philippines

METHODOLOGYConduct of written survey to selected ground troops in the Army Brigades and Battalions of the First Infantry Division in Zamboanga Del Sur and the Marine Brigade and Battalions in Basilan, both located in Mindanao, Southern Philippines.

The Project Management Team (PjMT) conducted an assessment, and concluded that the absence of an established doctrine is the most significant factor in the actual and perceived flaw for a responsive and efficient delivery of Forward Medical Service Support (FMSS). The lack of doctrine caused several other shortfalls in the forward delivery system including: Organization, Training, Materiel, Personnel, and Facilities.

DELIVERABLES1. Policies on the Career Development of Field Medical Service Personnel

a. Basic Medical Aidman Course/Advanced Medical Aidman Course accreditation as career course

b. Medical Service (MS) Military Occupational Specialty2. Support System through upgrading of Forward Support Medical Units

a. TO&E of Forward Support Medical Companyb. TO&E of Medical Platoon, Infantry Battalion

3. Standardized POI for First Aid Skills (Self-Aid/Buddy-Aid and Combat Lifesaver) of individual soldiers and Field Medical Service Personnel; Accreditation System for MS EP Trainers

4. Develop and expand medical support system through MOA/MOU with local hospitals and other healthcare providers

5. Forward Medical Support Doctrinea. FMSSS Manualb. Brigade and Battalion Medical Equipment and Supplies Templatec. SOP (Medical Records and Utilization of Field Line Ambulance)

FUNDAMENTALS Basic Medical Service Support (MSS) Doctrine Major Tenets of MSS MSS Challenges including planning, prevention, far forward care, and medical evacuation (MEDEVAC) Concept of MSS System Principles of MSSEchelons (Levels) of Care Applicability of the system in war and in Operations-Other-Than-War (OOTW)

MEDICAL SUPPORT SYSTEM (MSS)

Continuum of successive echelons (levels) of care, beginning at the point of injury up to an appropriate Medical Treatment Facility (MTF), both military and civilian.

 

Basic Doctrine of Medical Service SupportThe objective of the MSS system is to conserve the fighting strength of tactical units by:

 • Reducing the incidence of Disease and Non-Battle Injury

(DNBI) and Battle Fatigue (BF) through sound preventive medicine and Combat and Operational Stress Control (COSC) programs;

 • Providing care and treatment of acute illnesses, injuries, or

wounds; and 

• RTD as many soldiers as possible at each echelon.

• Far forward medical treatment including, but not limited to, Advanced Trauma Management (ATM);

 • Patient evacuation that is timely and efficient.

MAJOR TENETS OF THIS DOCTRINE:  

• Selectivity of Return to Duty (RTD) and Non-Return to Duty (NRTD) patients at lowest possible echelon;

 • Standardized Echelons I and II MSS units;

and 

• A medical system that provides continuous medical management throughout all echelons (levels) of care and evacuation.

MEDICAL SERVICE SUPPORT CHALLENGESPrevention

  Most effective and least expensive method of

providing the commander with sustained combat power.

Enhanced by the application of training programs on Self- Aid/Buddy-Aid (SA/BA) and Combat Lifesaver (CLS); continuous interface with Unit and Division level medical aidmen; Division-wide preventive medicine programs; COSC programs; and leadership emphasis at all levels of Command. Ultimately, whether it is individual or collective, prevention is the unit commander’s responsibility.

Far Forward Care

Self-Aid/Buddy-Aid (SA/BA), Combat Lifesaver (CLS), and Unit level Forward Medical Service Support (FMSS).

Combat Lifesavers are equipped with a higher degree of skill than SA/BA but their primary role is the performance of their duties as members of the Squad, Section, or Team, and their first-aid duties are performed as the mission permits.

Far forward care is provided to the frontline soldier by the combat medic and field medical evacuation personnel attached to the Maneuver Company.

More comprehensive care at a physician-directed treatment at Battalion Aid Station (BAS), Brigade Treatment Facility (BTF), Forward Mobile Emergency Deployable Intermediate Care System (Forward M.E.D.I.C.S.), or civilian treatment facilities with initial resuscitation and stabilization, and advanced trauma management capabilities.

Medical Evacuation (MEDEVAC) 

En Route Care Ground ambulances are used in the Division for slightly wounded, ill, or injured soldiers who are expected to RTD.

Air evacuation is used, when feasible, for seriously wounded, sick or injured soldiers who are NRTD patients. In a combat situation, air evacuation assets will fly as far forward as the Mission, Enemy, Time, Terrain & Troops available (METT-T) permit.

  Responsibility for MEDEVAC rests with the next

higher echelon of MSS. For example, the Medical Platoon is responsible for the evacuation of patients out of the Forward Maneuver Company to the BAS. The Forward Support Medical Platoon (FSMP) attached to the Infantry Brigade is responsible for evacuation from the BAS to the BTF, and the Forward Support Medical Company (FSMC) from the BTF to the Division Station Hospital or to pre-established civilian hospitals in the locality throughout the evacuation chain may be done, if and when the condition of the patients so warrants.Use of non-medical vehicles should be established and supplemented when casualties exceed the capability of MEDEVAC assets.

Concept of Medical Service SupportIt is organized into five (5) separate Echelons of Care which extend rearward from the area of operation to those located in the Division level.

Legend: Self-Aid/Buddy-Aid (SA/BA); Individual First Aid Kit (IFAK); Combat Lifesaver (CLS);Basic Medical Aidman Bag (BMAB); Mobile Medical Transport Kit (MMTTK); Emergency Lifesaving (ELS)

Medical Service Support Principles

CONFORMITY with the Tactical Plan Most fundamental element using medical intelligence data. MSS planner must participate in the development of the commander’s Operations Plan (OPLAN) to ensure adequate MSS at the right time and place and for rapid reinforcement or replacement of forward echelons of the MSS.

CONTINUITY Chain of medical units/elements from the combat zone (Echelon I) to the rear terminus (Echelon V) of medical care which may involve preventive medicine, COSC, treatment, evacuation, hospitalization, and rehabilitation. The medical goods and services are provided without break until the soldier is in RTD status or separated due to disability.

CONTROL Medical units are under the control of a single medical manager to ensure that scarce MSS resources are efficiently employed and support the tactical plan. Centralized control with decentralized execution permits the medical commander and his staff to rapidly tailor and adjust MSS assets.

  PROXIMITY Location of medical assets is as far forward as practicable and as the combat situation permits. Medical intervention is critical during the golden period of a traumatic injury.

FLEXIBILITY Ability to rapidly shift MSS resources to areas of greatest need in response to major shifts in the location and volume of casualties; changes in the supported unit composition and mission; and changes in the intensity of conflict. MOBILITY Mobility of MSS units organic to maneuver elements must equate to the forces being supported. Medical commanders must continually assess and forecast echelonment of medical units, through collective use of all transportation resources.

 ANTICIPATION Ability to foresee future operations and health support requirements by identifying, accumulating, and maintaining information required for MSS planning. RESPONSIVENESSProviding the right support in the right place at the right time and the ability to meet changing requirements on short notice.

SIMPLICITYMSS units and personnel usually operate with resource constraints and under severe battlefield conditions as such, planning and executing MSS operations must be understood easily with utmost practicality and economy.

IMPROVISATIONThe talent to create, enhance, arrange, or fabricate what is needed from what is on hand in order to provide sustained and responsive support. Innovative solutions to problems must be sought since not every eventuality can be anticipated.

Echelons of Medical Service SupportEach echelon of care reflects an increase in medical capabilities while retaining capabilities found in preceding echelon of care.  Echelon I Care - frontline medical care thru SA/BA, CLS, emergency first aid, initial wound surgery, relief of pain and discomfort, and prioritization for MEDEVAC. It also provides psychological SA/BA; support and/or referral; and CLS and combat medic cursory assessment and prescribed actions.

Echelon II Care - medical care provided to the rear of the battlefield by a team of medical personnel supported by a level of facilities; medical supplies; and equipment, either to stabilize casualties for further evacuation for a more definitive care or to treat them for RTD. For stress-related cases, this echelon provides outpatient counselling or the individual is held 1 to 3 days for rest and restorative activities.

 Echelon III Care - medical care provided in the combat zone at facilities staffed and equipped to provide resuscitation, initial and final wound surgery, and definitive and post operative treatment. For stress casualties, it provides hospital diagnostic capabilities and the individual is held 1 to 2 weeks for reconditioning treatment.  Echelon IV Care - medical care provided at General Hospitals staffed and equipped for definitive care, with a mission to rehabilitate casualties to duty status. Echelon V Care - medical care provided at the AFP Medical Center, civilian Medical Centers, or Specialty Hospitals for definitive, specialized, and rehabilitative care.

Division Level Forward Medical Service SupportThe Forward Support Medical Company (FSMC) provides Echelon II forward medical support for units operating in the division and brigade area of operation (AO). Each company consists of headquarters section and three (3) Forward Support Medical Platoons (FSMP) that will provide direct support (DS) to the infantry brigades.

ORGANIZATION

 • Patient holding for up to ten (10) patients per brigade and able to RTD within

seventy two (72) hours.

• Limited reinforcement and augmentation to supported maneuver battalion medical platoons.

 • Provide combat medic to the reconnaissance companies of the division and

security platoons of the brigade

Assignment Organic to the Service Support Battalion (SSBn), Infantry Division.

 Allocation

One (1) FSMC per infantry division.

  Concept of Appointment Deploy one (1) FSMP to provide direct medical support to each Infantry Brigade.

Capabilities

Battalion Level Medical Service SupportMedical Platoon, HHC, Infantry Battalion

Medical Platoon Organizational Structure

• Mission

To provide Echelon I medical support to elements of an Infantry Battalion to include EMT, evacuation, prevention of DNBI, and COSC

• Capabilities

Treatment and Outpatient consultation services 

Ground evacuation for patients from company aid posts (CAPs) and designated CCPs to BAS.

    Conduct of SA/BA and CLS refresher training. 

COSC program implementation in the AOR. 

Field Sanitation and Hygiene activities. 

Coordination of field blood support requirements. 

 

• Assignment    Headquarters and Headquarters company.

  • Allocation

   One (1) per infantry battalion.  • Concept of Employment

Provides Direct Support to an infantry battalion by operating a BAS; deploying combat medics to establish, man, and operate CAPs as needed; employ medical evacuation personnel to evacuate patients to the CAPs/CCPs, and ambulance team to evacuate patients from the CAPs/CCPs to the BAS.   

Unit Level Medical Service Support• Combat Lifesaver

A minimum of two (2) non-medical personnel per squad, team, or equivalent-sized unit are selected by the unit commander to undergo the CLS training program, which is normally provided by medical personnel assigned, attached, or in DS of the unit and managed by a designated senior medical person. Aside from his primary duty, the CLS is equipped with a kit to provide enhanced first-aid for injuries before the combat medic arrives.

• Self-Aid/Buddy-Aid (SA/BA)

SA/BA is the initial care applied by the individual soldier to himself or to other squad members if and when he gets sick or wounded in the field, using his knowledge and skills and individual first aid kit (IFAK) which is part of his individual clothing and individual equipment (ICIE). Most injured or ill soldiers are able to return to their units to fight and/or support primarily because they are given appropriate and timely first aid followed by the best medical care possible.  

  

Augmentation Medical Service Support• AFP Affiliate and Reserve Units (AFPARUs)

Certain government and private entities, corporations, establishments, and organizations at the national, provincial, and municipal levels which provide essential medical services and are considered vital and strategic in providing FMSS will be organized as medical affiliate and reserve units in coordination with the AFP Reserve Command (AFPRESCOM) to support the implementation of national defense plans or to meet an emergency. Key and technical personnel of the utility shall be commissioned/enlisted and included in the roster of personnel to cover all the activities of the management and operation necessary to function effectively in time of emergency.

  

• Field Surgical Hospital (Forward Medical Emergency Deployable Intermediate Care System Forward M.E.D.I.C.S.)

Nature:

Modularized deployable medical support system which may initially be attached to an ill-equipped, undermanned Station Hospital at Division level, or attached to an FSMC at Brigade level, or area FMSS to a Task Force conducting joint operations as a joint use facility, where the Major Services and Armed Forces of the Philippines Wide Service Support Units (AFPWSSUs) will contribute and rotate personnel requirements to augment its resuscitative surgical/trauma care capability.

Miniature mix of a clearing platoon and mobile surgical hospital.  

One of the major operating units of the AFP Medical Center (AFPMC).

 

Mission: To receive, sort, and provide emergency

or resuscitative treatment for patients until evacuated. 

Functions: Admits, sorts, and temporarily hospitalizes

injured and wounded soldiers.  Addresses life-threatening conditions of

combat casualties which are beyond the capabilities of combat medics.

  Provides emergency surgical care to stabilize casualties who might otherwise die or lose a limb before reaching definitive care.

  

Command Relationships:

The Chief of Staff, AFP (CSAFP) provides direction in the management and operation of the Forward MEDICS through the Commander, AFPMC. It shall be under the functional supervision of the Deputy Chief of Staff for Personnel, J1 through The Surgeon General, AFP. The Commander, AFPMC shall exercise command, control, and supervision to the Forward MEDICS unit. It shall be placed under operational control (OPCON) to the Unified Command to which it shall be deployed and placed under tactical control (TACON) to the joint task force or the operating command in the area of deployment.

The Forward MEDICS unit commander shall be authorized to coordinate with the MTFs in the adjacent area under its OPCON Unified Command on matters affecting the operation of the Forward MEDICS unit as in case of personnel augmentation during intense offensive operations when the probability of incurring trauma cases are high (surge casualties).

  

  

FORWARD MEDICAL TRAINING FACILITIES

  

Brigade Treatment Facilities (BTFs) 

Echelon II semi-fixed facility to stabilize and prepare casualties for further evacuation to an appropriate MTF for more definitive care. It also has the capability to treat minor injuries and sick call cases, and return the patients to duty.

Participates in the management of mass casualties through triaging, airway and breathing management, hemorrhage control, advance trauma management, casualty immobilization, minor surgical procedures, and as evacuation platform.

Provided with portable field equipment; instrument set; supply sets; furniture and office equipment to be able to attend to a wide variety of cases including observation cases. Figure 5-1.1 shows the basic medical equipment set found in the BTF.

    

  

Brigade Treatment Facilities 

BTF Medical Equipment Set (Echelon II) 

  

Battalion Aid Station (BAS) 

Echelon I primary medical care beyond the level of a combat medic.

Resuscitative treatment to prevent unnecessary evacuation and prepare the casualty for further evacuation to the appropriate level of care as necessary.

  It is mobile that allows maximum movement when the battalion is engaged in combat.

Provides scheduled appointments, unscheduled drop-ins or traditional sick call in garrison/base/camp during lull periods or when situation allows.

 

    

  

Battalion Aid Station (BAS) 

BAS Medical Equipment Set (Echelon I)

  

Mobile Medical Treatment and Transport Kit (for Echelon I & II)

  

Mobile Medical Treatment and Transport Kit Inserts

Individual First Aid Kit (IFAK)

 Issued to every personnel upon entry into the military service. Common medicines (anti-motility, antipyretic, anti-bacterial, and analgesic drugs ), dressings, band-aid strips. water purifying tablets and insect repellants and combat application tourniquet are contained in a canvass pouch which is carried by the individual soldier for easy access and use.

 

 

 

    

Individual and Organizational Medical Kits for Field Personnel

Individual First Aid Kit (Echelon I)

Combat Lifesavers Kit (CLS Kit) A rifle squad organizational equipment used by non-medical service personnel who have undergone CLS training. It is a folding canvass bag packed with critical life saving medical supplies in a handy carrying bag with strap for immediate emergency care of battle casualties. It has three separate compartments that contain supplies for airway and breathing management, hemorrhage control, trauma management and casualty immobilization. 

Combat Lifesaver Bag (Echelon I)

The Basic Medical Aidman Bag (BMAB)

an organizational equipment issued to every designated combat medic of the rifle squad, medical aidman, and medical evacuation personnel. It is a canvass bag containing medicines, medical supplies, and medical instruments needed for immediate resuscitative and initial trauma management of combat casualties on site or en route to MTF. 

The Basic Medical Aidman Bag (BMAB)

Medical Aidman Bag (Echelons I & II)

The Basic Medical Aidman Bag (BMAB)

The Basic Medical Aidman Bag (BMAB)

Medical Aidman Bag (Echelons I & II)

The Basic Medical Aidman Bag (BMAB)

FORWARD MEDICAL TRAINING FACILITIES

MTFs are so organized, and so located, as to provide the type and quality of medical care required with maximum internal efficiency and minimum interference with combat operations. The location of these facilities usually demands that large or complex MTFs be located at sites remote from active combat.

Evacuation Chain

 Evacuation is generally a staged process, not a continuous flow. Evacuation and treatment are interdependent. Evacuation flow is channeled through selected MTF along the evacuation route in order to provide necessary treatment. Response or non response to treatment at each facility dictates the need for, or urgency of, further evacuation.

Evacuation and Hospitalization

 Care and Treatment En Route

Medical personnel are assigned to all types of medical evacuation (MEDEVAC) vehicles in order to provide medical care en route. Before evacuating a patient, the MTF should note his condition and list special care requirements on the Field Medical Card or other medical record. The responsible medical officer will instruct medical personnel in the evacuation vehicle on any special attention that the patient may need en route. Evacuation personnel are responsible for the safety and comfort of all patients.

   Evacuation is medical support, not transportation. Patients are evacuated no further to the rear than their condition requires and the military situation permits. Evacuation of patients is normally, but not invariably, accomplished by the next higher level of medical support. An ambulance must have tactical and terrain mobility that is at least equivalent to that of the unit it supports. Field ambulances of maneuver units have capability for terrain mobility, and armor protection, to follow the supported units as close as possible in the front lines to substitute vehicles for man-carry. Evacuation of patients is normally, but not invariably, accomplished by the next higher level of medical support. Any means of transportation – medical or non-medical – may be utilized for the evacuation of patients. Rear higher echelon medical units are responsible in evacuating patients from supported units. Lower echelon supported and supporting units must ensure evacuation support plans are complete and current by close, direct coordination.

Principles which Guides Evacuation

Ground Evacuation Guidelines in the Use of Field of Ambulances

The safety and protection of the patient as well as the medical care providers shall be the primary consideration in the use of the field ambulances.  It shall be used to transport patients especially the critically ill/serious and/or injured.

 It is preferred for the evacuation of neuropsychiatric (NP) and battle fatigue (BF) casualties requiring restraints and or medications. However, a non-ambulance ground vehicle for evacuation is preferred for NP and BF casualties who can manage without medications and physical restraints.  It shall also be used to transport medical care providers and blood and emergency supplies.

It shall not be used to transport cadavers, transport able-bodied combatants, shelter of able-bodied combatants, as an arms and ammunition transport, or as military observation post.

Guidelines in the Use of Field of Ambulances The field ambulance shall be properly marked and identified.

The field ambulance must: 

Have appropriately trained and competent personnel.Have the prescribed equipment and supplies.Be regularly maintained.

The field ambulance must: 

Be always properly cleaned, sanitized, and decontaminated, before and after patient and medical care provider transport.

Medical personnel assigned to the ambulances that are positioned with the supported medical element will not be required to perform duties as kitchen police, perform as perimeter guards, and perform driver duties for other than their assigned vehicle.

 Adherence to Geneva Convention requirements for protection must be

ensured.