INTRODUCTION
Military Operations in Urban Terrain (MOUT) is the capability to operate and conduct military operations in built up areas. Urban areas of operations will tend to have high population densities, which include non-combatants. Typically, these areas also will have extensive infrastructure, including buildings, roads, bridges and health care facilities. MOUT will test the operational concepts of Joint Vision 2010 under the most demanding circumstances. MOUT is also the most complex and resource intensive environment that US forces are likely face. MOUT will test the capabilities of medical units, especially the Battalion Aid Stations supporting the Marine Ground Combat Element (GCE).
Urban centers are increasingly becoming sites of conflict though out the world. MOUT will require extensive use of Marine light forces, with a high potential for casualties. This high intensity conflict will place increased demands on the medical assets of these units. Since these operations will typically require battalion-sized forces, the battalion aid station (BAS) will become the key command and control element for the delivery of medical care. In order to meet these challenges, the BAS will have to adapt to these demands by altering it’s structure, inventory, and training. The Battalion Aid Stations of the 4th Marine Division have unique qualifications to adapt to supporting MOUT. These reserve units contain a large percentage of corpsmen who have extensive civilian experience and training as paramedics, firefighters, as well as other allied health care providers. This training and experience cannot be duplicated by the active forces and thus makes these units ideal for “specialization” in MOUT.
The 3rd Battalion, 25th Marines, 4th Marine Division has identified MOUT as a major focus of training to compliment its expertise in cold weather operations. In order to provide medical support to the 3/25 Marines, the members of NR 4MARDIV 3/25 (the 3/25 Battalion Aid Station) have developed a multi-year training plan to insure maximum readiness. This training plan begins with basic training in concert with the Battalion while capitalizing on the civilian skills of the unit members. As these training exercises progress and are evaluated, suggestions for equipment, supplies, individual training plan (ITP) modifications, as well as additional training requirements will be submitted to the Naval Readiness Command for review. Concepts of operations outlined in this paper will be tested and refined and ultimately, operational plans for BASS MOUT will be developed.
This paper will review the challenges facing the BAS in MOUT. It will attempt to identify potential problems that the BAS will face both in the field as well as within the current operational structure. Finally, it will highlight the steps taken by the 3/25 BAS to meet these challenges, as well as suggesting options for other medical units who will be called upon to provide medical support to MOUT. The Marine Corps Warfighting Laboratory is currently conducting exercises to develop strategies to address the problems faced by MOUT. Urban Warrior IV was specifically designed to look at medical support of MOUT. The results of these exercises are not yet available, but ultimately will be incorporated into our training and operational plans.
OPERATIONAL CAPABILITIES
Essential operational capabilities of engagement, force protection, and maneuverability must be applied to the medical assets of units employed in MOUT. These concepts need to extend down to the company level corpsmen and up to the level of the battalion surgeon. Engagement in terms of medical support can be interpreted as the ability to quickly locate and treat casualties. Force protection encompasses the ability of medical personnel to function within urban environments and ensure their personnel safety, as well as the safety of their patients. Maneuver will employ the ability to make use of informational technology and the ability to control patient flow from the field to higher echelons of care.
CHALLENGES OF BASS MOUT
Forward BAS operations: Currently, the battalion functions with corpsmen deployed with the line companies as well as at the BAS, along with one or two medical corps officers. This nucleus of corpsmen and medical corps officers comprises the BAS. Recent field exercises, including CAX 7/98, has demonstrated the advantages of having “dual” BAS’s. The forward BAS is located very close to combat operations, allowing casualties to be quickly cared for and stabilized. Casualties can be evacuated to the BAS by ambulance or litter. In “typical” combat operations, the first line of transportation will be by litter. In MOUT, it will likely require a medical team and vehicle to locate, treat, and evacuate the patient to the BAS. Once a casualty is received into the forward BAS, he or she can be treated and returned to duty or treated, stabilized and evacuated back to the rear BAS, Group or Combined Aid Station or to the Fleet Hospital.
Current operating procedures call for litter bearers to be supplied by individual line companies. These litter bearers are combatants. This is a very important consideration, especially when a single casualty may require 2 to 6 litter bearers. If a company of one hundred and fifty men sustains 6 casualties, this is a 4% decrease in manpower. However, if each casualty requires 4 litter bearers, there is an effective loss of 20% of the total company fighting strength. Although litter teams can be rotated or staggered, this will likely result in a delay in medical care and lead to higher morbidity and mortality. In MOUT, the combat forces will likely be functioning at very small unit levels, i.e. the platoon or squad level. A very small number of casualties can quickly reduce end strengths to the point of seriously jeopardizing the ability to complete the mission.
Although these small, forward units typically have organic corpsmen, better use of these medical personnel could be made by co-locating them with the forward BAS and making the BAS responsible for all aspects of evacuation. This would allow the combat units to perform their mission without sacrificing individuals to act as litter bearers. It would also allow the BAS to better manage a relatively small number of corpsmen while coordinating deployment of corpsmen to units that need medical assistance. Very effective communications between forward units and the forward BAS is required to accomplish this.
This concept will place greater emphasis on “buddy care” by the combat forces. Individual Marines will be required to provide initial care to their injured fellow unit members. At a minimum, this would involve the “ABC’s” of Airway management, assisted Breathing, and Circulation control (including controlling bleeding and cardiopulmonary resuscitation if required) until corpsmen support can arrive. Ideally, several Marines from each squad would be trained in advanced first aid techniques, including IV therapy.
The forward BAS should be located in a secure area, but still be close enough to the area of operations that an “ambulance” can arrive within 5 to 7 minutes. If possible, the BAS should be co-located near a landing zone for rotary wing aircraft to be used to evacuate casualties back to definitive care areas. Although having a landing zone in close proximity would be ideal, urban terrain may make this difficult or impossible. This will place a greater burden on delivering higher levels of care prior to evacuating patients to more definitive treatment facilities.
The main or rear BAS will operate as a forward staging area for all medical casualties. This is in contrast to the current practice where severely injured casualties may bypass the BAS to facilities with the ability to deal with higher acuity problems. This requirement to use the BAS as a staging area is directly related to the logistics of operating in urban and potentially unsecured areas.
Personnel protection and operations in an urban environment: Operations in urban terrain will place several challenges on both the BAS and the personnel manning the aid station. Since these operations will likely occur in cities, there will also be a large civilian population at risk. It may also be difficult to clearly define a forward edge of the battle area (FEBA). In essence, large areas may be insecure yet MOUT will require corpsmen and ambulances to operate within these areas. This necessitates that corpsmen revert to their basic military training and skills. So it is imperative that corpsmen actively participate in field training with the Marines that they support to hone such skills. MOUT also will require greater use of light armored vehicles functioning as ambulances.
Casualty types and numbers: The types of casualties that will be encountered in MOUT will in many ways be similar to more conventional operations, such as high velocity missile fragment, percussion and thermal injuries. However, several other injury types can also be expected. Crush injuries from collapsing buildings and falling debris are likely. Environmental injuries from industrial chemicals or other hazards should also be anticipated. This will require additional training to allow effective rescue and treatment of casualties involved in hazardous material (HAZMAT) environments. These HAZMAT encounters are likely to be relatively common given the vast variety and numbers of hazardous agents that are encountered routinely in urban settings.
The limited use of weapons of mass destruction (WMD) is also a major concern. The recent use of the nerve agent saran by terrorists in Japan further emphasizes this point. Small quantities of lethal agents can easily be deployed by small numbers of the adversary. Since many of these operations will be in small, confined spaces, these types of weapons would be especially attractive to the enemy.
Gunshot wounds from sniper fire are not unique to MOUT, but because of the extensive areas of cover and concealment offered in urban environments, it is likely that this will be a major source of casualties. It also represents a major threat to corpsmen attempting to evacuate such casualties.
Casualty location: One of the major challenges of BASS MOUT will be locating injured casualties in buildings and other confined areas. Since combatant forces will be utilizing precision insertion in darkness and inclement weather, medical personnel must be able to operate in similar environments. This will require increased battle space and situational awareness. It will also require greater reliance on technological tools such as GPS, individual sensors, and satellite imagery. The BAS will also need access to reliable sources of intelligence data. These requirements will mandate that the BAS be integrated into the Command, Control, Communication, Computer, and Intelligence systems (C4I) at the battalion and higher levels.
Casualty treatment in the field: Due to the unique nature of MOUT, a higher level of care will be required to be delivered in the field. The first echelon of care will be “buddy aid” as described earlier. The next level of care will be by true “combat medics”. This is analogous to the civilian emergency medical systems (EMS) that have highly trained paramedics in the field. Their training allows them to deliver Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS) in the field and en route to the treatment facilities. The level of corpsmen training needs to be commensurate with civilian paramedics. They should be expected to be able to perform oral endotracheal intubation, cyrcothyrodectomy, pneumothorax decompression, and other life saving ATLS/ACLS procedures.
Once the patient is stabilized, he or she can then be evacuated back to the BAS. In case of critically injured casualties, immediate air evacuation may be coordinated from the BAS to a higher echelon medical facility. Again, the BAS will need to be a C4I node and be coordinating care in the field.
Casualty evacuation: As eluded to earlier, the evacuation of casualties will be a major challenge. First, the level of care delivered on scene will become much higher. This will necessitate mobile intensive care units with protective armor. It will also require the development of a command and control network between the BAS and individual response units which is also coordinated with air and land evacuation assets. In many ways, this will parallel the evolution of the civilian EMS. The “load and go” type philosophy will be replaced with initial field stabilization and treatment followed by controlled transport to a medical facility.
MOUT casualty evacuation will likely also place corpsmen in unusual rescue type situations in which they have little or no training, at least military training. Because of the urban terrain, familiarization with closed space rescue, tower and high rise building rescue will also be required.
The BAS will serve as a central control point for directing these operations. It will also serve as a staging area for further evacuation. The BAS will also be required to provide the normal sick call functions as well addressing environmental issues such as water and food supply safety. These functions will typically occur at both the forward and rear BAS’s.
Utilization of local resources: The military strategist Sun Tzu proclaimed “one container of the opponents food is same as twenty containers of their own ”. Since these operations can take place in settings with mature infrastructure, consideration of adapting local resources to augment care should be considered whenever possible. In the event that local hospitals, fire departments, and EMS providers are available, arrangements to cooperatively use these resources should be made. This will become especially important for the local knowledge of the urban terrain that can be gained form these organizations. In addition, since it very likely that civilian casualties will be encountered, military assets can be used to augment the civilian EMS systems. Liaison with local authorities can greatly increase the ability of delivering effective medical support both to friendly forces and local civilians as well.
BAS RESPONSES TO MOUT CHALLENGES
Training: MOUT will require several changes in the current training received by corpsmen. First, basic military defense and survival skills need to be sharpened. This should include spending time with Marine Scout/Sniper Instructors. It will be very important to have an understanding the potential threat that snipers pose and techniques to avoid becoming a target. Second, medical skills will need to be increased to the level of a civilian paramedic. Once accomplished, participation in a modified combat casualty care course (C4) with ATLS should be encouraged. Training in various rescue techniques will also be needed, including HAZMAT. Many of these training evolutions can be performed in conjunction with civilian EMS and fire departments. Many of the reserve corpsmen already posses these skills through their civilian occupations. Ideally additional cross training can occur between corpsmen who are firemen, paramedics and other related occupations during drill weekends.
The training schedule for NR 4MARDIV 3/25 reflects this concept. Four training evolutions have been setup with local fire departments and EMS organizations. These exercises will focus on special rescue techniques, HAZMAT operations, rope skills, as well as other skills likely to be required in an urban environment. Advanced medical courses are also being planned, specifically advanced cardiac life support (ACLS), and trauma courses.
BAS training as a unit will require increased exposure to MOUT. Participation in MOUT exercises at one of the current Army installations will be of great benefit. Frequent exercises with a variety of casualty scenarios should be participated in throughout the year. The battalion surgeon, assistant battalion surgeon, and senior enlisted members should participate in command post exercises to familiarize themselves with the role that the BAS will play as a central coordinating site. These senior leaders should also participate in medical wargaming so that they may more effectively act as a C4I hub.
Since MOUT will be so dependent on communications, corpsmen will be required to be cross trained in operating radios, erecting and dismantling antennas and routine maintenance of communications equipment.
Specialized courses need to be developed for medical staff planners. These training course currently exist for amphibious landing operations, but as our likely areas of operation move towards rear area and urban settings, new course addressing the special challenges of urban warfare and urban medical support are required.
Individual training plans or ITP’s need to be revised to reflect the demands of MOUT. Ideally the current NEBC (8404) for corpsmen would represent the basic requirements for serving with the Marines. However, an advanced designator should be developed to include skills outlined in this paper. We are currently working on these requirements. However, they should include training equivalent to a civilian paramedic, communication/radio skills, and defensive and survival training. These changes in the ITP are very important for two reasons. First, they will allow individuals possessing these skills to be officially recognized. Second, they will allow training programs and classes to be funded for corpsmen to achieve the skills demanded by BASS MOUT.
Equipment: Equipment requirements will primarily revolve around developing an armored mobile ICU ambulance that can operate in urban terrain. Besides being equipped with routine medical supplies, it should also contain specialized rescue equipment to perform extrication and extraction of casualties from urban structures. After reviewing the current inventory, the ideal vehicle would likely be a modified light armored vehicle (LAV). The LAV would be able to maneuver through city streets yet provide protection from small arms fire. It would still be vulnerable to rocket propelled grenades and other similar munitions.
Also, required command, control, and informational equipment needs to be supplied to the BAS and individual corpsmen. Individual, light weight radios should be made available to each team of corpsmen. These teams should also have GPS units with graphic display capabilities. During CAX 7/98, our BAS tested small, line-of-sight radios manufactured by Motorola. These radios provided unsecured communication, however, they were of great utility for short range communications. They were relatively inexpensive and proved to be extremely durable in the extreme desert environment in which we operated. Although we did not have GPS capabilities within the BAS, this technology would have been of great benefit.
The currently issued “unit one” and “unit five” bags will require complete revision. These bags contain bandages and basic supplies, but are inadequate for corpsmen with advanced skills operating in urban areas. Our unit is currently field testing packs produced by Nighthawk Industries which would replace the unit one/five bag and ALICE pack. These packs have modular attachments which are easily detached and large enough to carry intravenous supplies, intubation and airway management equipment, and other items. In theory, the main body of the pack could carry specialized equipment needed for various operations, including ropes, backboards and spinal immobilization supplies, heavy rescue equipment, etc.
Logistics and supply The major supply issues focuses on developing a modular, easily replenished AMAL which is tailored for urban environments. The inventory of the current AMAL’s will not meet the needs of MOUT. In fact, the AMAL’s used in CAX 7/98 contained a large amount of supplies that were not usefull in a desert environment. We lacked intravenous supplies and fluids, splints, backboards, c-collars, oxygen, basic antibiotics and other routine supplies. In fact during CAX 7/98, a large amount of the medical supplies used was purchased and brought to the field by the corpsmen and medical corps officers.
We are currently reviewing the inventory of the standard AMAL and developing an ideal “wish list” to meet our needs in MOUT. These supplies and expendables should be generic enough to be used in most urban environments. In addition, specialized “blocks” for unique circumstances should be developed. These blocks would include rescue equipment and other specialized items that would be required for MOUT. Mogadishu and Sarajaevo both represent urban terrain’s, but each would likely have very different equipment requirements.
C4I: The cornerstone of BASS MOUT will be full and complete integration of the command, control, communication, computer and information networks. Complete battle space awareness will be critical, both to the delivery of medical services, but also to the survival of health care deliverers. Complete access to navigational technologies, computers, urban databases and digital mapping will become critical in these operations.
This may be the most difficult hurdle to overcome by BAS in MOUT. Although C4I integration is essential, it must be simple to access, lightweight, extremely portable. Carey et al provide an overview of informational technology requirements for Marine Corps Combat Medicine in their excellent paper in Military Medicine . This paper identifies several important points. First, most combat deaths occur within the first thirty minutes from the time of injury. Second, wide bandwidth informational systems are not cost-effective and likely will have little impact at the BAS level. Finally, there are several shortcomings in our existing informational systems.
Any system used at the level of the BAS needs to be simple, light, and non-mission critical. In other words, total reliance on any system needs to be avoided and built in redundancy is important. The system needs to be shared with the battalion commander and battalion staff. The simplest system to meet the needs of the BAS would likely include a portable (lap-top) computer with secure electronic mail and file transmission capabilities. This should include a medical regulating program as described by Carey. This would allow patient information, re-supply and medevac request, as well as other important information to be effectively transmitted to the GCE battalion or higher echelons of medical care. It would also allow patient regulating task to be performed at the BAS level. The system should incorporate GPS capabilities to allow tracking of both patients and medical assets. We are currently experimenting with portable GPS systems and laptop computers to develop a user-friendly system to meet our needs within the BAS.
Secure voice communication between BAS personnel and the Battalion Surgeon or medical regulator is essential. A dedicated MEDNET needs to be established which can be accessed by the forward combat units and all BAS personnel as well as other friendly medical assets, FSSG units and transportation assets.
The BAS needs to be able to function autonomously during combat operations. It will be critical to be able to support the GCE without becoming a logistical burden. For this to occur, the BAS needs access to tactical information from the battalion and its C4I systems. The BAS needs to function as its own “node” within the GCE. This will require BAS commanders and surgeons to become trained in the “art of war” as well as the “art of medicine”.
CONCLUSIONS
BASS MOUT will challenge the current organization and assets of the Battalion Aid Station. In order to meet the challenges, the BAS must become the central command and control center for the delivery of medical care. The reserve BAS’s offer an unique resource and talent pool which should be taken advantage of and cultivated to operate in urban environments. Individual corpsmen must increase their skills and medical training to deliver a higher level of care in the field than ever before. They must also receive special training in combat operations in urban settings to insure their survival and minimize their “signature” and footprint. The individual training plans of the corpsmen needs to be changed to reflect the new requirements. This will allow the corpsmen to be recognized for their special skills, but also will allow funding to be made available to pursue the additional training required for MOUT.
Training with civilian EMS providers and fire department members should be encouraged. This should be the initial contact point, especially as our medical systems began to adopt many of the operational aspects of civilian agencies. These assets can be used as an interim training aid until formal military training programs are developed. Cooperating with our civilian counterparts will offers many mutual benefits. The BAS benefits by their experience in operating and providing care in urban environments. The civilian EMS providers can benefit by our experience and knowledge of intervening in special circumstances, especially those that concern the use of chem-bio weapons or other weapons of mass destruction.
Courses involving medical planning, command and control and other aspects of MOUT need to be developed and made available to senior NCO’s and officers of the BAS. Special equipment, including light armored ambulances with mobile ICU capabilities need to be developed and placed into the inventory. The current BAS AMAL’s need to be reconfigured into smaller, deployable modules to support MOUT. These modified AMAL’s need to be easily replaced and should include supplies likely to be required in these urban operations. The BAS needs to evolve as a major node and command center in the C4I network as it relates to providing medical care. This would include dedicated communication networks and access to informational technology including personal GPS equipment.
Corpsmen and Medical Corps Officers serving with the United States Marine Corps have distinguished themselves in the past operations. In order to continue this proud tradition and continue to provide the “best care anywhere” we must adapt to the challenges presented by MOUT. The ideas provided in this paper represent the starting point and foundation to build upon to meet this challenge. Given the large number and diverse missions that United States Armed Forces are currently involved in, these ideas need to be swiftly tested, adapted and finally implemented to maintain our readiness.
Acknowledgement: I would like to thank the men of NR 4MARDIV 3/25 for their dedication to meeting the MOUT challenge and especially thank LtCol John Ballard, USMCR and LtCol David K. Undeland, USMC for their review and assistance with this manuscript.
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