Seven P's in Battalion Level Combat Health Support in the Military Operations in Urban Terrain Environment: The Fallujah Experience, Summer 2003 to Spring 2004, The

Military Medicine, Apr 2006 by Earwood, J Scott, Brooks, David E

Combat health support in the Military Operations in Urban Terrain (MOUT) environment represents a common challenge on today's battlefield. We identified seven key aspects of battalion level health support which required consideration before combat operations in this type of environment. We called these the "seven P's" of combat health support: prevention, proportion, preparation, portability, proximity, protection, and projection. We developed an easy to use framework for using these principles to quickly develop combat health support plans during periods of high operations tempo.

Introduction

rp here is very little in the military medical literature, or for that 1 matter in Army doctrine1-6, regarding medical coverage for battalion -sized elements in the Military Operations in Urban Terrain (MOUT) environment. Yet between August 2003 and March 2004 as members of Task Force 1 Panther (1/505th Parachute Infantry Regiment (PIR), 82nd Airborne Division, and various attached elements to include 1 Company from 1/32 Infantry Battalion), we found ourselves providing battalion-level combat health support (CHS) in a MOUT environment. Our task force's sector of operations included most notably a city of >250,000 people named Al Fallujah. It is located approximately 50 kilometers west of Baghdad and in the heart of what is known as the Sunni Triangle. Our task force consisted of between 850 and 1,000 soldiers at any given time during that period.

The Battalion Task Force included one medical platoon for combat health support. The platoon included: 1 battalion surgeon (family physician), 1 battalion physician's assistant, 1 field medical assistant (Medical Service Corps officer), 1 platoon sergeant, and 30 medics. Eighteen of the medics were imbedded in the infantry companies along with each company's organic combat lifesavers. The remaining 12 medics provided care at the battalion aid station and participated as members of our advanced trauma packages. These packages were forward during many missions. An advanced trauma package consisted of at least the battalion surgeon or physician's assistant and usually included two to three medics along with an evacuation platform (a cargo HMMV fitted with advanced airway capability or a front line ambulance). Advanced trauma packages were forward deployed >150 times during this 8-month period. During this time, our battalion task force sustained >90 wounded in action, 18 soldiers evacuated out of theater, and 1 killed in action (KIA). In addition to caring for our own task force soldiers, we provided the medical piece for the quick reaction force (QRF) of our sector. We were most notably called on to respond to five helicopter crash sites which included >20 KIA and another 20 wounded in action. Finally, we cared for multiple Iraqi nationals wounded by both enemy and friendly forces. Examples of some of the combat injuries we cared for includes both high- and low-velocity penetrating trauma, blunt trauma, and open and closed head injuries. The majority of the injuries were low-velocity extremity penetrating injuries.

The threats encountered evolved as the deployment progressed. During the entire period, improvised explosive devices (IEDs) were the major threat. Our battalion's KIA occurred secondary to an IED. In addition to IEDs, rocket-propelled grenades and small arms attacks were quite frequent in the city. Our forward operating base (FOB), where our battalion lived, was mortared on a regular basis (on average three times per week). The foreign fighter extremist threat increased later in the deployment, and with this came a shift to more direct action attacks. The rapid operational tempo precluded deliberate medical planning by decreasing the time available for mission planning (operational tempo continued to increase until the end of the deployment). It was not uncommon during several highintensity periods to have multiple companies involved in cordon and search missions every night of the week. This tempo required an efficient and effective needs analysis process, allowing appropriate medical coverage regardless of time allowed for planning. By necessity, objective mission factors were identified to facilitate rapid and appropriate combat health support plans. This article will describe these factors and demonstrate their usefulness.

During this 8-month period, we were able to identify factors that influenced whether we pushed advanced trauma assets on a combat mission. These factors along with operational necessity allowed us to tailor the advanced trauma package requirements to appropriately place the advanced trauma assets on the battlefield, maximizing forward care capability for the mission. It was not entirely preconceived. In fact, these factors were refined up until the day we stopped combat patrols in Iraq. We have condensed these factors into what we called the seven Fs of infantry battalion medical support in the MOUT environment. The seven Fs are: proportion, preparation, portability, proximity, protection, projection, and push. This concept was new. One only needs to look at examples from Hue City in Vietnam and even Somalia to see that physicians and physician assistants were not pushed forward into the urban combat environment to provide far-forward care in the past.7

Observations

The concept of "prevention" involves multiple methods used to either avoid attack or to make surviving an attack more likely. Force protection is usually the term used for this concept. The majority of force protection has very little to do with medical assets and involves the commanders and the plan chosen (i.e., varying routes, avoidance of obvious ambush sites, clearance of roads for IEDs, Kevlar blankets, and ARMOX armor added to the vehicles, increasing the number of up-armored vehicles, use of sufficient combat power to ensure overwhelming victory, etc.). In fact, all preventative measures were command directives. However, as advisors to the commanders, we were able to convince the commanders about multiple initiatives that decreased both mortality and morbidity. Some examples of these efforts include the merits of appropriate wear of the individual body armor to include the neck piece, which is often excluded for comfort. In addition, there were modifications to the individual body armor (side and shoulder panels) which were designed by medical providers within our brigade, tested, and demonstrated to be effective on soldiers in our battalion. Eye protection was another area where medical advisors helped line commanders implement policies that prevented catastrophic eye injury on multiple occasions. The use of seat belts, while proven in the civilian world, was considered a restraint that impeded a soldier's reactions when in contact with the enemy. Despite this bias, restraint systems were devised by command that offer protection while allowing quick release. In the urban environment, unpredictable driving habits and use of headlights (very difficult with blackout drive and night vision devices used by our soldiers) made some sort of restraint system an absolute necessity. Bottom line, preventive measures saved soldiers' lives and avoided many injuries. These measures were crucial in the success of our task force in Al Fallujah.