Written by Major Clarence L. Ketterer
Problem Statement: How do we retain required uniformed medical force structure given the constraints of the National Defense Authorization Act (NDAA) 2017 while increasing survivability on the battlefield during large scale combat operations in accordance with Field Manual 3–0 (Operations), 2017 [i]?
Requirement: NDAA 17 is changing the Army Medical Department (AMEDD) business model, transforming the AMEDD into an operational force [ii]. Specifically, section 721 of the NDAA 17 requires the uniformed medical force to convert any military medical function that is not an operational requirement to a civilian position [iii]. There is a requirement to identify operational medical gaps and create a relevant medical force to support Large Scale Combat Operations (LSCO).
Gap Analysis: The largest medical gap identified in the universal joint task list (UJTL) is ST 4–2.2 Coordinate Health Service Support [iv]. Several of the metrics measured are associated with the movement of a casualty to a definitive role of care. The Army does not have the required Role III capability at the division level to support the listed UJTL metrics during LSCO.
While the current alignment of medical organizations works well during Counter Insurgency Operations (COIN), it is not suitable for LSCO.
Critical shortfall: The critical shortfall is at the division level. Currently, Army maneuver battalions each have a Role I and brigade combat teams each have a Role II. Role III care is not found until the corps level; bypassing the division altogether. While the current alignment of medical organizations works well during Counter Insurgency Operations (COIN), it is not suitable for LSCO [v]. A Role III capability needs to be created within the division.
The Division Hospital Company provides Role III care to all Soldiers within the division and can hold patients until an evacuation window is created.
Proposed solution: The Army develops a Division Hospital Company (DHC) that is organic to the division’s sustainment brigade. The DHC provides Role III care to all Soldiers within the division and can hold patients until an evacuation window is created. This extended hold capability for surgical patients is not currently available in any other unit outside of the Field Hospital. The DHC would be 100% mobile and would have increased capabilities if collocated with a Role II element. This increase of surgical capability would allow the uniformed Army to retain critical medical professions.
Capabilities-Based Assessment (CBA): The proposed solution for the identified problem will fall under the DOTMLPF-P Change Recommendation (DCR) rather than an Initial Capabilities Document (ICD) as the solution is non-material [vi]. Although there will be minor impacts to all elements of DOTMLPF-P, the two largest impacts are to doctrine and organization.
Doctrine: Currently the Army sustainment community is rewriting FM 4–0 (Army Sustainment). The reason that it is being rewritten according to the Quartermaster Commandant is that it failed to meet the requirements imposed by LSCO as written in FM 3–0 (Operations) [vii]. Sustainment doctrine must meet the operational requirements of the maneuver warfighter. Aligning organic surgical care at the division level can be readily written into the FM 4–0 and AMEDD doctrine re-writes.
Organization: The Quartermaster Commandant also stated that the current field hospital was much too large and immobile to support the requirements of FM 3–0 from a whole of sustainment perspective [viii]. The Commander of the Health Readiness Center of Excellence recently submitted a memorandum outlining the need for Army medicine to re-engineer itself to best deliver operational medicine [ix]. A new, mobile surgical organization can fill the gap at the division level to help transform Army medicine for the future operating environment.
Proposed organization structure: The Division Hospital Company is comprised of 100 Soldiers; 31/1/68. The preponderance of the Soldiers required for the DHC are within a Table of Distribution and Allowances (TDA) that exceeds the Modified Table of Organization and Equipment (MTOE) requirements. As an example, the Army lists that 233 general surgeons (61J) are required across all TDAs but only has a requirement for 72 across all MTOEs. Even with 97 TDA positions for resident training, there is still an excess of 90 general surgeons on the TDA [x]. Re-purposing TDA medical Soldiers to the DHC MTOE would mean no new personnel costs.
The DHC would have to be 100% mobile and operate within a much smaller footprint than current Role III Army structures.
The major equipment required is currently in the Army’s inventory and would not have to be significantly altered to support organizational needs. The difference is that the DHC would have to be 100% mobile and operate within a much smaller footprint than current Role III Army structures. This would represent a more austere environment than which Role III elements have become accustomed to operating within during the last 17 years of counterinsurgency fighting.
The following are the medical capabilities that the DHC would provide. The DHC will have three operating room beds (one of which is provided by the veterinary element in emergencies), a Role II veterinary team (which also provides a food inspection capability for the division), a 12-bed intensive care ward, a 20-bed intermediate care ward, and a 20-bed minimal care ward. The DHC would also have a six-bed trauma/ pre-operative ward capable of resuscitative care. Additionally, it would have a small laboratory, pharmacy, and x-ray element to provide ancillary support. Finally, the DHC would have a small medical maintenance team, a medical supply team, and a motor maintenance team to ensure the company is 100 percent mobile. The combat aviation brigades (CAB) currently are assigned at the division level. This presents an opportunity for a close relationship between the DHC and the aeromedical evacuation assets. External support from corps medical assets is required to support additional medical functions.
Force Integration Functional Area Analysis (FIFA): There are nine total FIFAs that will be impacted. The two most significantly affected will be manning and readiness [xii].
Manning: To man the personnel required by the DHC, AMEDD will be forced to retain certain areas of concentration (AOCs) at the expense of others. AMEDD will also have to work with the national medical match registry process to identify Army doctors and match them with a medical skill that is critical to the Army. This is difficult as the national match board is a civilian system that the Army will have to influence. Recruiting and retaining medical personnel that are forced to work within very specific skill sets will be challenging as well. There are many positions the Army currently offers which transfer easily to jobs and practices in the civilian market. Many of those jobs will no longer be needed by the Army as it transitions to an operational medicine approach. The Army will utilize physician assistants to perform many of the required medical and surgical functions. Currently the Army has done so with the surgical, orthopedic, and emergency medicine PhD programs that can be expanded to meet requirements.
Another readiness system that may be utilized to maintain medical skills is to authorize memorandums of agreement with civilian medical centers and facilities close to the units.
Readiness: Maintaining the medical readiness and skills required by Soldiers serving in the DHC is done utilizing the Professional Officer Filler System (PROFIS) or the reverse PROFIS. There are several problems associated with PROFIS however. The first problem is that the medical providers, even in reverse PROFIS, will not be located at the same duty station as the enlisted Soldiers that they are responsible for training. The second major problem is that most Army hospitals do not replicate the same types of procedures encountered in an operational environment. Another readiness system that may be utilized to maintain medical skills is to authorize memorandums of agreement with civilian medical centers and facilities close to the units. Working in these centers will give medical providers opportunities to practice the type of procedures they will utilize in combat daily. A possible impact is that Soldiers across the Army may not have the same access to care that they currently do, therefore decreasing overall Soldier medical readiness.
Conclusion: A division hospital company is an organization that fills a critical shortfall for both the Army in large scale combat operations and Army medicine transforming in response to the NDAA 2017. The personnel and the equipment to create DHCs already exists in the Army’s inventory. Re-purposing people and equipment on paper is easy; changing the mindset of the Army and the AMEDD is more difficult. While the current medical organizations work well in a COIN environment, there is a gap for divisions serving at the tactical level [xiii]. By creating the DHC, we will apply Army medicine to where it matters most; saving lives on the battlefield during large scale combat operations.
Areas for further study: This gap analysis looks only at a Role III organization at the division level. There are other organizations that I believe can be developed to function organic to the division area. There are possible implications for a division support medical company (DSMC) to provide Role II care or perhaps a division medical battalion to manage both a DHC and DSMC. The medical battalion can easily be organic to a sustainment brigade. These ideas, among others, are the opportunities that the NDAA 17 have provided to the AMEDD.