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SUPREME HEADQUARTERS ALLIED POWERS EUROPE

GRAND QUARTIER GENERAL DES PUISSANCES ALLIEES EN EUROPE

B-7010 SHAPE, BELGIUM

Tasker no: 271074 Tel: +32-(0)65-44-7111 (Operator) Tel: +32-(0)65-44+ext NCN: 254 + ext

Date: I / October 2010 Fax: +32-(0)65-44-3545(Registry)

ACO DIRECTIVE (AD) 83-1 (Edition 2)

MEDICAL SUPPORT TO OPERATIONS

REFERENCES: A. SACEUR Strategic Plan 2010 - 2012. B. MC 326/2. C. AJP 4.1 O(A). D. ACO Directive on military medical services engagement in

humanitarian assistance, and governance, reconstruction and development (AD 83-2).

E. AJMedP-2 F. STANAG 3204. G. COMEDS (Chair) L (2008)0011 minutes of 30th COMEDS

Plenary, 26 - 28 November 2008. H. STANAG 2087 (Edition 6), dated 30 October 2008. I. MC 319/2.

1. Status. This Directive supersedes the first edition of Allied Command Operations (ACO) Directive 83-1, dated 17 March 2009.

2. Purpose. To set out medical support principles for the guidance of commanders and their staff, and to provide functional direction to the medical staff, in order to optimise health and healthcare support on NATO led current operations, and NATO Response Force (NRF).

3. Applicability. This Directive is applicable to all ACO headquarters and their subordinate commands, including deployed headquarters, and should act as a guide for operational plans, directives and training for deployment on operations.

4. Supplementation. Supplementation is not authorised without the agreement of the proponent at SHAPE.

5. Publications Updates. Updates are authorised when approved by the Director of Management (DOM), SHAPE.

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6. Proponent. The proponent of this Directive is the ACO Medical Advisor and Director of Medical Support, SHAPE.

;.JYU:::..ffil;~U COMMANDER, EUROPE:

-tautas enkevicius Brigadier General, L TU A Director of Management

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ALLIED COMMAND OPERATIONS DIRECTIVE FOR MEDICAL

SUPPORT TO OPERATIONS

AD 83-1 (Edition 2)

Promoting excellence in healthcare support on operations

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TABLE OF CONTENTS

REFERENCES

CHAPTER 1 - ORGANISATION Allied Command Operations (ACO) Medical Group ACO Medical Directorate

CHAPTER 2 - PURPOSE AND SCOPE OF THIS DIRECTIVE Purpose Aim Doctrine Development

CHAPTER 3 - OPERATIONAL ENVIRONMENT,MEDICAL DIRECTION AND MISSION The operational environment Medical direction and guidance ACO Medical Mission

CHAPTER 4 - CONCEPT OF MEDICAL SUPPORT Intent Core principle Approach Command, co-operation and co-ordination Inform Protect Prepare Deploy Operate Sustain Develop - Continuous improvement in healthcare support on operations

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1-1 1-2

2-1 2-2 2-3 2-4

3-1 3-2 3-3

4-1 4-2 4-3 4-4 4-5 4-6 4-7 4-8 4-9 4-10

4-11

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CHAPTER 1

ORGANISATION

1-1. Allied Command Operations (ACO) Medical Group. The ACO Medical Group comprises the medical support staff within the Supreme Headquarters Allied Powers in Europe (SHAPE), the Joint Force Commands (JFC) and their subordinate Component Commands, and within deployed formation headquarters on NATO led missions.

1-2. ACO Medical Directorate. The ACO Medical Advisor and Director of Medical Support (ACO MEDADIDIR MED) advises the Supreme Allied Commander Europe (SACEUR) and provides functional medical direction to the ACO Medical Group under the authority of SACEUR ACO MEDAD/DIR MED heads the Medical Directorate, within the Support Division at SHAPE.

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CHAPTER 2

PURPOSE AND SCOPE OF THIS DIRECTIVE

2-1. Purpose. The purpose of this ACO Directive on Medical Support is to set out medical support principles for the guidance of commanders and staff in all ACO headquarters and their subordinate commands, including deployed headquarters, and to provide functional direction to the medical staff of these Has. The Directive forms the authority for forward medical evacuation (described as MEDEVAC in this Directive) timelines and standards used on all current NATO-led joint operations, component specific maritime, land and air operations, and in support of NATO Response Force (NRF) operations.

2-2. Aim. The aim is to furnish commanders, as well as their medical advisors, with concise and consistent guidance for the optimal provision of medical support. The Directive informs the estimate of resources required, and thus underpins Force Generation, and forms the basis for the medical annex to OPLANS and directives for the NATO Reaction Force.

2-3. Doctrine. References Band C form the basis of this directive 1. AD 83-1 will in turn contribute to the further development of doctrine in light of continued experience on operations. Troop contributing nations are requested to utilise the guidance contained within this Directive in the training and preparation of their forces pre-deployment, and that their deployed forces should follow the principles therein, notwithstanding formal command states.

2-4. Development. This second edition of AD 83-1 is derived from the SACEUR Strategic Plan at Reference A and builds on the experience following implementation of the first edition (17 Mar 2009) on current operations, particularly in Afghanistan, but also on other operations including Kosovo and counter-piracy operations. Engagement with deployed medical advisors has accordingly been a critical step. As for the original Directive, Edition 2 has been prepared in co-operation with nations, principally through the forum of the Committee of the Chiefs of Medical Services in NATO (COMEDS), in consultation with COMEDS working groups and expert panels, and in co-operation with Allied Command Transformation (ACT).

1 Para 2019 b of Reference C refers to the authority for the NATO commander to promulgate such directives. 6

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CHAPTER 3

THE OPERATIONAL ENVIRONMENT, MEDICAL DIRECTION AND MISSION

3-1. Operational environment. Forces deployed on operations and exercises are subject to many and varied threats to health. The care of those with battle injuries will be the immediate concern; historically however, disease and non-battle injury exceed battle casualty rates. Concerns include environmental factors, motor vehicle accidents, disease and a range of hazards and toxins, including Chemical, Biological, Radiological and Nuclear (CBRN) threats. Long term effects on health, including mental health, should be considered. On many operations, medical staff may also make a significant contribution to support of health sector development, particularly healthcare support to host nation security services, as described in AD 83-2 (Reference D).

3-2. Medical direction and guidance. COMEDS provides medical advice to the NATO Military Committee (and as required, the North Atlantic Council). Strategic medical direction for current operations is developed by ACO in consultation with COMEDS. ACO MEDAD/DIR MED is a member of COMEDS.

3-3. ACO Medical Mission:

a. To promote and protect the health of deployed forces and to optimise the outcome of those among the force who become sick and injured on operations.

b. To support the development of excellence in military healthcare support provided by NATO medical services and their partners.

c. To engage appropriately in the development of healthcare support in those host nations in which NATO operates, and also the delivery of emergency medical care and other humanitarian assistance, where this is necessary, in support of civilian authorities and agencies.

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CHAPTER 4

CONCEPT OF MEDICAL SUPPORT

4-1. Intent. The intended outcome is:

a. To minimise morbidity and mortality among deployed forces (hence contributing to sustaining the force) and others for whom healthcare is provided on operations.

b. To contribute to improved health outcomes, and thereby to stabilisation, where this is appropriate within those fragile states in which NATO operations are conducted.

c. To build and sustain a culture of multinational co-operation and trust, and a commitment to continued development in healthcare excellence among the community of military medical services in NATO and partners, including host nations.

4-2. Core principle. A central principle (Reference 8) is that all patients must be afforded the appropriate standard of emergency medical care based on clinical need, be they members of the NATO or allied forces, host nation security forces or civilians presented to military medical staff, or casualties from opposing elements with various status regarding the applicability of the Law of Armed Conflict (e.g. prisoners of war, detainees, captured pirates) but with the same ethical consideration.

4-3. Approach. The ACO approach to supporting operations is illustrated at Figure 1. ACO Medical Group supports commanders through liaison with Force Generation and national medical staff to secure sufficient and capable medical elements from nations, coordinated at the tactical and operational level, and continually improved in the light of experience and the sharing of best practice, such that patient2 outcome is optimised.

2 Throughout this Directive, the term "patient" is used to indicate all those who become sick and injured and are received into a NATO or allied medical facility for care or treatment.

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Figure 1. Schematic illustrating the process through which ACO Medical Group co-ordinates the delivery of medical capability on operations. The intended outcomes (para 10) are

achieved through sourcing sufficient resources (particularly trained and motivated personnel) by means of the processes described below, and optimised through evaluation and feedback

in order to continually improve outcome through learning and development.

4-4. Command, co-operation and co-ordination.

a. The provision of effective medical support is the responsibility of the Commander, co-ordinated on his behalf by the formation Medical Director (MED DIR). However, medical resources provided for operations will normally remain under national command, except those provided under NATO common funding, which would be under command of the deployed NATO commander. For effective and efficient support throughout the patient care pathway, from point of illness or injury through initial treatment, evacuation, definitive treatment and rehabilitation, multinational cooperation will be necessary. The degree of co-operation will vary at different stages of this pathway, but effective liaison is essential at every level, particularly where patients are handed over; the patient care pathway should be "seamless".

b. Primary healthcare and pre-hospital emergency care (Role 1 medical support) is usually a national responsibility. In the context of multinational facilities, particularly deployed headquarters, the Commander shares responsibility with national support elements for ensuring Role 1 provision for all members of that headquarters. Unless other arrangements are agreed, the nation providing Role 1 support would be the nation of the Commander of that deployed headquarters or other multinational facility.

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c. To sustain medical support to ongoing operations, as the capacity of each facility increases and decreases with patient flow, it will often be necessary to share patients among the appropriate available facilities. Although the formation MED DIR may not have direct command of the medical facilities, the MED DIR is responsible for co-ordinating support in his or her area of responsibility (AOR). The MED DIR will need to develop good working relationships with national medical leads and foster a climate of co-operation. Further to this, it is strongly recommended that liaison officers are exchanged between major medical treatment facilities that routinely share the patient load.

d. The formation MED DIR (or his/her staff) will advise on the most appropriate forward medical evacuation (defined at References E and F as MEDEVAC) response and the destination deployed hospital facility for all casualties within the AOR. Launch authority for MEDEVAC is usually vested in the Executive chain of command. This is a key driver of the necessity for medical staff to be embedded in the Combined Joint Operations Centre (CJOC) within the formation HQ, in order to perform a MEDEVAC risk assessmene and advise on intelligent tasking4 of medical assets. Medical C2 therefore should be aligned with the operational command.

e. References E and F describe tactical aeromedical evacuation (in this Directive described as TACEVAC) from one medical facility and another, and strategiC evacuation (STRA TEVAC) to definitive care out of theatre, which also requires coordination by the MED DIR and his/her staff, in order to optimise the care of individual patients, and to maintain deployed hospital capacity. TACEVAC may be complex to execute; successful co-ordination delivers "the right patient, at the right time, on the right platform, with the right escort to the right destination." TACEVAC and STRATEVAC airframes and in transit care teams will usually be under national (rather than NATO) command; in order to achieve optimal co-ordination it is important that all TACEVAC and STRATEVAC activity is reported to the MED DIR within the appropriate NATO formation HQ.

f. A key principle is that the formation Medical Advisor (ME DAD) has direct access to the Commander, as a member of the special staff, in order to provide specialist medical advice. Such advice will be less effective if this must pass through subordinate layers. The term MEDAD should refer to a medically qualified advisor; alternatively a medical support advisor (MED SPT ADV) may be appointed. The MEDAD or MED SPT ADV may be dual-hatted as the MED DIR, responsible for coordination and functional direction of medical support.

g. To effect all medical support tasks the Combined Joint Medical branch (C~IMED) supporting the MED DIR requires the following functions:

J An appropriate risk assessment for each mission to assess the clinical needs of the patient (a medical responsibility), the tactical situation on the ground and consequent operational risk to the air crew (a J3 and Avn responsibility) with the capability and capacity of the medical facilities that may be reached within timelines (a medical responsibility). 4 Intelligent tasking of medical assets to determine the medical staff and equipment needed follOWing assessment of the nature and number of casualties, and risk due to uncertainties in evolution of the incident.

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• MED DIR (Chief CJMED) • Medical Plans/Deputy MED DIR • Medical Operations lead and sufficient personnel to man the medical desk in

the CJOC (to sustain 24 hr manning three will be needed)5. • Evacuation Co-ordinating Officer (ECO), usually also based in the CJOC6

.

• Force Health Protection and/or preventive medicine officer • Health advisorlliaison officer for host nation health sector developmenf • Medical logistics officer • Administrative assistant and information manager

4-5. Inform.

a. Information is required by the MEDAD to advise commanders on health issues, and also to inform decisions on medical planning and during the conduct of medical support to ongoing operations. Information will also be needed for continuous improvement in healthcare support on operations (healthcare quality assurance); a trauma registry adds value to this.

b. Significant amounts of health information may be "open source" and should be shared (as needed) for medical situational awareness; engagement with local national health officials is important in this respect. However, any information, which when analysed exposes vulnerabilities, will of necessity be classified, in order to protect the force from an enemy capitalising on these.

c. Effective communication is essential to the co-ordination of medical support. The necessary communications infrastructure for this will need to be in place, in order to promote the sharing of information, such that the deployed MED DIR can speak and communicate electronically with the medical leads in subordinate headquarters and national support elements, and all medical facilities in his or her AOR, as well as with the higher formation.

d. ACO Medical Directorate maintains websites to promote sharing of information on NATO SECRET WISE .

4-6. Protect

a. Force Health Protection (FHP). The purpose of FHP is to reduce the risk of disease and injuries, in order to enhance operational health readiness and combat effectiveness. The FHP function includes the identification of threats to health of deployed forces, and the measures to control the risks these represent. Such measures will include recommendations on immunisation against biological threats, as well as hygiene measures to reduce the risk of gastro-intestinal disease. FHP staff should also be engaged in the assessment of threats from physical injury, and the effectiveness of measures to reduce associated risk. FHP is a responsibility of the

5 The number of personnel may be increased or reduced depending on tempo, as determined by the estimate. Medical services personnel running the medical desk - which may be referred to as the Patient Evacuation Coordination Centre (PECC) in the CJOC - require access to clinical expertise at all times. 6 Including patient regulation for TACEVAC between medical facilities, and co-ordination of STRATEVAC. 7 This health advisor might usually work within the branch responsible for reconstruction and development

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commander; the role of FHP staff is to provide timely and accurate information in order to advise commanders and staff on the management of these risks.

b. Personal protection of deployed medical personnel. Medical vehicles may be armed for personal protection proportionate to the threat; in principle MEDEVAC assets (ground, sea or aircraft) should be configured to meet similar force protection levels as the forces they support. Medical vehicles and personnel should be afforded protection by the Geneva symbols, but only where all parties respect these symbols. In conflicts where vehicles marked with the Red Cross or Red Crescent may be targeted, ACO recommends that these symbols are not displayed, but instead that medical vehicles are provided with an escort, and also provided with the force protection measures needed to counter the threat. MEDEVAC rotary wing (RW) marked with the protective emblems should not be armed, but protected by another RW as escort, should the tactical situation require such protection.

4-7. Prepare. To prepare for the provision of medical support to operations, a medical estimate will be undertaken, in which the mission will be analysed, factors assessed (a risk assessment) and possible courses of action analysed prior to the development of a plan. In the formulation of this plan, a statement of requirement for resources will be generated, set in the context of the following medical planning timelines:

a. It is a fundamental prinCiple that the seriously injured should be treated as soon as practicably possible, but planning timelines are needed in order to provide guidance on where medical evacuation assets and medical facilities should be sited. Building on the foundation of existing doctrine, evidence from accumulated experience and that published in peer reviewed literatureS shows that there are three key timelines (described here as the 10·1·2 Guidelines):

• Bleeding and airway control for the most severe casualties should be achieved as soon as possible - within 10 minutes of wounding

• MEDEVAC assets should reach the seriously injured casualty with skilled medical aid9 within one hour of wounding at the latest.

• Casualties that require surgery should where possible be in a facility equipped for this within two hours of wounding.

b. The intention is to reach the seriously injured casualty with skilled medical aid as soon as possible, to sustain the casualty, and to achieve timely evacuation from or near the point of wounding to the most appropriate facility:

• Ensuring sufficient combatant personnel are trained and competent to deliver enhanced first aid, principally to stop bleeding, and where possible to place medical services personnel skilled in pre-hospital care (termed Role 1 medical

8 Tai N, Brooks A, Midwinter M, Clasper J, Parker P. Optimal Clinical Timelines - A Consensus From The Academic Department Of Military Surgery And Trauma., JR Army Med Corps 155(4): 253-256 accessible on line at: http://www.ramcjoumal.comI2009/dec09/tai2.pdf 9 By "skilled medical aid" we mean that provided by medical services personnel (e.g. doctors, nurses or paramedics) with competences that include awareness and experience of the pre-hospital environment, and the ability to control bleeding, provide advanced airway support, intravascular access and pain control (e.g. ATLS).

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http://www.ramcjoumal.comI2009/dec09/tai2.pdf


support) with troops at risk10 such that the casualty may be sustained until the arrival of MEDEVAC

• To reach the seriously injured casualty as soon as possible with MEDEVAC, for morale reasons as well as the clinical imperatives

• To take the casualty to the most appropriate facility, which where possible should include CT scan and other advanced diagnostic capabilities, noting the complexity of battle injuries, within timelines. The most appropriate facility may not be the closest medical facility.

c. Categorisation of priority for evacuation of casualties has been defined by STANAG 2087 (Reference H) and reflected in the MEDEVAC request form ("9-line") as revised in 2009. There are three evacuation priority categories:

• Category A: urgent casualties who need to be evacuated as soon as possible (reached within 1 hr of wounding) and to be in a deployed hospital within a maximum of 2 hrs from injury ("10-1-2" Guidelines).

• Category B: other stretcher cases, in hospital within 4 hrs • Category C: others requiring MEDEVAC (i.e. with medical escort) but whose

condition permits waiting for up to 24 hours prior to evacuation (allowing for aircraft availability and environmental conditions to improve)

d. MEDEVAC response is monitored by means of the "90 minute standard", rather than actual time from wounding until surgery. This is because the exact time of wounding may not be readily available. It may take 10 to 15 mins for the MEDEVAC request to be received (due to the friction of operations) and approximately 15 mins to transfer the casualty from the helicopter landing site (HLS) to the operating room. Therefore, to achieve evacuation to surgery within 2 hrs of wounding, time from notification (usually taken as receipt of "9-line" in the CJOC) until arrival of MEDEVAC at the destination hospital- "wheels down" at the HLS - should be less than 90 mins.

e. With a 20 min notice to move (NTM) then (as illustrated in Figure 2) MEDEVAC assets should usually be no more than 30 min flying time from casualties on the ground if the timeline of 1 hr to MEDEVAC can be achieved.

10 The level of pre-hospital emergency care skill required will be determined by the estimate, including likelihood of injury and numbers likely to be injured; e.g. medical services combat medic for an opposed boarding at sea.

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-----------------

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Point of wounding Capability - the "10-1-2" Time ZERO medical planning timelines

Bleeding and airway control in less than 10 mins (enhanced first aid)-Reach casualty with skilled medical aid within 1 hr of wounding

sU'l'ery for those who need it.within 2 hrs of wounding

Time for u9-line" to reach Ops Room controlling incident response «15 mins)

MEDEVAC to reach casualty <45 mins incl NTM from "9-line"

NTM «20 mins; reduce as soon as aware of incident emerging)

(Forward evac loop requires 30 mlns range ring)

Time from notification to "wheels down" at HLS (90 mins)

"90 minute standard" Transfer from HLS (15 mins)

o 1015 60 105 120 Time (minutes) 8

Figure 2. The "10-1-2" Medical planning timelines, and the "90 minute standard". "Skilled medical aid" is provided by medical services personnel (e.g. doctors, nurses or paramedics) with competence that include awareness and experience of the pre-hospital environment, and the ability to control bleeding,

provide advanced airway support, intravascular access and pain control.

f. There may be a number of reasons why for individual missions the timeline has not been met, e.g. continued hostile fire, or adverse weather states at sea or in support of land operations. The emphasis should not be on the proportion that achieve compliance, but rather on assessing those MEDEVACs taking longer than 90 mins, in a "no blame" manner, in order to identify how improvements can be made. To identify further opportunities for improvement, all missions taking longer than 60 mins should also routinely be evaluated. The overriding consideration is to examine patient outcome, rather than time alone, and to consider what might be done to continually improve this outcome.

g. MEDEVAC should be achieved as soon as practicably possible, and so RW assets should be forward based, but deployed hospital care should be concentrated in fewer, more highly capable facilities. As in civilian trauma practice, serious cases should where possible be moved to the most appropriate medical facility, taking into account their medical stability and injuries. The laydown of medical facilities will be determined by means of the medical estimate, consideration particularly being given to the factors of demand, distance, duration and destination. Lighter surgical facilities will be needed to meet timelines when operating at extended distances.

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medical crew embarked capable of sustaining up to 2 x Cat A casualties. For intensive care, the capacity will be the number of patients requiring full intensive care (including ventilation) that can be managed to the standard of the lead nation for that facility, in line with applicable NATO standards and as agreed at the Multinational Medical Management Steering Group (MMMSG) or similar body, 24 hours a day for an indefinite number of days. A surge capacity for up to 24 hours should also be declared. How this is to be achieved is up to the provider.

i. It should be emphasised that the medical planning timelines are in essence a means to mitigate the risk that has been assessed. For some operations, where the risk of serious injury is very low, commanders may be advised that surgical support cannot realistically be provided within these timelines; examples would include routine maritime patrols (opposed boarding would however require access to surgery within the recommended timelines). For activities of particularly high risk, it is prudent to preposition medical assets close by, to allow evacuation times to be as short as possible.

j. The continuum of patient care must be maintained through evacuation at the appropriate time following treatment to definitive care (see para 4.9 f below). For those casualties taken initially to a light surgical facility (para 4.9 c), which will usually have only limited holding capability, this will usually necessitate TACEVAC to a more capable facility before STRATEVAC to definitive care. This transfer may be necessary within a few hours of surgery, depending on the condition of the patient11

and other circumstances, particularly intensive care capability and capacity. Recommended timelines for TACEVAC requests are URGENT (2 hours), PRIORITY (12 hours) and ROUTINE (which should be specified as within 24 or 72 hours). Arrangements must be in place for TACEVAC and STRATEVAC, with the level of in transit care that meets the needs of the patient, either through nations providing this on a national basis, or through agreements with other nations or contractors.

4-8. Deploy.

a. The medical laydown of medical support resources will be determined by the Estimate. For an intervention operation, a "foot on the ground" will be required to sustain the force, and similarly there will be a requirement for lighter redeployable facilities in support of manoeuvre operations.

b. The "10-1-2" planning timelines will form part of the risk assessment that is integral to the Estimate process. A key requirement will be to identify the capabilities and capacity needed to meet these timelines in the context of the environment and the predicted casualty load and mix, and to identify the people needed to undertake the medical support roles identified, in terms of both their professional skills and level of military proficiency needed.

11 As a guide, those requiring surgery for bleeding causing pressure inside the skull will need to have such surgery within 4 hours of injury. Decompressive surgery may be carried out by a general surgeon, but a neurosurgeon will have particular expertise in this area. In general the more complex the case, the better it is in terms of outcome to deliver the casualty from point of wounding to the most appropriate facility for that patient. This judgement is a key role for the formation MEDAD and Med Ops staff in the CJOC.

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c. It is essential that such personnel are prepared for their role through appropriate selection, relevant knowledge and experience, and pre-deployment training that includes individual preparation, team training (for example for clinical teams and for the CJMED) and collective training (including mission rehearsal exercise). The JFC responsible for the operation will liaise with the troop contributing nation; a forum for this is the MMMSG. The NATO School Oberammergau and the NATO Military Medical Centre of Excellence (Mil Med CoE) play important roles in building multinational medical capability.

d. Notwithstanding the above, no programme of pre-deployment training can prepare individuals, teams or deployable facilities for every eventuality. Predeployment assessment of these individuals, teams and units should identify risks, and in consultation with those who are to deploy, devise an appropriate means to mitigate the risks identified.

4-9. Operate. Healthcare provision will principally be concerned with sustaining the deployed force. To effect this provision, from point of wounding or illness through to definitive outcome, engagement is required particularly with planning, operations and aviation colleagues. The principal modalities are:

a. Pre-hospital emergency care and primary healthcare. Referred to as Role 1 medical support, this capability includes emergency healthcare provided by medical services personnel at or near the point of wounding, and routine healthcare provision (including occupational health measures) to deployed elements. To deliver life saving aid as soon as pOSSible, it is recommended that in addition to embedded medical services personnel, combat troops be trained in a ratio of one per team of four to six in the provision of enhanced first aid, at a higher level than "buddy aid" training provided for all troops. The primary purpose of enhanced first aid is to achieve bleeding and airway control for the most severe casualties within 10 minutes of wounding.

b. Forward medical evacuation (MEDEVAC). Provided by ground evacuation assets, or by rotary wing (RW) or fixed wing (FW) aircraft, in order to move casualties from, or near, the point of wounding as soon as possible to deployed hospital care. In some environments RW may be the primary means. The deSignated RW platform will need to be assigned and equipped for the MEDEVAC role, and dedicated to that role while so assigned. MEDEVAC must be undertaken with medical services personnel on board, with advanced skills to treat and maintain the patient; these skills will include control of bleeding, advanced airway support, intravascular access and pain control.

c. Deployed hospital care. Those with serious illness or injuries will require specialised care in a deployed hospital. A deftloyed hospital capable of managing the most complex injuries, within current doctrine 2 termed Role 3 (R3) or Role 2 Enhanced (R2E), will provide a range of diagnostic facilities, that where possible would include CT scan, and will necessarily be relatively fixed (R2E less so than R3). R3 deployed hospitals will usually provide a greater range of specialised capability and have greater capacity than R2E. R2E and R3 facilities may be under national or NATO command. For operations beyond the coverage of existing R2E and R3

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facilities, or to ensure flexibility and agility for mobile operations, a smaller but more mobile Role 2 Light Manoeuvre (R2LM) - which may be described as a light surgical facility - may be deployed. R2LM may also act as a reserve. R2LM will necessarily have limited capability (for managing complex injuries) and limited post-operative holding capacity, so move to R3 (or R2E) in a few hours will usually be required. Where possible all significant casualties should be admitted directly to R2E or R3, and then evacuated by STRATEVAC to definitive care (Role 4). In support of maritime operations, depending on the level of likely demand and distance from other support, it may be necessary to embark light surgical capability on warships. Vessels with larger helicopter landing platforms such as amphibious warfare ships would usually be suitable for embarking R2E level care. R3 support to maritime operations might be at sea or land based; again the requirement will be determined by the estimate. R2E or R3 afloat might similarly support land (or littoral) operations.

d. Tactical medical evacuation (TACEVAC). Transfer of patients requiring a move from one deployed medical facility to another will usually be undertaken using FW assets as a planned tactical medical evacuation mission (TACEVAC), again with the level of in transit care that meets the clinical needs of the patient. Effectiveness of handover is optimised by having a hospital evacuation co-ordinating officer at each facility, who acts as the interface between the agencies involved and facilitates the necessary processes, including assistance with the patient movement request (PMR) and confirmation of the patient's fitness to be flown ("validation"). Patients admitted to R2LM (or light surgical facilities afloat) will usually require transfer by TACEVAC to R2E or R3, preferably by FW. MEDEVAC assets should usually not be used for TACEVAC missions; if exceptionally this becomes necessary, forward MEDEVAC coverage must be sustained by other assets. Where it is necessary to use MEDEVAC assets for T ACEVAC, "pull/patient retrieval" using RW from the receiving hospital is preferable to TACEVAC "push" using RW from where the patient is located. However, dedicated TACEVAC (and STRA TEVAC) assets might be placed forward in order to be prepared to clear casualties at the optimal time, or alternatively they may be based at the destination and called forward as required. Ambulatory patients transferred for non urgent medical care should not usually be undertaken on aircraft dedicated to MEDEVAC, but instead be moved on routine transport, with medical escort if required.

e. Strategic evacuation (STRATEVAC). Following surgery or other necessary treatment at R2E or R3, those patients requiring further treatment will normally be evacuated out of the operational theatre to definitive care. This is undertaken by means of FW STRATEVAC assets, usually provided on a national basis. Commonly nations will undertake bilateral agreements with those nations providing STRATEVAC; STRATEVAC might also be provided through a contractor.

f. Definitive healthcare. Definitive healthcare for NATO and other forces will usually be provided in those forces own nation, or another nation by arrangement. This is R4 medical care. Host nation patients admitted, be they security forces or civilians, will normally be transferred to their national military or civilian healthcare system following emergency treatment/stabilisation.

g. Medical rules of eligibility for emergency care on operations. National caveats may be in place in respect to the treatment of patients that are not part of

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national, coalition or NATO forces. Experience has shown however that notwithstanding these caveats it will be necessary to admit some host nation casualties on NATO-led operations. In order to sustain medical capacity it is necessary to have common "medical rules of eligibility" for admisSion, recognising that the patient care pathway will be different for patients who are members of NATO and allied forces compared to those whose ongoing care will be in the host nation. These may be summarised as follows:

• Deployed forces of any NATO or allied nation, including NATO civilians (such as HQ staff, NC3A, NCSA, NAMSA) are to be provided with MEDEVAC and treated as for own nation forces in national facilities.

• Members of the host nation security forces are to be provided with emergency medical care as for the above, then transferred to host nation healthcare facilities as their condition improves to allow transfer.

• Host nation civilians injured as a result of the conflict are to be provided with emergency care when this is requested, and thereafter should be transferred to local healthcare facilities as soon as their condition allows.

• International medical ethical principles place a duty on medical staff to provide emergency treatment for serious cases presenting to them, based on clinical need, within their capability to manage their condition.

h. Medical engagement with Reconstruction and Development (R&D). Medical elements may contribute to host nation health sector reconstruction and development (R&D), which although not their primary purpose, promotes stabilisation and the conditions for operational success. Achieving this requires engagement with a broad range of experts, civilian and military, from National Governmental, International and Non-Governmental Organisations (NGOs). AD 83-2 (Reference D) sets out the principles for military medical engagement in humanitarian assistance and health sector development. A key issue covered in AD 83-2 is that NATO medical facilities should not offer treatment to host nation civilians unless this for humanitarian reasons in emergencies; doing so may undermine the local healthcare infrastructure. However, mentoring host nation medical colleagues is encouraged, as this builds human capital.

i. Medical engagement with host nation Security Sector Reform (SSR) on deployed operations. Mentoring, engagement and partnering with colleagues in the security forces medical services may be a key contribution to stabilisation operations. AD 83-2 outlines the general principles to be applied.

j. Ethics. All medical personnel must conform to international medical ethical standards, including those expressed in the Geneva Conventions. In particular, all patients must be treated with courtesy and as appropriate to their clinical condition and circumstances - including casualties who are members of the opposing forces. Medical personnel have a responsibility to report violations of this principle to the appropriate authority (the Commander and MED DIR).

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4-10. Sustain. Healthcare support described above has a major role in sustaining deployed forces. The following are key to sustaining medical capability and capacity:

a. Medical logistics. Supply of blood, pharmaceuticals and specialised equipment are essential to sustaining the medical effort. This is usually undertaken under national arrangements, but the formation of multinational medical units provides the opportunity for efficiencies by sharing supply chains (Reference I).

b. Logistic support. Logistic requirements of deployed medical facilities include safe water, power and mechanisms for disposal of clinical waste safely.

c. Infrastructure support. Engagement with Engineering and other branches will be required, especially in regard to major infrastructure work. A designated theatre infrastructure projects officer will usually be necessary.

d. Innovations in multinational medical support. COMEDS has agreed (Reference G) the principle of a multinational Primary Healthcare Facility, the provision of such a capability allowing Role 1 care to continue to be provided by national contingents (or by bilateral agreements), within a higher quality environment, promoting best practice and bringing economies of scale, particularly for dental care, physiotherapy and staffing low dependency beds.

4-11. Develop - Continuous Improvement in Healthcare Support on Operations (CIHSO)13. It is essential that medical support is sufficient and capable. CIHSO assures the standard of healthcare support (as mandated at Reference 8); the principle having been agreed by COMEDS (Reference G). In this context, assurance is a systematic process to confirm that healthcare delivery is meeting the medical support requirements of the meeting. Key components of CIHSO as an assurance process are:

a. Risk management, through identifying and reporting problems, then preparing and implementing risk mitigation actions. Where suboptimal care or other challenges have occurred, and also where risks are identified proactively, for example through visits to medical facilities by the MED DIR, risk mitigation action should be taken by the appropriate commander. A collaborative approach is essential, as effective risk mitigation will be best achieved by co-operation between all relevant agencies, and a culture that promotes communication of these risks in the interest of patient safety and optimal care for all (as for example in the context of aviation safety). The MED DIR should routinely be informed of feedback on cases provided from R4 as a key component of the CIHSO process.

b. Sharing best practice, providing the opportunity to learn from colleagues, in order to continually improve the standard of healthcare provided. This is achieved through reporting the outcome of CIHSO meetings through the medical functional chain of command, including the formative reporting and analysis of inCidents, showing the follow up actions and solutions implemented to minimise the risk of adverse events occurring. It is also important to share the lessons drawn from examples of where patients have fared especially well (including "unexpected

13 Continuous improvement is the process by which best practice is shared, and challenges acknowledged and reflected upon, in order to learn from experience and so optimise healthcare support on deployed operations.

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survivors). In order to share best practise, feedback from CIHSO meetings and R4 should be reported on routine MEDASSESSREPs; in the interest of patients confidentiality, all details of cases must be anonymised.

c. Sustaining a learning organisation. MEDASSESSREP reports from the deployed theatres (via JFCs) are assessed and conclusions reported in the ACO monthly medical summary. Some lessons drawn from these reports may be acted immediately; the ACO medical summary provides feedback to the JFCs and deployed MEDADs in part of this purpose. MMMSGs have been created for the co-ordination of medical support efforts by the troop contributing nations and the JFC responsible for that operation or a part of it. The outcome is then presented to the NATO Operations Medical Conference (NOMC), jOintly chaired by ACO and ACT, in order that resultant lessons may inform the conduct of current operations, training, and development of doctrine. The Mil Med CoE attends the NOMC in order to capture such lessons identified, which are also submitted to the Joint Analysis Lessons Learned Centre (JALLC).

d. Building capacity. It is essential to the long term sustainability of medical support to operations that capabilities and capacity within all the NATO nations and their partners are sustained and developed. The MMMSGs and NOMC provide a forum for this, directly in respect to best practice and lessons identified, and also by providing opportunities for engagement among nations.

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