2.1

Levels of Medical Care

Chapter 2

Levels of Medical Care

Military doctrine supports an integrated health services support

system to triage, treat, evacuate, and return soldiers to duty in

the most time efficient manner. It begins with the soldier on the

battlefield and ends in hospitals located within the continental

United States (CONUS). Care begins with first aid (self-aid/

buddy aid, and combat lifesaver), rapidly progresses through

emergency medical care (EMT) and advanced trauma management (ATM) to stabilizing surgery, and is followed by critical

care transport to a level where more sophisticated treatment

can be rendered.

There are five levels of care (also known as “roles”), previously

referred to as echelons by NATO and ABCA (USA, Britain,

Canada, Australia) countries. Levels should not to be confused

with American College of Surgeons use of the term in US

trauma centers. Different levels denote differences in capability,

rather than the quality of care. Each level has the capability of

the level forward of it and expands on that capability. Soldiers

with minor injuries can be returned to duty after simple

treatments at forward locations, all others are prepared for

evacuation with medical care while en route to a higher level.

Level I

 Immediate first aid delivered at the scene.

ο First aid and immediate life-saving measures provided by

self-aid, buddy aid, or a combat lifesaver (nonmedical

team/squad member trained in enhanced first aid).

ο Care by the trauma specialist (91W) (combat medic),

assigned to the medical platoon, trained as an Emergency

Medical Technician-Basic (EMT-B). Some other primary
2.2

Emergency War Surgery

care providers, with various levels of training, include the

Special Forces Medical Sergeant 18D, Special Operations

Combat Medic 91W, SEAL Independent Duty Corpsman,

Special Boat Corpsman, Pararescueman, and Special

Operations Medical Technician.

ο Initial treatment of nuclear, biological, and chemical

casualties, treatment of toxic industrial material casualties,

primary disease prevention, combat stress control

measures, and nonbattle injury prevention.

 Level I medical treatment facility (MTF) (commonly referred

to as the Battalion Aid Station [BAS]).

ο Provides triage, treatment, and evacuation.

ο Physician, Physician Assistant (PA), and medics.

ο Return to duty, or stabilize and evacuate to the next level.

ο Can be chem/bio protected.

ο No surgical or patient holding capability.

 US Marine Corps (USMC): Shock Trauma Platoon (STP).

ο Small forward unit supports the Marine Expeditionary

Force (MEF).

ο Stabilization and collecting/clearing companies.

ο 2 physicians.

ο No surgical capability.

ο Patient holding time limited to 3 hours.

Level II

 Increased medical capability and limited inpatient bed space.

 Includes basic primary care, optometry, combat operational

stress control and mental health, dental, laboratory, surgical

(when augmented) and X-ray capability.

 100% mobile.

 Each service has a slightly different unit at this level.

 Army.

ο Level II MTFs operated by the treatment platoon of

divisional/nondivisional medical companies/troops.

♦ Basic/emergency treatment is continued.

♦ Packed RBCs (Type 0, Rh positive and negative), limited

X-ray, laboratory, and dental.

♦ 20–40 cots with 72-hour holding.
2.3

Levels of Medical Care

♦ Can be chem/bio protected.

♦ No surgical capability.

ο Forward Surgical Team (FST).

♦ Continuous operations for up to 72 hours.

♦ Life-saving resuscitative surgery, including general,

orthopedic, and limited neurosurgical procedures.

♦ 20-person team with 1 orthopedic and 3 general

surgeons, 2 nurse anesthetists, critical care nurses and

technicians.

♦ The supporting medical company must provide

logistical support and security. (Doctrinally, the FST is

collocated with a Medical Company.)

♦ ~1,000 sq ft surgical area.

♦ Can be chem/bio protected.

♦ Operational within 1 hour of arrival at the supported

company.

♦ May be transported by ground, fixed wing, or helicopter;

some fleet surgical teams (FSTs) are airborne deployable.

♦ 2 operating tables for a maximum of 10 cases per day

and for a total of 30 operations within 72 hours.

♦ Post-op intensive care for up to 8 patients for up to 6

hours.

♦ X-ray, laboratory, and patient administrative support

provided by the supporting medical company.

♦ Requires additional electricity, water, and fuel from the

supporting medical company.

♦ The FST is not designed, staffed, or equipped for stand

alone operations or conducting sick-call operations.

Augmentation requirements are discussed in FM 4-02.25.

 Air Force.

ο Mobile Field Surgical Team (MFST).

♦ 5-person team (general surgeon, orthopedist, anesthetist,

emergency medicine physician, and OR nurse/tech).

♦ 10 life/limb saving procedures in 24–48 hours from five

backpacks (350 lb total gear).

♦ Designed to augment an aid station or flight line clinic.

♦ Not stand alone, requires water, shelter of opportunity,

communications, among other things.
2.4

Emergency War Surgery

♦ Integral to remainder of Air Force (AF) Theater Hospital

System.

ο Small Portable Expeditionary Aeromedical Rapid

Response (SPEARR) team.

♦ 10-person team: 5-person MFST, 3-person CCATT (see

Chapter 4, Aeromedical Evacuation) and a 2-person

preventive medicine (PM) team (flight surgeon, public

health officer).

♦ Stand alone capable for 7 days, 600 sq ft tent.

♦ 10 life/limb saving procedures in 24–48 hours.

♦ Designed to provide surgical support, basic primary

care, post-op critical care, and PM for early phase of

deployment.

♦ Highly mobile unit, with all equipment fitting in a onepallet–sized trailer.

ο Expeditionary Medical Support (EMEDS) Basic.

♦ Medical and surgical support for an airbase, providing

24-hour sick call capability, resuscitative surgery, dental

care, limited laboratory and X-ray capability.

♦ 25 member staff includes SPEARR team.

♦ 4 holding beds, 1 OR table, 3 climate controlled tents,

and 3 pallets.

♦ 10 life/limb saving procedures in 24–48 hours.

♦ ~2,000 sq ft.

ο EMEDS + 10.

♦ Adds 6 beds to EMEDS Basic, for total of 10.

♦ No additional surgical capability.

♦ 56-person staff.

♦ 6 tents, 14 pallets.

♦ Can be chemically hardened.

 Navy.

ο Casualty Receiving & Treatment Ships (CRTS). CRTSs

are part of an Amphibious Ready Group (ARG) and

usually comprise one landing helicopter assault or

amphibious (LHA) Tarawa-class or landing helicopter deck

(LHD) Wasp-class ship, which are Marine amphibious
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Levels of Medical Care

assault helicopter carriers that function as casualty

receiving platforms. An ARG includes up to 6 ships with

surgical capability only on the CRTS.

♦ 47-48 beds, 4-6 ORs, 17 ICU beds.

♦ 300 additional medical care beds may be available once

Marines diseembark.

♦ Fleet Surgical Teams (FSTs): 3-4 physicians, 1 surgeon,

1 CRNA or anesthesiologist and support staff.

♦ Usually 2 general surgeons and 2 orthopedic surgeons.

OMFS (oral maxillofacial surgery) support available

through the dental department. Can be substantially

augmented.

♦ Laboratory, X-ray.

♦ Excellent casualty flow capability (large helicopter flight

deck and landing craft units [LCU] well deck).

♦ Mass casualty (MASCAL) capability with triage area

for 50 casualties.

♦ Doctrinally, holding capability is limited to 3 days.

 Aircraft Carrier (CVN) Battle Group.

ο 1 OR, 40–60 beds, 3 ICU beds.

ο 1 surgeon, 5 other medical officers.

ο Up to 9 ships, but usually only the CVN has physicians.

Medical assets aboard aircraft carriers are intended for use

by the aircraft carrier and its task force. Aircraft carriers

are NOT casualty receiving ships and are not figured into

medical assets for support to ground forces.

 USMC.

ο Surgical Company.

♦ Provides surgical care for a MEF (Marine Expeditionary

Force). Basis of allocation is 1 per infantry regiment.

♦ 3 ORs, 60-bed capability.

♦ Patient holding time up to 72 hours.

♦ Stabilizing surgical procedures.

ο Forward Resuscitative Surgical System (FRSS).

♦ Embedded organically as part of the TO&E of the

surgical company, if employed reduces the capability

of its parent surgical company.
2.6

Emergency War Surgery

♦ Rapid assembly, highly mobile.

♦ Resuscitative surgery for 18 patients within 48 hours

without resupply.

♦ 1 OR, 2 surgeons.

♦ No holding capability.

♦ No intrinsic evacuation capability.

♦ Chem/bio protected.

♦ Stand alone capable.

Level III

Represents the highest level of medical care available within

the combat zone with the bulk of inpatient beds. Most

deployable hospitals are modular, allowing the commander to

tailor the medical response to expected or actual demand.

 Army.

ο Two different Corps-level Combat Support Hospital (CSH)

designs.

♦ Medical Force 2000 (MF2K) CSH.

♦ Medical Reengineering Initiative (MRI) CSH will

replace the MF2K.

ο Combat Support Hospital.

♦ MF2K CSH.

◊ Resuscitation, initial surgery, post-op care, and either

return to duty or stabilize for further evacuation.

◊ Up to 296 patients, typically divided into 8 ICUs (96

ICU beds), and 7 Intermediate Care Wards (ICWs)

(140 beds), 1 neuropsychiatric (NP) ward (20 beds),

and 2 minimal care wards (40 beds).

◊ 175 officers, 429 enlisted; specialty attachments may

increase numbers.

◊ Up to 8 OR tables for a maximum of 144 operating

hours per day.

◊ General, orthopedic, urologic, neurosurgical, dental

and oromaxillofacial surgery.

◊ Blood bank, laboratory, X-ray/computer tomography

(CT); nutrition, physical therapy and NP capabilities.

◊ Dependent on a number of Corps support elements

for personnel, finance, mortuary, legal, laundry,
2.7

Levels of Medical Care

security, and enemy prisoners of war (EPW)

management, support.

◊ Transportation support required for both incoming

and outgoing patient evacuation, and to transport

the hospital.

◊ Transported via semitrailer, railcar, air cargo, or ship.

◊ Fully deployed CSH (including motor pool, billeting,

heliport, and other life support activities) covers 30.3

acres.

◊ Divided into modules, deployed as a single unit or

separately as the mission dictates. The main modules

are the Hospital Unit-Base (HUB) and the Hospital

Unit-Surgical (HUS).

HUB is the infrastructure of the CSH.

 Up to 236 patients, divided into 36 ICU, 140

intermediate, 40 minimal, and 20 NP beds.

 Two operating modules with specialty

surgical care capability.

 HQ, administrative, personnel, chaplain,

laboratory, pharmacy, X-ray, and blood bank

services.

 Part of the HUB can be chem/bio protected

(FM 4-02.7).

HUS capabilities.

 60 ICU patients, 2 OR modules, X-ray.

 Dependent on the HUB for all logistical

support.

 Can be deployed forward, separate from the

HUB, for brief periods as the mission dictates.

 MRI CSH (Corps).

ο Provides hospitalization and outpatient services for all

classes of patients in the theater, either returned to duty

or stabilized for further evacuation.

ο Headquarters/headquarters detachment: 15 officers and

44 enlisted.

ο Up to 248 patients, typically divided into an 84-bed

hospital company and a 164-bed hospital company, with

split base operations capability.
2.8

Emergency War Surgery

♦ 84-bed hospital company.

◊ 24 ICU beds.

◊ Up to 2 OR tables, maximum of 36 operating hours

per day.

◊ 3 ICWs (total 60 beds, including NP patients).

◊ 56 officers and 112 enlisted personnel.

Some patient care areas can be chem/bio protected.

♦ 164-bed hospital company.

◊ 24 ICU beds.

◊ Up to 4 OR tables, maximum of 60 operating hours

per day.

◊ 7 ICWs (total 140 beds, including NP patients).

◊ 84 officers and 169 enlisted personnel.

Some patient care areas can be chem/bio protected.

♦ Applicable to 84-, 164-, and 248-bed (see CSH [Echelon

of Care, EAC] below) hospital companies.

◊ General, orthopedic, urologic, thoracic, OB/GYN,

neurosurgical, dental and oromaxillofacial surgery.

◊ Blood bank, laboratory, X-ray, nutrition, and physical

therapy.

◊ Dependent on EAC support elements for personnel,

finance, mortuary, legal, laundry services, security

and EPW support.

◊ Parts can be chem/bio protected.

◊ Transportation support required for both incoming

and outgoing patient evacuation, and to transport

the hospital.

◊ Transported by semi-trailer, railcar, air cargo, or ship.

◊ Fully deployed, covers 5.7 acres.

◊ Minimal care wards are provided by an attached

minimum care detachment.

 Air Force.

ο EMEDS +25.

♦ 25-bed version of EMEDS Basic.

♦ 84 personnel, 2 OR tables, 9 x 600 sq ft tents, and 20

pallets.

♦ 20 operations in 48 hours.

♦ Can be chemically hardened.
2.9

Levels of Medical Care

♦ Additional specialty modules can be added, including

vascular/cardiothoracic, neurosurgery, OB/GYN, ear,

nose and throat (ENT), ophthalmology teams; each

comes with own personnel and equipment.

 Navy.

ο Fleet Hospital.

♦ 500-bed hospitals, 80 ICU beds, and 6 ORs.

♦ 1,000 personnel.

♦ Stand alone; full ancillary services.

♦ 8–10 days to be operational.

♦ Large footprint — 28 acres, 450 isolation (ISO) shelters.

♦ No limit on holding capability.

ο Hospital Ships (TAH) — USNS Mercy and USNS Comfort.

♦ 1,000 beds, 100-bed ICU capability, and 12 ORs.

♦ 1,000 staff, over 50 physicians.

♦ Extensive laboratory and X-ray capabilities.

♦ Patient holding is doctrinally limited to 5 days.

Level IV

 Definitive medical and surgical care outside the combat zone,

yet within the communication zone/EAC of the theater of

operations (TO).

 Patients requiring more intensive rehabilitation or special

needs.

 Traditionally includes the MF2K Field Hospital (FH) and

General Hospital (GH).

 In some situations, the MF2K CSH or a fixed hospital may

act as a Level IV facility (eg, Landstuhl Army Regional

Medical Center, Germany).

ο Field Hospital.

♦ Semipermanent hospital that provides primarily

convalescent care.

♦ At least 2 OR tables for 24 OR hours per day.

♦ General, orthopedics, OB/GYN, urologic, oral surgery,

and dental services.

♦ Up to 504 patients, with 2 ICUs (24 patients), 7 ICWs

(140 patients), 1 NP ward (20 patients), 2 minimum care

wards (40 patients), and 7 patient support sections (280

patients).
2.10

Emergency War Surgery

ο General Hospital.

♦ Usually a permanent or semipermanent facility.

♦ At least 8 OR tables for 144 OR hours per day.

♦ General, orthopedic, gynecologic, urologic, and oral surgery.

♦ Dental and optometry services.

♦ Outpatient specialty and primary care services.

♦ Up to 476 patients, with 8 ICUs (96 patients), 16 ICWs

(320 patients), 1 NP ward (20 patients), and 2 minimum

care wards (40 patients).

The MRI CSH Echelon Above Corps (EAC) will replace

the FH and GH.

 CSH (EAC).

ο Headquarters/headquarters detachment: 17 officers and

33 enlisted.

ο Cannot operate in a split-based mode like the CSH (Corps).

ο 248-bed hospital company.

♦ 4 ICUs (total 48 ICU beds), and 10 ICWs (total 200 beds,

including NP patients). A specialty clinic section that

can treat NP patients. Minimal care wards are provided

by attached minimum care detachments.

♦ 140 officers, 244 enlisted personnel.

♦ Up to 6 OR tables for 96 operating hours per day.

♦ Fully deployed (including motor pool, troop billeting,

heliport, and other life support activities), covers 9.3

acres.

♦ See other general characteristics under MRI CSH

(Corps).

Level V

This level of care is provided in the CONUS. Hospitals in the

CONUS sustaining base will provide the ultimate treatment

capability for patients generated within the theater. Department

of Defense (DoD) hospitals (military hospitals for the triservices) and Department of Veterans Affairs (DVA) hospitals

will be specifically designated to provide the soldier with

maximum return to function through a combination of medical,

surgical, rehabilitative, and convalescent care. Under the
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Levels of Medical Care

National Disaster Medical System, patients overflowing DoD

and DVA hospitals will be cared for in designated civilian

hospitals.
2.12

Emergency War Surgery