Field Manual No. 8-55: Planning for Health Service Support

Chapter 2: Health Service Support Estimates, Plans, and Orders

Headquarters, Department of the Army, Washington, DC

Section I. Principles of Planning

2-1. Health Service Support Planning
a. Current HSS planning addresses the management of normal day-to-day operations, while short- and long-range planning cover projected operations of successively longer periods. Planning is a continuous process. The planner must remain sensitive to the demands for HSS based upon constantly changing situational and operational requirements. During current operations, staffs at all levels (especially higher command levels) must continuously plan for subsequent operations. Regardless of the type of military operation being supported or the level of command providing the support, HSS plans must be made. These plans may be either formal written plans or informal thought processes. Either plan must be well-communicated to be effective. The planner must proceed in an orderly, progressive manner to ensure maximum effort and completeness. The specific time required to plan varies with the type, size, and level of the command concerned. The amount of detail required to plan will also vary with the--

• Type of command.

• Experience of all personnel in the command.

• Complexity of the operation.

• Factors of combined, joint services, or interagency participation.

• Time available.

b. Planners must develop well-thought-out plans and validate the plans through field training exercises and command and staff simulations. The process of thinking through a plan and conducting "What if?" drills by changing critical variables is especially useful. This process allows the HSS planner to envision potential results and to anticipate problems. Consequently, the planner can become proactive instead of being reactive. The proactive planner can eliminate potential problems before they cause adverse consequences. He has more time to accomplish the required synchronization to adjust operations when adverse consequences arise because he has anticipated problems and has already considered potential solutions. The proactive planner has more time to address unanticipated problems and more time to plan HSS for future operations.

c. Effective and timely planning is essential to operate successfully on the battlefield. Failure in the planning process will result in commanders, their staffs, and subordinate units finding themselves unprepared to function in military operations. The modern, mobile battlefield is the wrong place to be operating precariously. That approach will cost soldiers' lives. Planners must have the initiative to ask questions that may affect the performance of their units, and they must know their units well enough to answer questions when asked.

2-2. Planning Sequence
The planning sequence is a series of steps representing a logical progression of command and staff actions required to develop plans. The planning sequence attempts to prepare for all developments that can reasonably be anticipated. Although some actions ordinarily occur sequentially, others take place concurrently. Field Manual 101-5 provides an in-depth discussion of the planning process.

2-3. Current Plan
A plan developed in the planning sequence described in FM 101-5 is not necessarily implemented on completion. As new information becomes available or as events occur, the plan is reviewed and updated accordingly. This action continues until the plan is implemented or until no requirement exists for the plan.

2-4. Coordination of the Plan
a. Coordination is one of the most essential elements in successful planning. From the beginning, the planner must continuously coordinate the various types of operations with the commander and his assistants. With a knowledge of the mission, the current situation, and the objectives, the planner can better plan for the support that will be required. This method enables him to begin the planning for support early and allows him time for more thorough planning. He must ask questions such as, What resources will I need to do the job? Where will I obtain them?

b. The planner must also coordinate with those staff representatives at the various headquarters who can furnish him needed information and who must coordinate their plans with his. He must begin early coordination in those areas requiring close HSS interface within the CSS community.

c. Building the HSS interface as part of the CSS community is critical. Health service support depends on the CSS system for a multitude of support services such as--

(1) Class I (Subsistence, including medical B rations and gratuitous health and welfare items).

(2) Class II (Clothing, individual equipment, tentage, tool sets and tool kits, hand tools, and administrative and housekeeping supplies and equipment). This class includes items of equipment (other than principal items) prescribed in authorization/allowance tables, and items of supply (not including repair parts).

(3) Class III (Petroleum, oils, and lubricants [POL]: Petroleum fuels; lubricants, hydraulic and insulating oils, preservatives, liquid and compressed gases, chemical products, coolants, deicing and antifreeze compounds, together with components and additives of such products, and coal).

(4) Class IV (Construction: Construction materials including installed equipment and all fortification/barrier materials).

(5) Class V (Ammunition: individual small arms ammunition, and pyrotechnics for defense of self and patients).

(6) Class VI (Personal demand items).

(7) Class VII (Major end items such as vehicles and aircraft which are ready for their intended use).

(8) Class IX (Maintenance repair parts for associated support items of equipment [ASIOE]).

(9) Class X (Material to support nonmilitary programs).

(10) Other support services such as--

(a) Nonmedical transportation.

(b) Potable water resupply.

(c) Liquid waste disposal.

(d) Direct support(DS)/general support (GS) maintenance backup.

(e) Trash/solid waste disposal.

(f) Medical intelligence dissemination.

(g) Rear operations.

(h) Mortuary affairs.

(i) Site support by engineer units.

(j) Movement control.

(k) Reconstitution.

(l) Delivery of Class VIII supplies.

(m) Assistance in movement of medical units.

(n) Nonmedical augmentation, such as personnel and air and ground transportation from nonmedical units, to medical evacuation assets in mass casualty situations.

d. Commanders and staff (planners) within units must know how, when, and with whom to coordinate (synchronize) both internally and externally. Proficient synchronizers tend to think about what is happening and what will be happening two levels down, two levels up, and on each side.

e. Just as HSS commanders must be multifunctional to recognize CSS requirements, so too must future multifunctional CSS commanders recognize medical requirements to integrate CSS effectively across the spectrum of military operations. They will have to understand what the HSS system is all about as they will have an inherent responsibility for ensuring that HSS is planned and provided in a timely, responsive, and effective manner.

2-5. Characteristics of the Plan
A good HSS plan--

• Provides for accomplishing the mission. Is based on facts and valid assumptions. All pertinent data have been considered for their accuracy, and assumption shave been reduced to a minimum.

• Provides for the use of existing resources. These include resources organic to the organization and those available from higher headquarters.

• Provides for the necessary organization. It clearly establishes relationships and fixes responsibilities.

• Provides for personnel, materiel, and other arrangements for the full period of the contemplated operation.

• Provides for decentralized execution of the plan. It delegates authority to the maximum extent consistent with the necessary control.

• Provides for direct coordination during execution between all levels.

• Is simple. It reduces all essential elements to their simplest form and eliminates those elements not essential to successful action.

• Is flexible. It leaves room for adjustments because of operating conditions and, where necessary, stipulates alternate courses of action (COA).

• Provides for control. Adequate means exist, or have been provided, to carry out the plan according to the commander's intent.

• Is coordinated. All elements fit together, control measures are complete and understandable, and mutual support requirements are identified and provided for.

2-6. Planning Guidance
The commander provides planning guidance to the staff as required. The frequency, amount, and content of planning guidance will vary with the mission, time available, situation, information available, and experience of the commander and staff. The commander may choose to issue initial planning guidance to the staff when the mission to be supported is announced; however, he must take care not to unduly bias staff estimates. This guidance is used to direct or guide the attention of the staff in the preparation or revision of staff estimates and serves to expedite the decision-making process. Planning guidance should include all elements of the commander's intent.

2-7. Basic Planning Considerations
The commander's intent and the mission assigned to the combat forces must be the basic consideration of all components in their planning for HSS.

a. Health service support preparations and planning must be initiated early and designed specifically to support the operation.

b. Certain basic factors and premises must be used for sound HSS planning, Among the most important are--

(1) Preparing a HSS estimate and a concept of the HSS operation.

(2) Coordinating the efforts of the health services of the component forces to make maximum use of available resources.

(3) Planning to assure flexibility for unforeseen contingencies such as nuclear, biological, and chemical (NBC) and directed-energy (DE) warfare.

Section II. The Health Service Support Estimate

2-8. Surgeon's Responsibility
a. After the commander provides planning guidance, the surgeon should prepare estimates of requirements and descriptions of projects to be undertaken for establishing adequate HSS systems to support the mission. He prepares this in his role as a special staff officer. The surgeon makes a health service estimate that may stand alone, or that may be incorporated into the personnel estimate. This estimate forms the basis for the subsequent HSS plan. All HSS possibilities that could affect the successful support of an operation must be considered. (See FM 8-42 for additional discussion.)

b. The surgeon must determine what basic load modifications are required, what additional people skills are required, and any mission unique training that must be conducted. The surgeon must know his intelligence element, how medical information requirements are made known to the appropriate intelligence element, what medical intelligence is available, how medical intelligence is disseminated, and how to integrate intelligence in general and medical intelligence in particular into HSS operation plans (OPLANs)/operation orders (OPORDs). (See Appendix F and FM 8-10-8.)

c. The commander uses the HSS estimate, along with estimates of other individual staff members, in the preparation of his own estimate. He uses the information in the HSS estimate to select the best COA for the command, and for inclusion in the operational and logistics support plans.

d. After considering all the staff estimates, the commander completes his own estimate and makes his decision. In the case of a medical command (MEDCOM) or medical brigade headquarters, the estimate is made by the commander, assisted by his staff, and normally results in the publication of the HSS plan for the command. At lower echelons, the estimate is a continuous mental process integrated in the planning process.

2-9. Format for the Estimate
The process followed in preparing a HSS estimate of the situation is the same as that followed in preparing an operational estimate.

a. Staff estimates may be presented orally, or in writing. Often, only the staff officer's conclusions or recommendations are presented to the commander.

b. An example for a health service estimate is found in Appendix B. This format is applicable to any echelon of command and can be used under any operational condition. It is lengthy and includes many more details than may be needed in some situations. Each HSS planner must vary it according to his needs. There is no beginning or end to the estimate. It must be continuously and constantly revised as circumstances change, so that planned support can be provided to the command from the time it is mobilized until it is inactivated.

c. The estimate is intended to be a timesaving and integral part of providing adequate support for all types of operations. If the estimate is prepared by the command surgeon (corps surgeon/corps support command [COSCOM] surgeon), it must support the tactical commander's intent. If prepared by a command such as a MEDCOM, medical brigade, or medical group, it becomes the estimate of the medical commander assisted by his staff. Normally, estimates at the division surgeon's level are not formal written documents; however, health service considerations may appear in a written personnel estimate prepared by the G1/S1 (Personnel/Adjutant, respectively). The commander or the staff officer should use the format as a guide and checklist.

2-10. Mission
a. The senior medical commander/command surgeon is responsible--

(1) For analyzing the mission of the command from the HSS perspective.

(2) For outlining the concept of HSS operations, assigning taskings, and providing guidance for a casualty care system in support of the commander's intent and concept of operations.

(3) For coordinating HSS with civil affairs, other Services, and/or alliance and coalition partners, and other government agencies.

(4) For coordinating HSS with host nations by providing medical liaison teams to countries with which the US has HSS agreements or with relief agencies participating in the operation in concert with civil affairs.

(5) For anticipating the lack of HSS infrastructure in a host nation and determining the impact upon refugee management.

b. The HSS mission is the basis for the estimate and is stated clearly in paragraph 1 of the estimate. It always conforms to the operations in which the supported personnel are engaged. For example, the mission might be to provide HSS to the 52d Mechanized Division in a deception operation on 10 and 11 June 92. The division attacks on 110310 June to secure high ground on Hills 123, 456, and 789. 3d Brigade makes the main attack on the west. In another example, the mission may be to save lives by providing basic medical care, medical evacuation, and preventive medicine (PVNTMED) sanitation enforcement and education.

2-11. Situation and Considerations
The health service situation will consist of HSS facts, assumptions, and deductions that can affect the operation. In this logical and orderly examination of all the HSS factors affecting the accomplishment of the mission, the HSS planner must be familiar with the commander's intent. The information required includes medical intelligence which is obtained through supporting intelligence channels. (See FM 8-10-8 for a discussion on information requirements and priority intelligence requirements.) The planner must conduct a thorough evaluation of the enemy situation and the area of operations (AO) from the standpoint of their effects on the health of the command and HSS operations. These are enumerated as follows in paragraph 2 of the estimate:

a. Enemy Situation. From his specialized point of view, the surgeon must consider the enemy's ability to adversely affect the HSS operations of the command.

(1) The enemy's attitude toward the Geneva Conventions could alter HSS if he is likely to attack the friendly HSS system, or if he is known to have attacked it. It could also determine the type of medical care friendly prisoners of war can expect.

(2) The enemy's strength, disposition, probable movements, logistic situation, and combat efficiency must be considered to estimate the number of patients requiring hospitalization and evacuation.

(3) The enemy's ability to inflict conventional and unconventional (NBC and DE warfare) casualties is a concern. The type of enemy weapons employed will influence the number and type of combat casualties. Heavy artillery bombardment, air attack, surprise weapons and tactics, and continuous operations increase battle fatigue casualties, while guerrilla or terrorist attacks cause other combat stress reactions. Supplementary hospitalization and evacuation resources may be required.

(4) The enemy's medical capabilities, sanitation discipline, and the health of potential enemy prisoners of war (EPW) can be expected to influence the command's medical work load as well as the EPW patient work load.

b. Friendly Situation. A preliminary estimate of medical work loads can be made when the friendly forces' strength, combat efficiency, position, weapons, and plan of action are compared with those of the enemy.

(1) This comparison considers the tactical plan of the commander to determine the location of areas of casualty densities and the best placement of HSS units.

(2) He must consider the enemy's ability to disrupt the rear operations of the command. Medical units in the rear must be incorporated into base clusters. Units must be positioned logically to ensure maximum security. These facilities are so numerous that in many cases the ideal type of security may not be available. The threat to these units must not be aggravated by positioning them near areas of high attack probability such as ammunition or nuclear storage facilities. To successfully defeat enemy deep operations, clear-cut lines of authority for security must be established. These lines of authority must be clearly identified at all echelons before any plans or operations are initiated. (See FM 100-15 or FM 71-100 for detailed discussions.) Field Manual 8-10 addresses Article 24 of the "Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field (GWS)." It also discusses US Army policy on the use of Article 24 personnel in perimeter defense.

(a) Article 24 of the GWS provides special protection for "Medical personnel exclusively engaged in the search for, or the collection, transport, or treatment of the wounded or sick, or in the prevention of disease [and] staff exclusively engaged in the administration of medical units and establishments. . . . [Emphasis added.]"

(b) The GWS does not itself prohibit the use of Article 24 personnel in perimeter defense of nonmedical units such as unit trains logistics areas or base clusters under overall security defense plans, but the policy of the US Army is that Article 24 personnel will not be used for this purpose. Adherence to this policy should avoid any issues regarding their status under the GWS due to a temporary change in their roles from noncombatant to combatant. Medical personnel may guard their own unit without any concurrent loss of their protected status.

c. Characteristics of the Area of Operations. The HSS planner should obtain medical intelligence regarding the AO from the supporting intelligence element (FM 8-10-8). This information must be considered in the planning process. The characteristics of the AO influence the number of patients, as well as their collection and evacuation.

(1) Terrain.

(a) Topography has the same bearing on HSS planning as it does on tactical planning. Using terrain to one's advantage may reduce combat casualties therefore decreasing the anticipated patient work load.

(b) Natural conditions may favor large populations of arthropods (insects, arachnids, and crustaceans) which commonly are vectors of many diseases and therefore could directly increase the incidence of disease.

(c) Mountains, forests, and swamps can be expected to hamper HSS. Altitude exposure at high terrestrial elevations frequently results in reduced military performance and can result in acute mountain sickness. Transfer of patients from shore to ship is particularly dependent upon coastline and harbor conditions. Availability of roads, landing strips, and railroads will be important in developing evacuation alternatives. Terrain factors such as protection, shelter, and water supply are considered in consonance with evacuation alternatives and with the selection of medical treatment facility locations. Evacuation resources must be augmented when using difficult terrain.

(d) An increase in the hospital bed allocation should be considered if the terrain analysis suggests a significant increase in battle injury (BI), wounded in action (WIA), disease admissions, or difficulty in evacuating patients. Preventive medicine detachments should be tasked to reinforce forward deployed units if disease potential warrants.

(e) The duration of hazards from chemical-biological warfare agents may increase in the forest where the air is still and the foliage is thick.

(2) Weather and climate.

(a) Climate influences the incidence of frostbite, hypothermia, snow blindness, immersion injuries, sunburn, heat exhaustion, heatstroke, combat stress, and other medical manifestations that detract from combat unit effectiveness.

(b) Tropical, desert, and tundra conditions strongly favor the growth of arthropod populations that highly increase the incidence of disease casualties. Preventive medicine units become increasingly important under such adverse conditions.

(c) Humidity may affect storage life of medical supplies and equipment.

(d) Precipitation affects available water supply, may impact on hospital site selection, and may damage unprotected supplies. Rain and snow will have dramatic effects on roads, changing evacuation routes and increasing turnaround times.

(e) Temperature variations may require special protection of medical supplies and may increase patient load because of heat and cold injuries. Weather also impacts on the level of degradation incurred while in mission-oriented protective posture (MOPP) and thus has a direct impact on heat casualty volume. Additionally, requirements for medical facilities, supplies, and evacuation resources can be expected to increase. Because the rate of deterioration of health service logistics is influenced by both climate and weather, storage facilities must be estimated accordingly. Evacuation alternatives, particularly by air, will be highly influenced by weather conditions. (See FM 1-230.)

(3) Dislocated civilian population and enemy prisoners of war.

(a) Wartime stress and physical damage can lead to rapid deterioration of urban and rural utilities such as electricity, water, and sewage services. Consequent increases in communicable disease could present a threat to which friendly forces are vulnerable. Enemy prisoners of war and refugee populations also tend to be sources of communicable disease. Because cities and towns tend to be located along axes of peacetime economic activity, they invariably confront CSS units moving on main supply routes (MSRs) and at crossroads of principal highways. Even if a disease outbreak is suspected, bypass of such areas is generally impractical. Refugee populations, if not properly managed by local authorities or military police, also tend to concentrate on major transportation routes.

(b) Civil Affairs (CA) and military police have the responsibility of working with the local authorities to manage the flow of refugees.

(c) Preventive medicine teams could be tasked to assist local authorities to reactivate essential civilian sanitary services, or to establish hygienic refugee assistance facilities.

(d) Veterinary units may be used to assist in the control of animal diseases that present a risk to the human population or to the agricultural economy. Veterinary units will also inspect subsistence fed to dislocated civilians and EPW to prevent foodborne diseases, as required. This will limit the impact these populations have on Army Medical Department (AMEDD) resources.

(e) If resources permit, MTF or medical treatment/holding cot allocations could be increased to accommodate known or suspected outbreaks of disease.

(f) Class VIII and Class X materiel (materiel to support nonmilitary programs) could similarly be accumulated in anticipation of a larger demand.

(g) Increased evacuation and hospitalization requirements for dislocated civilian populations will be supported by local resources, nongovernmental organizations, and relief agencies, whenever possible. Coordination with these local medical agencies should be proactive and accomplished in concert with CA units. This should minimize the strain on military medical resources.

(4) Flora and fauna. Certain kinds of arthropods, animal diseases, and toxic plants encountered in the area may also contribute to the noneffective rate of the command. Orientation of personnel and safeguards against arthropods, animals, and vegetation may be necessary. Preventive medicine units can develop desired information. Veterinary units can evaluate the local crops and animals for availability and suitability as fresh food sources. As a TO expands and matures, more fresh food will be needed to support US Forces.

(5) Disease. The effects of major diseases are delayed because of incubation periods. Knowledge of potential losses to malaria, dengue, sandfly fever, typhus, and other endemic disease is invaluable in determining appropriate preventive and control measures. These measures include requirements for basic personal protective measures, immunizations, chemoprophylaxes, immunoprophylaxes, pest management, or other appropriate measures. Should time not allow for preventive measures, disease information will be essential in estimating disease rates and for projecting strength changes in maneuver units.

(6) Local resources. The HSS planner requires information concerning the availability from local sources of such items as food, ice water, pharmaceuticals, and medical gases (oxygen and anesthetics).

(a) Although other units of the command are responsible for procuring food and water, appropriate veterinary services or PVNTMED detachments are responsible for food wholesomeness, hygiene, safety, and quality assurance and for water treatment and storage.

(b) Availability of pharmaceuticals or medical gases in the area affects supply stockage levels and transportation required for the operation.

(c) The use of local facilities such as hospitals, medical clinics, dental and veterinary schools, and their associated staffs should be considered.

(d) The civil-military operations (CMO) staff can provide liaison with indigenous health professionals and organizations.

(7) Nuclear, biological, and chemical and directed-energy weapons. The numbers and types of NBC/DE casualties depends on the scenario. However, these weapons produce mass casualties (MASCAL) whenever they are used. (See FM 8-10-7.) The uncertainty concerning the numbers, types, and extent of injuries from NBC or DE weapons is made even more complex since injuries from more than one type of these weapons can affect the methods of patient treatment and prognosis. Another example is that acute ionizing radiation exposure increases the morbidity and mortality of virtually all patient types. Such insidious weapons and devices also produce a large number of patients with stress-related injuries whose symptoms may be difficult to distinguish from true signs of injury. Nuclear, biological, and chemical weapons may produce large numbers of patients during a single attack so that medical units will have to face large peak patient loads. Directed energy weapons may also be used by the threat force. The effects could be severe on HSS operations.

(a) The CMO staff can identify nonmilitary organizations to support HSS operations under these conditions.

(b) The NBC and DE threat must be evaluated and included in the overall planning concept to determine how to counter it. All medical units must be prepared to execute coordinated MASCAL plans.

(c) Health service support units will not generally establish themselves in a contaminated environment. However, all units in the theater are at risk of attack. Furthermore, remaining or entering a contaminated area may be required to provide HSS. Commanders must ensure that units and personnel are prepared to survive, defend, and continue operations in or near a contaminated area by instituting MASCAL standards for medical treatment. Presence of critical facilities such as nuclear power plants or chemical plants could impact on medical operations. The Bhopal and Chernobyl incidents are excellent examples of how these type facilities could affect medical operations.

(d) Veterinary service personnel will advise all DOD theater logistics units and user units on storing subsistence to prevent NBC contamination, on monitoring and detecting NBC contamination of rations and, when necessary, on decontaminating rations to ensure food safety.

(e) Preventive medicine units and all HSS personnel will be alert for abnormal disease patterns in order to detect NBC effects. The sick soldier or local population is likely to be the first indication of biological warfare use; rapid identification may be critical to the survival of theater forces.

(f) The Area Medical Laboratory (AML) has special capabilities to support HSS units in NBC environments. The AML is described in Chapter 7.

d. Strengths to be Supported. The strengths to be supported are usually shown in a table in which the personnel strength is broken down into categories indicating the types and amounts of support to be required. These categories may include Army, Navy, Air Force, Marines, allies, EPW, indigenous civilians, detained persons, and civilian internees. Various experience rates are applied against these strengths to estimate the expected patient load. The detail in which the tabulation is prepared varies with the scope and type of the operation.

e. Health of the Command.

(1) An important consideration in making the estimate is the health of the command. The following factors affect casualty estimates and indicate command and medical measures that should be taken prior to each operation being planned:

Acclimation of troops. Presence of disease. Status of immunizations and drug prophylaxis. Status of nutrition. Adequacy of clothing and equipment. State of fatigue, morale, unit cohesion, and training. Physical conditioning. Oral health fitness level.

(2) The planner is concerned with providing HSS regardless of patient origin. He is interested in all causes for patient admission, requirements for beds, geographic dispersion of patients, and the accumulation in medical work load. Combat commanders are primarily interested in assessing combat power from which they can develop alternatives for subsequent operations. The surgeon is best served by data expressed as "rates/l000/period," which simplifies planning for HSS. The commander can better evaluate alternative operational concepts if projected losses are expressed as "percentage reduction" in combat strength of combat units. Recognizing that major disease impacts are delayed because of incubation periods, knowledge of potential losses to malaria, dengue, sandfly fever, typhus and similar diseases is invaluable for--

Phasing the proposed tactical operations. Managing individual replacements. Task organizing maneuver units for the next operation.

(3) Therefore, if disease is expected to exert a significant impact on the force, consideration should be given to projecting changes in the strength of subordinate components not only for disease and combat losses expected during the operation of concern but also for disease losses that will exert their operational impact during following periods. The return to duty (RTD) rate of WIA and disease and nonbattle injury (DNBI) cases is also of primary interest to the commander and staff.

f. Assumptions. An assumption is a supposition on the current or future course of events, assumed to be true in the absence of positive proof. Assumptions are sometimes necessary to enable the planner to complete the estimate of the situation and to decide on a COA to support the operation. In addition to a statement of facts, logical assumptions are included in this paragraph as a basis for development of the estimate. Subsequently, these assumptions may be deleted or modified as new information becomes available. Assumptions are usually restricted to higher levels of planning and normally apply only to factors beyond the control of friendly forces such as enemy capabilities and weather.

g. Special Factors. Factors that are not listed elsewhere or items of such importance to the particular operation that they merit special consideration are mentioned. For example, how patients suffering from combat stress may affect the operation is a consideration.

2-12. Health Service Support Analysis
The analysis in paragraph 3 of the estimate is a logical comparison of the estimated requirements of the command and the support means available for the operation.

a. Patient Estimates. Estimates of patients can be prepared from data compiled in paragraph 2 of the estimate. Patients are estimated as to number, distribution in time and space, areas of patient density, possible MASCAL, and lines of patient drift and evacuation. The surgeon can consult experience tables to assist him in determining requirements for the operation. From this data, hospital bed estimates can also be made. (See Chapter 5.)

b. Support Requirements. Requirements are calculated from the estimate of patients and the data contained in paragraph 2 of the estimate. The planner should consider separately the requirements for the following:

(1) Patient evacuation, medical regulating, and patient reporting and accountability (Chapter 4).

(2) Hospitalization (Chapter 5).

(3) Health service logistics, to include blood management (Chapters 6 and 8, respectively).

(4) Medical laboratory services (Chapter 7).

(5) Dental services (Chapter 9).

(6) Veterinary services (Chapter 10).

(7) Preventive medicine services (Chapter 11).

(8) Combat stress control (CSC) services (Chapter 12).

(9) Area medical support (Chapter 13).

(10) Command, control, communications, computers, and intelligence (Chapter 14).

(11) Support to other Services (Chapters 2, 6, 8, and 10).

(12) Others, as appropriate.

Neither the resources available nor the allotment of specified units should be considered at this stage in the analysis. Only the HSS resources REQUIRED to support the commander's operation plan are determined.

c. Resources Available. Having determined the HSS requirements, the surgeon then considers the resources on hand or readily available to meet the requirements. See paragraph 3 of the estimate, Example B-1, Appendix B. Maximum use of available personnel and supplies promotes the overall effectiveness of the HSS of the command. To ensure all aspects of HSS are considered, review the following supporting categories:

(1) Organic HSS units and personnel. Medical units that are organic components of the command are listed and under each is a statement describing its location, strength, and readiness for action. Professional and specialty personnel capabilities must also be considered.

(2) Attached medical units and personnel. Medical units already attached and those that may be readily available, their locations, strengths, readiness, and professional and specialty personnel capabilities are considered.

(3) Supporting medical units. Consideration is given here to the evacuation and other support furnished by higher echelons as well as from the Air Force and the Navy.

(4) Civil public health capabilities and resources. Host-nation medical personnel and supplies reported by CA as available from civil public health must also be listed. Civilian medical facilities and personnel may be used in some cases to augment military facilities; in other cases, the surgeon may be requested to give them support. He should be acquainted with their potential. Cultural differences and medical care philosophies can impact on health care provided. Civil Affairs personnel assist in planning for the maximum of host-nation support. They also assist in carrying out host-nation agreements.

(5) Indigenous or retained medical personnel. Consideration is given to the use of indigenous and retained personnel and their supplies in providing medical care for their respective categories of personnel.

(6) Health service logistics. The surgeon must consider supplies and equipment on hand, immediate resupply availability, the condition of this materiel, and the organization's capability to maintain it.

(7) Medical troop ceiling. The medical troop ceiling should be reviewed by the command surgeon to determine the possibility of securing additional medical support units. This action should be effected as early as possible to ensure the timely receipt of the required units. See Chapter 14 for a discussion of the medical troop ceiling.

d. Courses of Action. By taking into consideration all support requirements and resources available, the planner can then determine major problem areas and difficulties. Based on this determination, several possible COA can be developed and listed which will provide the necessary HSS. In this subparagraph, the planner lists these COA and considers policies, standing operating procedures (SOPs), and procedures that will accomplish the support mission. He limits himself to such considerations as--

Centralization versus decentralization of HSS. (Will authority be delegated to the maximum extent consistent with the necessary control?) Dependence on evacuation by other Service components. Extent to which civilian and EPW labor will be used. Evacuation policies.

2-13. Evaluation and Comparison of Courses of Action
In paragraph 4 of the estimate, the planner evaluates and compares the various COA developed in paragraph 3. He does this by comparing the COA to determine which one CAN best BE SUPPORTED FROM THE HSS PERSPECTIVE. He lists those difficulties which will have different effects on each possible COA. This then enables him to evaluate these COA in terms of their inherent strengths and weaknesses. By next comparing the possible COA in the light of these strengths and weaknesses, he is able to identify further the basic advantages and disadvantages of each. He does not draw conclusions at this time, but defers this action until the comparison of all possible COA is completed.

2-14. Conclusions
a. Paragraph 5 of the estimate represents the end of the thought process of the estimate and is the basis for the development of the HSS plan. The statements represent the command surgeon's or medical commander's "decision" and serve as a guide to other staff members and/or subordinates in their planning.

b. The planner--

(1) Indicates whether the HSS mission for the operation can/cannot be accomplished.

(2) Indicates which COA can best be supported from the HSS perspective.

(3) Lists factors which may adversely affect the health of the command.

(4) Lists the limitations and deficiencies in the preferred COA that must be brought to the commander's attention.

(5) Includes a COA which is less than desirable, but which best supports the commander's operational mission with the most economical use of available HSS resources.

(6) Provides a general statement if the HSS mission cannot be accomplished.

c. Further details regarding general estimates of the situation are contained in FM 101-5.

2-15. Mission, Enemy, Terrain and Weather, Troops, and Time Available
The acronym METT-T (mission, enemy, terrain and weather, troops, and time available) is a useful tool to remember and organize planning considerations, particularly when the plan is not a formal written plan, or when the planner does not have quick access to planning references.

a. Mission refers to the same responsibilities and considerations as discussed in paragraph 2-10.

b. Enemy refers to considerations discussed in paragraph 2-11a, enemy situation.

c. Terrain and weather refers to the considerations discussed as "characteristics of the AO" in paragraph 2-11c.

d. Troops refers to the friendly situation, paragraph 2-11b, and to the resources available, paragraph 2-12c.

e. Time refers to the amount of time available to formulate and execute the plan.