Training and developing formations to fight and win a decisive action battle against a near-peer enemy requires Soldiers to open their minds and think beyond current doctrine and norms. Knowing the potential destructive capability of a near-peer enemy and the need to give brigade combat team (BCT) commanders flexibility to defeat this threat, the Army needs to relook at how units plan, implement, and use role II medical capability.Every decisive action fight requires planning and transparency across the warfighting functions. Such planning includes a detailed concept of medical support within the sustainment warfighting function. Assessing where to position medical assets by phase requires an in-depth understanding of the ground tactical plan.The employment of medical assets must be rehearsed during the sustainment and combined arms rehearsals to ensure shared understanding. Role II and supporting medical assets need to be placed within supporting distance of the maneuver forces but must not impede ongoing operations.During the 2017 rotation of the 1st Stryker Brigade Combat Team (SBCT), 25th Infantry Division, to the National Training Center (NTC) at Fort Irwin, California, adding an additional role II asset within the BCT's area of operations provided redundant capability, reduced time and distance to care, greater patient survivability, flexibility, and the ability to medically weigh the decisive effort. These benefits came with some costs though, the greatest being the reduced ability of the role II facility to ground medevac casualties from the forward role I facilities back to role II care. This article discusses the split role II concept to reveal the need for this capability in BCTs.THE ROLE II FLEThe role II forward logistics element (FLE) is positioned far forward and is designed to provide medical care for casualties. This element fills the gap caused by the extensive distance to the main role II facility.When maneuver elements are constantly adapting to enemy action, it is expected that the medical care does the same. By allowing for secondary role II care to be established, the number of deaths can be minimized. Role II care provides the immediate treatment of casualties by an element with a trauma section, laboratory, and X-ray services for prompt and definitive diagnoses. This element increases the casualty turnover rate and gets Soldiers back into the fight.ROLE II FLE MANNINGHaving two operational role II facilities in the decisive fight is not covered in doctrine. However, at their NTC rotation, role II FLE personnel from C Company, 25th Brigade Support Battalion, sought to deliver medical care as far forward as possible to mitigate sending the Soldiers to the main role II facility within the brigade support area.The manning for the role II FLE met the minimum requirements for NTC exercise operating procedures. The role II FLE was equipped with laboratory capabilities, including a lab technician, i-Stat with cartridges, and multistix urine tests. The 1st SBCT requisitioned a portable digital filmless X-ray apparatus from U.S. Army Alaska in order to maintain the same radiological capabilities of the main role II facility.Dental capabilities were reserved for emergent dental care only. The designated physician assistant was tasked with treating pericoronitis, avulsions, and abscesses with the dental push pack instead of a dental medical set.Patient hold was covered by two medics and a vital signs monitor, while the trauma intake was received by a physician assistant with a tactical combat medical equipment set. Personnel used Standard Form 600, Chronological Record of Medical Care, for patients so that the information could be entered into the Armed Forces Health Longitudinal Technology Application once the role II FLE reconsolidated with the main role II facility.A behavioral health provider and a physical therapy technician were pushed forward to cover those facets of care. Medical supply was covered by a medical logistics specialist equipped with preconfigured push packs and a basic supply of class VIII (medical materiel).SUPPORTING THE OPERATIONThe role II FLE was pushed from the brigade support area and was established in under two hours, postured to provide care to the decisive maneuver elements far forward. However, when the unit assessed the casualty data from phase I, it realized that roughly 10 percent had received care from the role II FLE, which left the main role II with 90 percent of the recorded casualties. This phenomenon was attributed to the lack of transparency, poor dissemination of the medical common operational picture, and poor communication across the formation due to a lack of mission command systems. Units simply did not know the role II FLE's location during the first phase.As the battle progressed, the location and capabilities of the role II FLE were reiterated across the formation, and there was a noticeable decrease in the died-of-wounds rate. Thanks to the role II FLE, the brigade's died-of-wounds rate decreased from 68 percent in phase I to 35 percent in phase II.Of the 561 casualties evaluated, 104 were seen and treated at the role II FLE. Having a more forward line of care allowed maneuver units to evacuate their patients quickly, receive more expedient care, and lower their died-of-wounds rates.Phase II was arguably the more complex phase in the decisive action fight. However, the role II FLE was readily available and could adapt to changes in mission and location. After jumping its location on two occasions, the role II FLE was able to establish operations and receive patients in under two hours.RECOMMENDATIONSTime is always a factor when treating casualties. The "golden hour" for an urgent patient refers to the one-hour survivability window from point of injury to role I care. This survivability window is greatly affected by how prepared each unit is. If the proper rehearsals for litter teams and movement of casualties to care are not completed, the increased time it takes to reorganize forces eats into that casualty's survivability window.Pushing evacuation assets forward to the decisive maneuver units to evacuate patients from role I to role II and allowing for a trigger-based ambulance shuttle system could reduce this rate. This shuttle system would use the battalion main aid stations as ambulance exchange points. Having the ambulances shuttle straight from role I locations would reduce navigation errors and the need for extra security and time to conduct exchanges. This shuttle system not only would provide faster casualty movement across the battlefield but also would ensure greater consideration of medical resources in planning.Based on the observations and results of this NTC rotation, pushing forward a role II element during a decisive action operation is vital to avoid surpassing the golden hour of care window.By pushing forward the role II FLE, the distance between the objective and definitive was reduced. Further testing is needed, but based on these results, having a medical company with role II FLE capabilities could reduce deaths in actual combat.If incorporated into doctrine, slight manning and equipment changes, including the addition of another X-ray specialist, laboratory specialist, and organic portable X-ray device, would need to be considered to permit these increased capabilities. These changes could allow underutilized lines of care, such as patient hold, to be employed as quarantine areas or research sections.Ultimately, having two locations to provide a second echelon of care allows medical treatment to be seamlessly embedded in operational planning and gives casualties a greater chance at survival. With minimal additional resources, a secondary role II facility may provide operational commanders with the flexibility that is vital to mission success. -------------------- Lt. Col. Garrick L. Cramer is the commander of the 25th Brigade Support Battalion, 1st SBCT, at Fort Wainwright, Alaska. He holds a bachelor's degree in history and a master's degree in emergency management. He is a graduate of the Army Medical Department Officer Basic Course, Combined Logistics Captains Career Course, Combined Arms and Services Staff School, and Command and General Staff College.Capt. Khalid R. Rodriguez is a Medical Service Corps officer and commander of the Headquarters and Headquarters Company, 1st SBCT, 25th Infantry Division. He was the commander of C Company, 25th Brigade Support Battalion, when he wrote this article. He has been selected to attend the Army-Baylor master of health administration degree program this year. He is a graduate of the Army Medical Department Captains Career Course and Ranger School.For more details about the concept used, visit this article in milSuite at -------------------- This article is an Army Sustainment magazine product.