CHAPTER 1 - INTRODUCTION

GENERAL

The Royal Medical and Dental Corps (RMDC) is responsible in the provision of
health services support to the Malaysian Armed Forces (MAF). The Health Services Support
(HSS) system is a continuum of medical management throughout all levels of healthcare,
extending from the Forward Edge of Battle Area (FEBA) through to the Main Supply Base
(MSB) in the Area of Responsibility (AOR).

Mission

The mission of the RMDC is to conserve the fighting strength of the MAF. The
Health Service Support (HSS) mission is to minimize the effects of wounds, injuries, and
disease on unit effectiveness, readiness, and morale. This mission is accomplished by a
proactive preventive medicine services and a phased health care system (echelons of care)
that extends from actions taken at the point of wounding, injury, or illness to evacuation from
a theater for treatment at a hospital.

Essential care includes resuscitative care and en route care. The effectiveness of HSS
is measured by its ability to save life and limb; to return a wounded soldier to duty (within the
stated theater evacuation policy) or to begin initial treatment required for optimization of
outcome and to ensure the patient can tolerate evacuation with minimum delay to the next
level of care or out of the theatre of operation.

Commanders need to maintain their fighting strength in order to achieve mission

success. This will allow the continued functioning of the unit and the achievement of its
specified mission. The retention of these experienced personnel would alleviate the load on
the personnel replacement system as well as the load on the medical evacuation system. It is a
given fact that the accumulation of casualties in any combat unit would restrict its ability to
be deployed. The presence of casualties not evacuated to a care providing unit too would
have a negative effect on the morale and fighting will of the combat unit. The HSS to the
Armed Forces is provided by the Armed Forces Health Services (AFHS). The AFHS is tri-
service serving the Army, Navy and Air Force. This document shall serve to delineate the
HSS provided to the Army by the AFHS.

The Army is currently organized into three major groupings, which are:
a. Combat Units.
b. Combat Support Units
c. Combat Service Support Units

Units of the RMDC are a component of the Combat Service Support group within the
Personnel Services Support Unit together with the various sub-divisions of the GSC and the
KAGAT. The other component of the Combat Service Support group is the Logistic Services
Support Units. These are the GSC, the ROC and the REME.
 HEALTH SERVICE SUPPORT (HSS) PRINCIPLE

The principles applied herein are certain ideas as to strategic planning and the conduct
of operations that has been deduced from the experience of the past. These ideas are define
and expressed in the form of principles, usually of a single word. These principles are in the
nature of self-evident truths or axioms. They generally overlap and sometimes may even
appear to contradict each other. They are neither immutable nor absolute, since nations
amend their lists from time to time. These principles are known as the Principles of War, it
must be understood that the these principles are not laws and merely indicate a course of
action than has been successful in the past and serve as a warning that to disregard them
involves risk and has often brought failure. The principles are as followed :

a. Conformity. Integrate and comply with the commander’s plan. Conformity with the
operational and tactical plan is sought and is the most basic principle in providing effective
HSS. The HSS planner should be involved in the development of the formation commander’s
plan of operation. This would allow the HSS planner to determine the requirements of HSS to
support the operational plan and conduct the planning to conform to the tactical operations
needed to implement the plan. Conformity to the operational and tactical plan would hence
support the aim of and maintain the operational and tactical plan.

b. Concentration of Force. As with all service support units, HSS units must be capable of
rapid adjustment to changes in the tactical situation. The sustainment of the fighting strength
of the formation is contingent on a well developed and responsive HSS plan. The medical
commander and staff must be capable of identifying the needs of medical support to the
formation and adjusting the HSS to areas with large casualty concentrations. A responsive
HSS system is crucial to the morale of troops within a formation.

c. Co-operation. Co-operation between Combat Units, Combat Support (CS) Units and
Combat Service Support (CSS) Units is essential to allow the efficient and appropriate
delivery of HSS, co-operation between all elements in the Combat Zone (CZ) and
Communication Zone (Comm Z) to allow the flow of casualties rearward and the mobility of
HSS units in conjunction with the operational and tactical plan.

d. Economy of Effort. The above does not mean over committing the available HSS units.
These units must be placed on and behind the battlefield in such a manner as to maximize
their organic capability while in support of tactical secondary efforts.

e. Security. Commanders need to be aware of the need for the security in HSS units within
their Area of Operation (AO) and plan accordingly. This is essential when field HSS units are
deployed in accordance with Law of Armed Conflict (LOAC).

f. Offensive Action. While HSS is not an offensive in nature, its planning shall be so
designed that the operational and tactical plan is supported to its completion. The HSS
planners should take into consideration the offensive plan to allow the HSS provided to be
commensurate with the intensity and expected duration of the operational plan. The HSS
planners also need to evacuate casualties efficiently such that conservation of the fighting
strength of the force committed is maximised.

g. Surprise. In this principle, its applicability to HSS planning is marginal at best and as such
is seldom employed.
h. Flexibility. This reflects the ability of the HSS commanders and staff to shift HSS
resources to meet changing requirements. Changes in tactical plans or operations make
flexibility essential in HSS operations. The HSS units must retain the capability to adjust and
change to meet the evolution of tactical plans or operations.

i. Administration. Military operations cannot succeed unless administrative arrangements

are adequate. Hence the administrative plans are to provide for healthcare details and the HSS
commanders are to provide appropriate input to those plans and to ensure the administrative
planning take into account the HSS administrative needs.

j. Maintenance of Morale. The HSS is an essential part in the maintenance of the morale of
the troops employed. The knowledge that adequate HSS exists for their needs causes these
troops to be more confident and enhances their morale.

In addition to the above, the following principles are also used in the planning of HSS:

a. Proximity. The intent is to provide HSS to the sick, injured and wounded at the right time
and to keep morbidity and mortality to the minimum. To achieve this, the HSS units must be
employed as far forward to the combat operations as the tactical conditions permit. Following
immediate supportive medical management the injured soldiers are then evacuated quickly to
a rear medical treatment facility where they will eventually receive a thorough care. However
this must be tempered by the need to keep the forward HSS units away from interfering in
combat operations.

b. Continuity. The objective is to ensure the continuity of care of the sick, injured and
wounded soldier in an uninterrupted manner. It is achieved by mobilising these patients
through a progressive, phased HSS system, extending from FEBA to the rear where higher
levels of care medical treatment facilities are available. Therefore each HSS unit located
either forward or rear with its own unique capabilities contributes greatly in ensuring a proper
and efficient care delivered to these soldiers.

c. Control. The scarce HSS resources must be efficiently employed to support the tactical
and strategic plan. It must also ensure than the scopes and quality of medical treatments given
meet professional standards and policies. In order to ensure these resources are efficiently
employed to support the tactical plan, all medical assets should be under the control of a
single medical commander.

d. Mobility. All HSS units whether forward or rear must remain close to the supported
combat unit in order to efficiently managed casualties at any situation. Mobility is the key
factor and these units must match the mobility of the combat units. The HSS planner must
monitor and forecast all its unit movement and deployment to achieve this goal. A large HSS
unit must plan in advanced the requirement for movement either forward or rear when
situation arises in order to support combat operations at all time.

e. Simplicity. Direct, simple plans, and clear, concise orders are essential to reduce the
chances of misunderstanding and confusion.

f. Unity of Command. The health support in the MAF is tri-service in nature. In any conflict,
all services will be involved and here a single health services commander play his role in
maintaining technical command authority to coordinate and plan provision of HSS to all its
units to allow seamless continuum of health care to the MAF personnel.

LEVELS OF HEALTH SERVICE SUPPORT (HSS)

The HSS is arranged into four levels of medical care (Level I - IV). In the AO, the
levels of care are organised into four levels of support that extends rearward from the FEBA
to the MSB. Each level reflects an increase in medical capabilities while retaining the
capabilities found in the preceding level.

Each higher level of care shall possess the same treatment capabilities as the levels
forward of it. Each higher level provides a new increment of treatment capability, which
distinguishes it from the lower levels of care. There are 4 levels of care in use within the HSS
system, which are Levels I through IV.

Level I. This level of care consists of care rendered at the unit level. It includes self-aid,
buddy aid, and combat lifesaver skills, examination, and emergency life saving measures
such as the maintenance of the airway, control of bleeding, prevention and control of shock,
splinting or immobilizing fractures, and the prevention of further injury. Treatment may
include restoration of the airway by invasive procedures; use of IV fluids and antibiotics; and
the application of splints and bandages. These elements of medical management prepare
patients for return to duty or for transportation to a higher level of care. Supporting medical
units are responsible for coordinating the movement of patients from supported medical
facilities.

a. Self aid / buddy aid. This is initial first aid provided by non-medical personnel
immediately.

b. Company Aid Post (CAP). Medical support given here does not need the skills and
knowledge of a doctor. The level of skill and knowledge will be that of paramedics. The tasks
here include:
(1) Casualty collection
(2) Immediate life support
(3) Evacuation from the CAP
(4) Disease prevention

c. Regimental Aid Post (RAP). This is manned by a RMO with his team of paramedics. It is
to support a battalion sized collection of combat troops and is tasked with:
(1) Receiving casualties evacuated from the CAP.
(2) Immediate life saving procedures such as :
i. Airway access
ii. Chest drainage
iii. Haemostasis.
(3) Stabilisation of casualties.
(4) Evacuation to Fwd Hosp.
(5) The detached CEU will be located in the vicinity of the RAP.

Level II. At a minimum, Level II care includes physician-directed resuscitation and

stabilization and may include advanced trauma management, emergency medical procedures,
and forward resuscitative surgery. Supporting capabilities include basic laboratory, limited x-
ray, pharmacy, and temporary holding facilities. This is the Fwd Hosp, which is generally in
the vicinity of the BMA/BMG. Surface or air movement is coordinated for transfer to a
facility possessing the required treatment capabilities. Level II is the first level where Group
O liquid packed red blood cells will be available for transfusion. The Fwd Hosp is formed by
one company from the Divisional Med Bn. The Fwd Hosp provides the following
capabilities:

a. 3 surgical teams with each surgical team being capable of performing 8 -12 major surgeries
over a 24 hour period. Each surgical team is capable of performing up to 36 major surgeries
without resupply.
b. Basic laboratory facilities with blood banking services available.
c. A wide range of medicaments and fluids to support the injured and ill.
d. Basic X - ray facilities.
e. Able to hold a patient for a maximum of 72 hours.
f. Patients are held only for stabilisation until fit, to be transferred.
g. Evacuation is done to the next higher level, either a field hospital or a RAFH by land or air
routes.

Level III. Care is administered that requires clinical capabilities normally found in a facility
that is typically located in a reduced-level enemy threat environment. This is the Fwd Hosp or
RAFH (depending on the location of the operations) which is generally located in the vicinity
of the DMA/DMG. The facility is staffed and equipped to provide resuscitation, initial wound
surgery, and postoperative treatment. This level of care may be the first step toward
restoration of functional health, as compared to procedures that stabilize a condition to
prolong life. Blood products available may include fresh frozen plasma, Groups A, B, and O
liquid cells and may include frozen Group O red cells and platelets. A Fwd Hosp is
traditionally formed from 2 companies from a Med Bn. The following are tasks of the Fwd
Hosp/RAFH :

a. Resuscitation, stabilisation and treatment of seriously injured prior to further evacuation.

b. Life and limb saving surgery as soon as possible, no longer than 6 hours after injury
c. Diagnosis and treatment of patients suffering from serious and lifethreatening diseases.
d. Diagnosis, treatment and holding of those sick and injured who can receive definitive care
and return to duty.
e. Medical resupply to Levels 1 and 2.
f. The Fwd Hosp shall contain:
i. 6 surgical teams
ii. Full laboratory and blood banking services.
iii. Full X - ray support.
iv. Full pharmaceutical support.

Level IV. In addition to providing surgical capabilities found at Level III, this level also
provides rehabilitative and recovery therapy for those who can return to duty within the
theater patient movement policy. This level of care is handled by the RAFH in the AO or a
BAFH or a designated MOH GH in the CommZ. Here endeavours are made which complete
the recovery of the patient. Definitive treatment proceeds with greater degree of deliberation
and preparation. Its completion represents the maximum of recovery and preservation of limb
and function. This scope of treatment requires the type of clinical capability found only in a
hospital that is properly staffed and equipped and located in an environment with a low level
of threat from enemy action.
 SUMMARY

The HSS provides prompt, effective, and unified health services to enhance the
combat fighting ability. HSS in operations requires continuous planning, coordinating,
synchronizing, and training. HSS is based upon a phased health services system with varying
capabilities of care and situationally tailored to each operation. The mission of the RMDC is
to conserve the MAF fighting strength. It accomplishes this mission by implementing a
robust, effective and efficient HSS. The HSS system is built upon the principles of war and
conforms to the Army plan. The HSS system can be divided into four levels of care that can
extend from the battlefield to the base hospital. Through the HSS system casualties are
provided seamless health care from the initial point of injury through successive levels of
health care to a facility that can provide definitive or rehabilitative care specific only to his
injury.

The mission of the RMDC is to conserve the Mechanized Brigade fighting strength. It
accomplishes this mission by implementing a robust, effective and efficient HSS. The HSS
system is built upon the principles of war and conforms to the Army plan generally and
specifically towards the Mechanized Brigade. The HSS system can be divided into four
levels of care that can extend from the battlefield to the base hospital. Through the HSS
system casualties are provided seamless health care from the initial point of injury through
successive levels of health care to a facility that can provide definitive or rehabilitative care
specific only to his injury.

The medical brigade provide pre-hospital emergency care to take clinical responsibility from
non-professional healthcare providers and give life-saving measures. It accomplishes this
mission by implementing a robust, effective and efficient HSS. Progressive resuscitation
extends these emergency measures from the pre-hospital care environment to the
capabilities of deployed hospital care. As the patient stabilises, the clinical focus shifts to
restoring physiological function through clinical care and medical evacuation. Once the
patient is physiologically stable, care shifts to promoting healing through wound care,
nutrition and psychological support. The effectiveness of HSS is measured by its ability to
save life and limb; to return a wounded soldier to duty (within the stated theater evacuation
policy) or to begin initial treatment required for optimization of outcome and to ensure the
patient can tolerate evacuation with minimum delay to the next level of care or out of the
theatre of operation.
1004. The medical personnel will advise on health matters aiming to deliver the medical care
required, but only the Commander can balance the health and medical risks involved in his
plan and decide if they are acceptable.