IDENTIFICACIÓN Y SELECCIÓN DE LOS PRINCIPALES TIPOS DE

213. Role 3 medical support is deployed hospitalisation and associated support elements. Whilst both Role 2 E and Role 3 provide Deployed Hospital Care (DHC), it is the greater range of specialist capabilities, found at Role 3, which differentiates between them.

214. UK Role 3 may be provided by the Royal Navy’s (RN’s) Primary Casualty Receiving Facility (PCRF) or by Army field hospitals. On enduring Land Operations, the RN and Royal Air Force (RAF) will, in future, contribute to the delivery of Role 3 capability. Alternatively, it may be acquired through Allied or Host-nation Support (HNS). The UK view of Role 3 differs from that of some NATO nations by being less prescriptive in terms of clinical capability, and more tailored to the nature and stage of the operation.

215. The deployment of Role 3 is designed to achieve 3 objectives beyond the treatment of the sick and injured:

a. To hold patients until their further evacuation.

5 For example, on operations at smaller scales of effort or for those operations unlikely to involve significant combat activity.

b. To offer the possibility, within the Theatre Holding Policy (THP),⁶ of returning personnel to duty.

c. To offer a range of clinical services not available elsewhere in the theatre of operations.

216. These objectives come at a price, and commanders must balance the capability offered by Role 3 MTFs and the logistic constraints imposed. Some need only be deployable in order to get into theatre, whilst others may need to be redeployable in order to support manoeuvring formations. Role 3 MTFs are complex and require a period of days/weeks to reconfigure and substantial logistic support to move them.

The Relationship between Role 2 and Role 3

217. Forward medical interventions generate particular problems⁷ and may carry significant clinical risk. Medical and surgical treatments conducted at Role 2

(particularly Role 2 LM) should be kept to a minimum in order to buy time and save lives. Clinicians should distinguish between patients who require medical intervention (including the scale of intervention) and patients for whom it might be delayed safely.

Sound clinical judgement will be influenced by the robustness of in-theatre

MEDEVAC to Role 3 MTFs, and requires situational awareness and an appreciation of the scope and limitations of specific treatments.

218. If Role 3 medical support is not available through PCRF or Allied

support/HNS and/or by evacuation to the Home Base, then carefully planned and engineered Role 3 builds in Tier 1 or Tier 2 accommodation⁸ will need to be included in the theatre infrastructure plan from the outset. Illumination and temperatures must be maintained at levels that permit advanced interventions and promote healing, and the infrastructure should be designed to provide a clinical environment and levels of infection control not possible in a Role 2 structure. With this improved environment comes the option of incorporating highly technical and often fragile medical

equipment (particularly in areas such as diagnostics, operating theatres and intensive care units (ICU)), enabling the development of an in-theatre referral centre for

specialist cases such as neurosurgery or burns.

219. Role 3 should be deployed where it offers the greatest benefit to the deployed population; in most theatres it is likely, for logistic and force protection (FP) reasons, to be deployed in the rear of an Area of Responsibility (AOR). In such circumstances, clinical timelines and surgical load may demand the deployment of one or more Role 2 MTFs closer to combat activities.

6 THP is discussed at paragraphs 123-125.

7 For example, refrigeration and/or special handling of medical equipment further forward.

8 JDP 4-00 ‘Logistics for Joint Operations’.

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220. The National Health Service (NHS) in the UK provides UK Role 4 medical care for all British casualties who require, specialist or prolonged (beyond THP) in-patient care, definitive treatment and rehabilitation. The seamless reception, triage, tracking and secondary care of military patients requires close cooperation between MOD and the Department of Heath (DH).⁹ Entitlement to evacuation to Role 4 should be a feature of the Permanent Joint Headquarters’ (PJHQ) eligibility matrix.

9 The current agreement is known as the Reception Arrangements for Military Patients (RAMP), and includes provision for infectious and CBRN casualties. The RAMP plan is modular in concept and based on 4 Levels, Level-1 being day-to-day Aeromedical Evacuation (AE) to the Royal Centre for Defence Medicine (RCDM) for admission to NHS care at the University Hospital Birmingham Foundation Trust (UHBFT). The plan can be escalated through all levels or activated initially at any level, but a planned major military campaign is likely to require a full Level-4 response with national DH coordination from the outset (DMSD Reception Arrangements for Military Personnel – Concept of Operations, Version 3).

NATO Descriptor based upon AJP-4.10 (A)¹⁰

Specified/Implied Tasks (UK) Clinical Capability based upon AJP-4.10 (A)¹¹ Contemporary Examples (UK)

• Includes packaging for evacuation.

• BATLS/BARTS resuscitation.

• Not necessarily Medical Officer led.

• Collective Protection (COLPRO) unlikely.

• Basic occupational and preventative medical advice to the Chain of Command.

• Routine ‘sick call’ and the management of minor sick and injured personnel for immediate return to duty.

• Casualty collection from the point of wounding and preparation of casualties to the next MTF.

• Primary dental care.¹²

• Additional capability may include:

• Minimal patient holding capability.

• Basic laboratory testing.

• Initial stress management.

• Sick bay afloat (RN, surgery (DCS). It will usually evacuate its post surgical cases to Role 3 (or Role 2 E) for stabilisation and possible primary surgery (PS) prior to evacuation to Role 4.’

• Utilised during high intensity combat, supporting manoeuvre (land or amphibious operations).

• Located forward in Brigade area of operations to deal with anticipated surge of casualties.

• Light & highly mobile.

• An intermediate treatment node in complex terrain.

• COLPRO depending upon operational risk assessment.

• All Role 1 capabilities (UK).

• Consultant-led¹⁴ resuscitation with the elements required to support it (UK).

• Routinely DCS with post-operative care.

• Field laboratory.

• Basic imaging (UK).

• Reception, regulation and evacuation of patients.

Role 2 Enhanced MTF. ‘Basic secondary care facility built around PS, ICU, and beds with nursing support. A Role 2 E facility is able to stabilise post-surgical cases for evacuation to Role 4 without the need to put them through Role 3 MTF first.’

• Theatre entry.

• A theatre or regional secondary health care hub mainly on stable operations where a full Role 3 is not justified. A Role 2 E will normally replace both Role 2 LM and full Role 3 units as an operation stabilises.

• A light manoeuvre hospital in advance

• All Role 2 LM capabilities.

• PS.

• Surgical and medical ITU capability.

• Beds with nursing support.

• Enhanced field laboratory including blood provision.

10 Any clinical capability missing from the stated requirement will reduce the Role designation of a MTF.

11 Capabilities marked ‘UK’ highlight areas the UK has either shaped NATO doctrine in order to reflect its own emphasis, or deviates from NATO doctrine.

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• COLPRO depending upon operational risk assessment

• Preventive medicine and environmental health capability.

• Psychiatry.

• Tele-medicine.

• Evacuation coordination.

Role 3 MTF. ‘Provision of theatre secondary health care within the restrictions of the Theatre Holding Policy (THP)’

• Force hospital.

• COLPRO capability present. • PS, ICU, surgical & medical beds with nursing and diagnostic support.

• Role 3 MTFs can include mission tailored clinical specialities (specialist surgery (neurosurgery, burns, OFMS, etc), advanced

& specialist diagnostic capabilities to support clinical specialists (CT scan, sophisticated laboratory tests, etc) and major medical &

nursing specialities (internal medicine, neurology, etc)

• PCRF (RN) with Surgical Support Teams (SST).

• Field Hospital (Army) with SSTs.

Table 2.2 – Summary of UK Capabilities across Roles 1-3