Chapter 2 Immediate Action
This chapter addresses the action taken immediately, following a
wounding or injury, on operations. It follows the immediate first-aid, the
helicopter ride back to medical support, the phone call to the family and the
first in-theatre medical treatment. It considers preparation individuals
receive prior to deployment, and the importance of families in the repatriation
and recovery of the individual.
The Department of Defence (Defence) summarised their responsibilities,
noting that the health and welfare of members is a command responsibility,
which ultimately rests with the Chief of each Service regardless of where the Australian
Defence Force (ADF) member may be posted. The Surgeon General Australian Defence
Force/Commander Joint Health is responsible for the technical control of ADF
The provision of health care to ADF personnel does not start when an
individual is injured or wounded, and the Defence health care system provides a
continuum of care from enlistment through to transition from the ADF and during
all phases of an operation – pre-deployment, provision of treatment and
evacuation during deployment and post-deployment.
When ADF personnel are injured or wounded, there is a reasonable
expectation that they will receive prompt and effective health care which meets
contemporary Australian standards and this underpins the continuum of care that
is provided to the men and women of the ADF. Air Marshal (AIRMSHL)
Mark Binskin AO, Acting Chief of the Defence Force (CDF), told the Committee:
The provision of health care to ADF personnel is a continuum
from enlistment through to transition from the ADF back into civilian life.
The Department of Veterans’ Affairs (DVA) submitted that each injury is
unique in terms of effects on the person and their family, and the care and
support they need. DVA takes full responsibility for care and support for
those wounded or injured personnel who leave the ADF.
Combat first aid
Defence submitted that, that the type of treatment received in-theatre is
based on the severity of wounds or injuries. Treatment can obviously be
complicated by the tactical situation, particularly if troops are still engaged
with the enemy.
Defence advised that the casualty treatment process is layered to
provide the best possible care for Australian troops. All Australian soldiers
are trained in basic first aid. Initially casualties are provided first aid or
administer self-aid with combat medical supplies they carry themselves, within
ten minutes of being wounded where possible.
During force preparation training at Al Minhad Air Base, all personnel
deploying into Afghanistan receive refresher training in first aid that
includes the management of catastrophic haemorrhage and airway management. The
care of battle casualties training is conducted in a simulated battlefield
scenario and provides personnel with the opportunity to refresh their skills immediately
prior to going into combat. In the event of battle casualties, personnel can then
correctly apply the lifesaving medical supplies provided to them.
During initial first aid, an assessment is made as to the severity of
the wounds and injuries and if required, the soldiers will then call for
additional medical support or an evacuation of the wounded or injured person.
Tactical units may also include combat first aid trained personnel who
have received advanced training in the initial treatment of wounds likely to be
encountered on a battlefield. Special Forces patrols often include a Patrol First
Aider or Advanced Combat First Aider. These soldiers are trained in advanced
first aid procedures and are similar to paramedics in the civilian sense.
If required, the wounded or injured person will be evacuated to a medical
facility for further treatment. This evacuation is conducted by the most
suitable and expedient means and this is most usually by helicopter. Timings
for aeromedical evacuation in Afghanistan are based on medical severity. For
life-threatening wounds or injuries the following timings are mandated by the International
Security Assistance Force (ISAF) and have been endorsed by Australia:
n Evacuation assets aim
to reach seriously wounded soldiers within one hour of wounding, and provide
en-route care based on the clinical needs of the patient. This one hour
guidance is not always possible when the tactical situation delays evacuation.
n All attempts are made
to evacuate casualties to a medical facility able to provide surgery within two
hours of wounding. This is the basis for the 10:1:2 rule – first aid within
ten minutes, advanced resuscitation within one hour and surgery within two
hours of wounding.
n For non-life
threatening wounds the timings are extended, although in many cases the
evacuation process is such that the same timings result.
The Committee received a body of evidence relating to the immediate care
of wounded or injured soldiers in the operational area as being exceptional
and world best, for which the Committee
commends the Department of Defence.
This sentiment was frequently echoed, for example the Returned and
Services League of Australia (RSL) Victorian Branch highlighted the lifesaving
skills of combat medics on the ground in Afghanistan:
Their skills have ensured greater survivability odds for
their colleagues. The Branch believed that the tried and true method of air
medical evacuation to the nearest medical treatment centre in the theatre of
operations has saved lives.
Defence advised that the initial response at the point of injury is
crucial. The provision of bleeding and airway control for the most seriously
injured must take place within 10 minutes of injury. To provide this, combat
personnel (non-health personnel) are trained and competent to deliver enhanced
first aid, principally to stop bleeding and secure the airway.
Every member of the ADF routinely receives training in first aid with an
emphasis on the skills required in a military environment. Selected members
are provided with advanced first aid skills tailored to their Service
environment and are periodically refreshed as part of the normal training cycle.
n the Minor War Vessel
Medical Care Provider Course;
n the Combat First Aid Course;
n the Patrol Advanced
First Aiders Course.
Based on the risk associated with the operational deployment there is
further tailored refresher and skills extension training conducted at all
levels of the first aid and emergency medical response. For forces deploying
into Afghanistan the pre-deployment training is conducted under the Exercise
Primary Survey framework. All members are trained and assessed in Care of the
Battle Casualty with significant resources being utilised to create realistic combat
scenarios where the skills in management of combat injuries are developed and
assessed by experienced medical observers.
Defence submitted that Combat First Aiders, Patrol Advanced First Aiders
and deploying health staff conduct additional high fidelity training focused on
comprehensive pre-hospital treatment and evacuation. The training is overseen
by both military and civilian trauma specialists and adapted to reflect current
best practice. Scenarios are based on the experiences of health staff that
have recently returned from Afghanistan. The final component of the exercise
series targets the health staff, refreshing and enhancing their trauma skills.
It involves live tissue training and challenging simulated resuscitation drills
overseen by military trauma specialists.
During Reception, Staging, Onward Movement and Integration (RSO&I)
in Al Minhad Air Base, all members deploying into Afghanistan receive further
high fidelity refresher training in Care of the Battle Casualty. This training
is delivered by a contractor utilising ex-serving, combat experienced medics
and overseen by ADF health staff. It involves a combination of lectures,
individual skill refresher stations with an emphasis on control of massive
haemorrhage, and extraction of casualties resulting from an improvised
explosive device strike. The training culminates in an assessment of all
skills within a realistic simulated battlefield environment.
Whilst deployed, members receive ongoing refresher training often
conducted in conjunction with range firing practices. Training focuses on
maintaining currency in the application of the Combat-Application-Tourniquet
(CAT) and production of the North Atlantic Treaty Organization (NATO) medical
evacuation request. This is a message that is transmitted quickly to request
an urgent medical evacuation and contains information that includes: the
condition; number and nationality of the casualties; their location; what
special equipment will be required; and the conditions on the ground that might
inhibit their extraction.
Combat First Aiders and health staff maintain their skills by routinely
participating in the Role 2E trauma roster and by augmenting during multiple
casualty incidents. The currency and competency of first aiders and health
staff are regularly tested with real time trauma patients. Defence submitted
that coalition partners have consistently observed that the quality and
responsiveness of Australian first aiders and health staff in trauma cases is
Specialist health personnel are qualified, current and competent in
their clinical and operational skills and must meet the credentialing
requirements of Australia and coalition partners.
In-theatre health facilities
The operational health care system provides for the continuum of care
from initial first aid via a dedicated evacuation chain to increasing levels of
specialist health care delivery. This system is organised into roles of health
care, which range from first aid through to definitive health care and rehabilitation.
Roles of health care extend from the point of injury or illness providing
continuous care to casualties. Each tier has increasingly sophisticated
treatment capabilities and each casualty is treated at the most appropriate
role of health care. This may involve either movement through the care
continuum or casualty evacuation to the most appropriate health facility.
Lieutenant Colonel (LTCOL) Michael Reade, Defence’s Professor of Military
Medicine and Surgery, told the Committee that:
The trauma care is excellent. It is a trauma system that has
evolved dramatically in the last 12 or so years. I think it would be fair to
say it was something in need of development at the start but that development
has been very actively pursued. I think it is a more responsive trauma system;
that would be true of any civilian system anywhere in the world. … It is
responsive to the operational need, it is very well resourced and it is
comprehensive in its care. It is very much focused on getting people out of the
deployed environment quickly.
Defence submitted that a Role 1 health facility provides primary health
care, triage and basic resuscitation and stabilisation in the theatre of
A Role 2 health facility provides enhanced clinical support based on
formed health teams and is capable of advanced resuscitation and treatment of
casualties prior to evacuation.
A Role 2 enhanced (Role 2E) health facility provides secondary health
care built around primary surgery, intensive care and nursed beds and treats
and prepares casualties for evacuation to a Role 3 health facility or directly
out of theatre.
A Role 3 health facility provides comprehensive secondary health care
including primary and specialist surgery, major medical and nursing services
and casualty holding for treatment and return to duty.
A Role 4 health facility offers the full spectrum of definitive care and
is provided from or within the national support base.
The ADF is responsible for the provision of Role 1 health support to ADF
elements in the Middle East Area of Operations (MEAO). Role 2 support is
provided at the ADF health facility at Al Minhad Air Base and Role 2E support
is provided at the United States (US) led ISAF facility in Tarin Kot. Role 3
health support is provided to ADF members at the Multinational US led ISAF
facility at Kandahar. Role 4 health support is provided from either the US
Landstuhl Regional Medical Center in Germany or from Australian tertiary
civilian hospital facilities.
Public information during incidents
The Minister for Defence provides information on broad categories of
injuries sustained by our troops in his regular Ministerial Statements to
Defence aims to provide public information on every operational incident
involving battle casualties (wounded and killed in action). Operational tempo,
ongoing operations and Special Operations are three factors which may lead to
occasional inconsistency in reporting. Media information about casualty
figures is however updated as appropriate, when operational circumstances
permit. Defence guidance on the release of public information during incidents
n The ADF will not
release the names of casualties until Next of Kin (NOK) procedures have been
n The ADF will not
comment on the circumstances or causes of an incident until any investigation
has been completed and if it is likely to be subject to disciplinary
n In order to align
with the civilian practice for reporting patient medical condition without
compromising the medical-in-confidence nature of the wounds and injuries,
Defence has adopted a nomenclature for public information relating to battle
Life Threatening. Injury and wounds that will likely lead to
death if not immediately treated (for example, fragmentation and gunshot wounds
involving vital organs or the head). Also applicable to an illness requiring
admission to an intensive care facility.
Serious. Injury and wounds requiring immediate medical care and
hospitalisation but not considered life threatening (for example, fragmentation
and gunshot wounds to torso). Also applicable to an illness requiring
Slight/Minor. Injury and wounds requiring medical care and
hospitalisation (for example, fragmentation and gunshot wounds to the
extremities). Also applicable to an illness requiring basic medical
care/monitoring and restriction of duties.
Superficial. Injury and wounds not requiring hospitalisation.
Notification of casualty
Notification of casualty (NOTICAS) is the name for the formal reporting
of casualties within the ADF. This reporting informs the chain of command and
provides information that is passed to families of deployed personnel. NOTICAS
reports are raised for every wounding and the reporting is undertaken as
quickly as possible.
Defence submitted that notification of wounding or injury is raised as
quickly as possible to ensure both the family and command chain is informed as
soon as practicable. Contact between the member and the family also takes
place as soon as possible.
Defence Families of Australia (DFA) submitted that NOK need to be kept
informed and included throughout the repatriation process in order to address
and allay concerns of the NOK and to reduce the family’s stress.
Public release of names
Defence advised the Committee that their policy regarding the release of
the names of members wounded or injured is:
n Names of ADF members
(not afforded protected identity status) remaining in an operational area
following an announced wounding or injury will not be released;
n Names of ADF members
(not afforded protected identity status) returning to Australia for treatment
will remain protected until authorised for release by the individual member
concerned while the names of ADF deceased will be released in consultation with
the member’s family;
n Only Special Forces
soldiers, who have protected identity status, may have their names withheld
when they are admitted into non-military hospitals; and
n There is no policy to
hide the identity of other Australian soldiers undergoing medical treatment and
rehabilitation in private or public hospitals.
Defence submitted that the objective of casualty evacuation is the safe
and efficient movement of casualties, with the provision of en route medical
care, from point of injury or illness to the appropriate health facility as
soon as possible. Evacuation comprises both surface evacuation and aeromedical
The evacuation system aims to evacuate casualties 24 hours a day, in all
weather, over all terrain and in any operational scenario. The system provides
clinical sustainment of the casualty throughout the journey, using
appropriately trained clinical staff and accurately tracks patients and
equipment throughout the evacuation. Casualties are evacuated to the most
appropriate facility in the shortest time while applying appropriate clinical processes.
This approach enables forward deployment of health elements and
concentrates resource-intensive casualty care in more secure areas where health
facilities are not required to move with changing tactical situations. Casualty
regulation directs the casualty to the health facility that is best able to
manage the condition in terms of nature and availability of required treatment.
Regulation ensures proper routing of patient to health facilities and minimises
casualty handling and transfer. In the MEAO, aeromedical evacuation of a patient
from the scene of injury or illness to the initial treatment facility and
evacuation of a patient between health facilities within the area of operation
is the responsibility of coalition partners.
Australians serving in Uruzgan rely on a team of highly skilled US and
Australian trauma and medical staff working in a well-equipped ISAF Role 2E health
facility in Tarin Kot. This facility performs initial trauma management
similar to that provided by the emergency department of a civilian hospital and
if required, the facility can also undertake emergency surgery to treat the
wounded or injured. One soldier who was
evacuated commented that the American medical staff were ‘really good…. they
were really helpful’.
Not everyone who is wounded or injured requires evacuation, and those
ADF members who suffer only minor physical impairment are treated and, once
fit, return to duty.
Casualties that require more specialist care than can be provided at the
Role 2E at Tarin Kot are evacuated to the Kandahar Role 3 Multinational Medical
Unit (MMU). Depending upon the treatment required, casualties may receive
further surgery, be clinically stabilised, and/or provided supportive care. The
facility is predominately staffed by US health specialists but is currently
being augmented by ADF specialist reserve staff. The ADF has a general surgeon,
anaesthetist, orthopaedic surgeon, two perioperative nurses and two intensive
care nurses embedded in this facility.
Once stabilised, seriously wounded or injured personnel will be returned
to Australia for additional treatment and rehabilitation which is managed by
Joint Health Command.
Operational health support
Defence informed the Committee that the ADF provides comprehensive
health services whether the environment is permissive, uncertain or hostile.
In addition to caring for Defence personnel, ADF health elements may provide
humanitarian health care to a civilian population in higher threat environments
until the situation has sufficiently stabilised for handover to civilian
Military health support is commensurate with force strength and assessed
health risks and is designed to ensure that appropriate treatment and
evacuation capabilities exist to maximise the early return to duty of
casualties. Support starts before deployment and expands as the force strength
expands and risks increase. It focuses on both battle casualties as well as
disease and non-battle injuries. Health support has a surge capacity to support
peak casualty periods.
As noted previously, when ADF personnel are injured or become ill, there
is an expectation that they will receive prompt and effective health care. ADF
health care meets contemporary professional Australian standards except when
the exigencies of military operations dictate otherwise.
LTCOL Reade told the Committee that ADF medical staff volunteering for
deployment to Afghanistan had shown ‘quite a depth of skill and were willing
LTCOL Reade went on to explain that it would be very expensive to train
a contract health practitioner to be able to go to Afghanistan and deal with
that high-level, high-intensity everyday trauma that is being experienced.
The Committee acknowledges Defence’s submission that management of the
wounded and injured in Afghanistan is currently the most difficult area for the
provision of health care and the lessons learnt in this operation have been,
and are applied to, other operations and exercises.
The Committee agrees that it is not appropriate for Defence to provide
more specific details on an incident immediately due to medical-in-confidence
and privacy reasons and that, where possible, contact with the NOK takes
precedence over all other considerations.
The Committee also agrees with the general Defence policy regarding the
release of the names of members wounded or injured.