Filling The Organic Medical Gap: How To Integrate and Fight A Multifunctional Medical Battalion In Large-Scale Combat Operations

Advanced Strategic Leadership Studies Program, School of Advanced Military Studies

By COL Tiffany R. Bilderback, MS

Article published on: July 1, 2025, in the July 2025 Issue of The Pulse of Army Medicine

Read Time: < 16 mins

Maneuver elements commonly have medical assets assigned at echelon. Battalions have an organic medical platoon, brigades have an organic medical company, but divisions do not have an organic medical battalion. According to FM 4-02 Army Health System, dated November 2020, the Multifunctional Medical Battalion (MMB) is designed to provide scalable and tailorable command posts that can be expanded and augmented as the operations mature in support of brigade combat teams and echelons above brigade forces. This figure shows an example task organization of a deployed MMB.

Figure 1. From FM 4-02 Army Health System, dated November 2020. The task organization of a notional deployed MMB.

From the Fall of 2023 to the Winter of 2024, the 61st Multifunctional Medical Battalion (MMB), 1st Medical Brigade (MED BDE) supported two III Armored Corps (IIIAC) divisions: 1st Cavalry Division (1CD) at Remagen Ready and 1st Armored Division (1AD) at the National Training Center (NTC) 24-03 rotation. This back-to-back experience provided insights and recommendations on how to fight an MMB in support of a division during Large-Scale Combat Operations (LSCO) to enable the division to maintain agility and endurance. This article argues that the MMB, when properly integrated with under defined command or support relationships, can fill the division-level medical gap in LSCO.

1st Calvary Division Experience

Photo 1. The aerial view of the Role 2E taken on an aerial leaders’ reconnaissance with the sustainment brigade commander.

When supporting 1CD, 61st MMB integrated with the 1st Cavalry Division Sustainment Brigade (CDSB) and the 1CD to provide medical command and control (C2) and a Role 2 Enhanced (Role 2E) in the Division Support Area (DSA) during a wet gap crossing exercise on Fort Cavazos, Texas. The MMB headquarters and all subordinate elements remained 100% self-mobile, empowering 1CD to maintain agility and displace the DSA if needed. The 61st MMB with subordinate units had a tactical control (TACON) command relationship to the CDSB. The 566th Medical Company (Area Support) (MCAS) provided the Role 2 with augmentation to create the Role 2E from a split surgical team from the 745th Forward Resuscitative and Surgical Detachment, one Ward from the 198th Medical Detachment, one Veterinary Services Support Team from the 43rd Medical Detachment Veterinary Services Support, and a forward distribution team and a contact repair team from the 582nd Medical Logistics Company. A Medical Company (Ground Ambulance) with twenty-four ground ambulances was replicated in the simulated environment to augment the live training environment, as 1st MED BDE does not have an organic MCGA.

1CD did have an organic brigade support medical company (BSMC), which pushed across the wet gap and provided Role 2 capability on the far side of the river crossing. The Role 2E remained in the DSA with a Role 1 pushed forward with the Forward Logistics Element (FLE) to the near side of the river in anticipation of the DSA advancing across the river. Additionally, to enable the agility of 1/1CD, the Role 2E conducted ambulance exchange points (AXPs) with the 1/1CD Role 2, which enabled that Role 2 to clear patients and be prepared for further movement. This builds off the doctrinal use of the MCAS for evacuation as stated in ATP 4-02.2 Medical Evacuation, dated July 2019, which states that an MCAS can evacuate patients from the supported Role 2 in the DSA to the MCAS Role 2.

1st Armored Division Experience

Photo 2. An ambulance exchange point (AXP) between 1/1 CD Role 2 and 566th MCAS, which enabled the agility of the brigade and the division. This allowed the Role 2 to evacuate all patients and be postured for further movement forward.

Just a couple of months later, 61st MMB integrated with the 1AD to provide medical C2 and a Role 2 (566th MCAS) in support of NTC 24-03. This rotation was the first of its kind with a division headquarters and enablers. It provided a unique opportunity for the MMB to support another IIIAC division with an operational control (OPCON) command relationship subordinate to the sustainment brigade while setting conditions for a Forward Passage of Lines (FPOL) during offensive operations. The MMB element was intentionally smaller due to the smaller supported force. The MMB element retained subject matter experts for all ten medical functions. Considering the overall battalion personnel shortages, this allowed the MMB to train which portion of the early entry element could support a division fight while maintaining flexibility to provide C2 of the rest of the subordinate units across the corps area of operations. This concept was replicated with a smaller element at NTC and the larger staff remaining at Fort Cavazos. The MMB and all subordinate elements remained 100% self-mobile, which enhanced the division commander’s agility and allowed the Role 2 to remain postured to reposition as needed and set conditions for the FPOL. The supported units were the division HQ across multiple C2 nodes and division organic and non-organic organizations. Some elements had organic Role 1, but others did not. 566th MCAS was the only Role 2 capability within NTC 24-03. Role 2 pushed forward with the FLE, and two Role 1s pushed further forward with the division C2 nodes, mitigating the lack of organic medical capability and reducing the distance for ground evacuation back to Role 2.

These two experiences were dynamic and instructive. Different capabilities were provided, command relationships, and different supported units. With 1AD welcoming and integrating 61st MMB as a training audience at NTC 24-03, the MMB could immediately build upon lessons learned from Remagen Ready going into final preparation and execution of NTC.

The table below describes the differences between the two exercises.

Friction Points → opportunities

These two exercises provided opportunities to work through and learn from several friction points and turn them in to opportunities.

Command Vs. Support Relationships

As described in FM 4-02 Army Health System, dated November 2020, relationships are paramount to building trust and confidence. The differences between command and support relationships allow for flexible allocation of the capabilities. These relationships are the basis for building task organization. OPCON and TACON are both types of command relationships. Both Remagen Ready and NTC proved that TACON or OPCON command relationships can work. The benefits of TACON at Remagen Ready created a command relationship with the CDSB but still allowed the MMB commander to retain command authority of subordinate medical organizations.

The OPCON relationship with 1AD’s sustainment brigade also worked because there were fewer subordinate capabilities and there was no desire from the sustainment brigade or division surgeon to re-task organize the Role 2. The team understood that the benefits of breaking apart the Role 2 into smaller than organic Role 1s would be detrimental to the overall purpose of the Role 2. The OPCON relationship did, however, require more interpersonal relationships that were built over time from NTC Academics at Fort Leavenworth and continued parallel planning at Fort Bliss.

What we have not tested yet is maintaining a general or direct support relationship, which could be tested in future warfighter exercises (WFXs) or NTC rotations. In a larger fight, the MMB could be in general support in the corps support area (CSA) and could surge to provide direct support to the division to synchronize and integrate the echelons above brigade and division medical capabilities for an operation such as a wet gap crossing. In this situation, maintaining a support relationship versus a command relationship would be more beneficial. The MMB would be in general support, once pushed to the DSA, would become direct support to the division and then go back to general support once the operation was complete as the division boundary moved forward and the MMB remained in the CSA. The MMB would then be available to flex to another division with the ability to preposition medical capability at the point of need to integrate and synchronize specific capabilities in support of a specific operation. Throughout this transition of support relationships, the MMB would retain the ability to support any unit with or without medical assets within the AO.

The type of command or support relationship, the type of division fight within the larger corps fight, the number of MMB subordinate units supporting the division, and the ability to maintain commander’s dialogue would all influence the MMB Commander’s location. The MMB HQ can split, and, if fully manned, could break down to a nodal concept, providing great flexibility for the commander. This could be collocated with the sustainment brigade commander, with division surgeon, in the division’s Rear Command Post (RCP), or in the CSA closer to the MED BDE.

Integration Into The Division

During Remagen Ready, due to co-location on Fort Cavazos, the MMB was able to integrate with the CDSB early and often. The CDSB support operations (SPO) section is where integration primarily occurred, including education of capabilities early during the military decision-making process (MDMP). This integration enabled a great working relationship between the CDSB and MMB in the execution of Remagen Ready.

During the exercise, the CDSB SPO and division surgeon cell were not co-located, so communication with the division surgeon then had to occur on upper tactical internet (TI). The integration remained best suited in the CDSB SPO because of the direct line of communication with the lower-echelon brigade SPOs, the ability to anticipate requirements, and the clear understanding of current and future operations. The integration required more than a liaison officer and evolved to a new concept – the Medical Capabilities Integration Element (MCIE). To start, the MCIE had four (two per shift) personnel from the MMB SPO section sitting in the CDSB SPO to create commander’s visualization, anticipate requirements, and provide friendly forces information requirements (FFIR) to drive the MMB commander’s ability to make decisions to align the available capabilities with the requirement.

The MMB was able to take the lesson of integration immediately into detailed planning with 1AD. Integration began with the division planning exercise with the division G35 then progressed to the division G4 and surgeon after the final planning conference. Integration was slightly more challenging not being collocated with 1AD at Fort Bliss, but it was overcome by integrating NTC Academics at Fort Leavenworth, Kansas, and then continued parallel planning. The MMB staff attended weekly meetings virtually for all the refined planning.

During execution at NTC, the sustainment brigade was co-located with the division surgeon cell in the RCP. The MMB was able to position the MCIE physically in between both nodes, creating a great opportunity for direct verbal communication on a routine basis, which mitigated any degradation to upper TI in the RCP. The MCIE was larger at NTC because it was the best position for the commander to maintain commander’s dialogue as well as have access to upper and lower TI. The MMB set up a separate battalion command post to hold internal meetings, that was within walking distance for the commander.

Figure 2.The Medical Capabilities Integration Element (MCIE) was developed throughout Remagen Ready and refined at NTC 24-03.

Integration with the supported unit is necessary to create shared understanding of division specific processes and procedures, the concept of the operation, and the commander’s priorities and intent. Integration with the sustainment brigade and division surgeon, if collocated as they were at NTC in the RCP, maximizes synchronization. Ultimately, the command or support relationship, capabilities that need to be integrated, and the location of the division surgeon and sustainment brigade, would determine the best integration point for the MCIE and the MMB. Opportunities remain for integrating assets of the MMB beyond the Role 2 with preventive medicine, combat operational stress control, and medical logistics. This can be tested constructively through future WFXs and can be tested in a live environment at NTC.

Communications

With both 1CD and 1AD, upper TI was a necessity. The MMB does not have organic upper TI or communications security (COMSEC) capability and requires external support. For Remagen Ready, the division’s primary means of communication was on upper TI using Transverse for chat and Ventrilo for voice. The common denominator in the communications plan across all battalion elements in the division was lower TI with Joint Battle Command – Platform (JBCP). Having not yet been fielded the JBCP, the MMB had a Joint Capabilities Release (JCR) in the battalion command post which was used to communicate with the CDSB. However, the primary means of communication between the MMB and the Role 2E was FM radio or runner. All messages received on upper TI were translated onto FM for execution by the Role 2E. FM radio was also the primary means of communication with deployed evacuation teams, which became limited once a certain distance was met between the DSA and forward AXPs.

Not being organic to the 1CD led to challenges with upper TI connection. As a corps asset, the communications support came from IIIAC, not the division. Therefore, the MMB command post did not always have access to the appropriate frequencies to dial into the correct Ventrilo rooms, and at times the latency was up to 30 seconds, directly impacting the MMB commander’s ability to communicate effectively with the DSB commander via upper TI. Due to the location of the MMB CP and the CDSB CP, the MMB commander was able to walk and speak to the CDSB commander in person to maintain the appropriate commander’s dialogue.

At NTC, rather than request signal brigade support, the MMB requested support through the sustainment brigade. This mitigated the latency problems as seen during Remagen Ready. Ventrilo remained the primary for voice with Spark for chat. The chat rooms were primarily used to communicate medical evacuation requests from the MMB. Having just been fielded the JBCP in November immediately after Remagen Ready, the common denominator in the communications plan across all elements, organic and non-organic to the 1AD was lower TI on JBCP. Therefore, the primary means of communicating between the MMB and the Role 2 and the Role 2 forward to the Role 1s was on JBCP. The MMB could mitigate a break in communications with planned push packages of Class VIII but was not prepared to mitigate degraded communications for patient evacuation. With the MMB collocated within the RCP with the sustainment brigade commander, commander’s dialogue could happen in person if there were degraded upper TI on Transverse for battle rhythm events.

If the commander intends to minimize the electromagnetic (EM) spectrum and turn off JBCPs, this leaves the MMB without the organic ability to C2 to its downtrace units, including casualty evacuation, which increases the risk to force. Units must train in degraded communications environments with mission orders, analog systems, and disciplined initiative.

Both exercises illuminated the necessity for establishing a medical evacuation communications plan that is tested between all forward Role 1s and Role 2s. This plan should be an input to the sustainment rehearsal of concept and validated through a standard and non-standard casualty evacuation communications exercise. This will limit confusion with the extensive ground medical and casualty evacuations that will be happening with both planned and unplanned AXPs in LSCO and will assist in determining the roles and responsibilities amongst the division surgeon, sustainment brigade, and MMB.

Key Takeaways

There were several takeaways from these two unique experiences. First, the MMB and subordinate units can effectively provide capabilities with either an OPCON or TACON relationship. Each type of relationship has its benefits. OPCON gives the division commander more flexibility in using and allocation medical assets. However, this could lead to Role 2 degradation if the capabilities were stretched too thin across the battlefield. TACON allows the MMB commander to retain the task organization and maximize the capability of the Role 2 and any other supporting organizations. General or direct support relationships could be assessed in future WFXs or NTC rotations.

Second, integration with the supported unit is necessary to create shared understanding of division specific processes and procedures, the concept of the operation, and the commander’s priorities and intent. Integration with the sustainment brigade and division surgeon, if collocated as they were at NTC in the rear command post, maximizes synchronization, especially in a degraded communications environment. As an external unit, the MMB’s integration across all methods of communication platforms should happen as soon as possible to provide ample time to mitigate any friction points and gaps in the ability to communicate effectively. The MCIE proved to be an effective and tailorable method to integrate.

Third, the type of command or support relationship, the type of division fight within the larger corps fight, the number of MMB subordinate units supporting the division, and the ability to maintain the commander’s dialogue would all influence the MMB commander’s location. With full manning, the MMB staff has the flexibility to shift and support the commander as necessary while maintaining C2 of all subordinate units across the area of operations. The staff can be split in two locations, but splitting further might degrade effectiveness.

Fourth, it is indispensable to establish and rehearse a medical evacuation plan between all forward Role 1s and Role 2s. This plan should be an input to the sustainment rehearsal of concept and validated through a standard and non-standard casualty evacuation exercise. With the MMB being an external unit, this is vital to synchronize the standard operating procedures at echelon across the formation with each supported unit.

Fifth, augmenting the Role 2 with additional units, such as a resuscitative and surgical detachment, medical detachment, or veterinary team, can enhance the Role 2 capabilities while keep the organization 100% self-mobile. As an example, the simple addition of a veterinary team as an ultrasound capability to the Role 2. The ability for the Role 2 to move itself and displace quickly, as compared to a larger hospital, enables the division to maintain agility, which is critical to protection and speed in LSCO, as described in ADP 3-0 Operations, dated March 2025.

Finally, we must continue to train as we fight. This includes education, building the supported-supporting relationships, and expanding integration across warfighting functions through future WFXs and CTC rotations. Preventive medicine, combat operational stress control, and medical logistics capabilities would provide additional capabilities in both protection and sustainment for the division commander. This should be tested in future exercises. We can also align task organization in garrison as it would support LSCO to build relationships and cohesive teams to mitigate the friction that comes with integration just before the time of need.

Conclusion

Supporting 1CD and then 1AD at NTC 24-03 was an invaluable opportunity that allowed the MMB to break new ground for the Army in a realistic learning environment and provide the unique insights on how to best integrate and fight the MMB in preparation for LSCO. Defined support or command relationships matter, effective integration is critical, and effective communications are paramount. The Army can continue to improve the ability to fill the division’s organic medical gap with an MMB and subordinate units through educating and building supported-supporting relationships and training as we fight to build the cohesive team, while expanding integration. Going forward, to support the Chief of Staff of the Army and the Secretary of the Army’s demands to transform and drive change to ensure we stay lethal and ready, the Army should institutionalizing the MMB’s support to the division by refining doctrinal guidance, aligning command and support relationships in garrison, and ensuring MMB participation in division-level and brigade combat team LSCO training events.