TRANSCRIBER'S NOTE
Italic text is denoted by _underscores_. Blank space in some sample
documents in the text is also denoted by ____.
Bold text is denoted by =equal signs=.
Superscripts are denoted by ^ eg abc^{TM}.
Subscripts in chemical formulae are denoted by _ eg CO_{2}.
Footnotes are all within a specific Table, including the Table of
Contents. They are positioned at the bottom of that Table, as in the
original text, and are denoted by [*] or [**].
Obvious punctuation errors have been corrected after careful
comparison with other occurrences within the text and consultation
of external sources.
More detail can be found at the end of the book.
=FM 4-02.7= (FM 8-10-7)
HEALTH SERVICE
SUPPORT IN A NUCLEAR,
BIOLOGICAL, AND
CHEMICAL
ENVIRONMENT
TACTICS, TECHNIQUES, AND PROCEDURES
OCTOBER 2002
HEADQUARTERS, DEPARTMENT OF THE ARMY
DISTRIBUTION RESTRICTION: Approved for public release; distribution
is unlimited.
[*]FM 4-02.7 (FM 8-10-7)
FIELD MANUAL HEADQUARTERS
NO. 4-02.7 (8-10-7) DEPARTMENT OF THE ARMY
Washington, DC, 1 October 2002
HEALTH SERVICE SUPPORT IN A NUCLEAR, BIOLOGICAL, AND CHEMICAL
ENVIRONMENT TACTICS, TECHNIQUES AND PROCEDURES
TABLE OF CONTENTS
=Page=
=Preface= viii
=CHAPTER 1. NUCLEAR, BIOLOGICAL, AND CHEMICAL WARFARE ASPECT
OF THE MEDICAL THREAT= 1-1
1-1. General 1-1
1-2. Medical Threat 1-1
1-3. Nuclear, Biological, Chemical, and Radiological Dispersal
Device Threats--The Health Service Perspective 1-2
=CHAPTER 2. COMMAND AND CONTROL= 2-1
2-1. General 2-1
2-2. Health Service Support Command and Control Planning
Considerations 2-1
2-3. Health Service Support Command and Control Appraisal of
the Support Mission 2-2
2-4. Health Service Support Units 2-2
2-5. Movement/Management of Contaminated Facilities 2-3
2-6. Leadership on the Contaminated Battlefield 2-5
2-7. Homeland Security 2-6
=CHAPTER 3. LEVELS I AND II HEALTH SERVICE SUPPORT= 3-1
3-1. General 3-1
3-2. Level I Health Service Support 3-2
3-3. Level II Health Service Support 3-2
3-4. Forward Surgical Team 3-3
3-5. Actions Before a Nuclear, Biological, or Chemical Attack 3-3
3-6. Actions During a Nuclear, Biological, or Chemical Attack 3-4
3-7. Actions After a Nuclear, Biological, or Chemical Attack 3-4
3-8. Logistical Considerations 3-5
3-9. Personnel Considerations 3-5
3-10. Disposition and Employment of Treatment Elements 3-6
3-11. Civilian Casualties 3-6
3-12. Nuclear Environment 3-7
3-13. Medical Triage 3-8
3-14. Biological Environment 3-8
3-15. Chemical Environment 3-9
3-16. Operations in Extreme Environments 3-10
3-17. Medical Evacuation in a Nuclear, Biological, and
Chemical Environment 3-10
=CHAPTER 4. LEVELS III AND IV HOSPITALIZATION= 4-1
4-1. General 4-1
4-2. Protection 4-3
4-3. Decontamination 4-8
4-4. Emergency Services 4-10
4-5. General Medical Services 4-11
4-6. Surgical Services 4-11
4-7. Nursing Services 4-12
4-8. Conventional Operations 4-13
=CHAPTER 5. OTHER HEALTH SERVICE SUPPORT= 5-1
=Section I. Preventive Medicine Services= 5-1
5-1. General 5-1
5-2. Disease Incidence Following the Use of Nuclear,
Biological, and Chemical Weapons 5-1
5-3. Preventive Medicine Section 5-3
5-4. Preventive Medicine Detachment 5-3
=Section II. Veterinary Services= 5-4
5-5. General 5-4
5-6. Food Protection 5-4
5-7. Food Decontamination 5-4
5-8. Animal Care 5-5
=Section III. Laboratory Services= 5-5
5-9. General 5-5
5-10. Level II 5-5
5-11. Level III 5-5
5-12. Level IV 5-6
5-13. Level V (Continental United States) 5-6
5-14. Field Samples 5-6
=Section IV. Dental Services= 5-7
5-15. General 5-7
5-16. Mission in a Nuclear, Biological, or Chemical
Environment 5-7
5-17. Dental Treatment Operations 5-7
5-18. Patient Treatment Considerations 5-7
5-19. Patient Protection 5-8
=Section V. Combat Operational Stress Control= 5-9
5-20. General 5-9
5-21. Leadership Actions 5-9
5-22. Individual Responsibilities 5-10
5-23. Mental Health Personnel Responsibilities 5-11
=Section VI. Health Service Logistics= 5-11
5-24. General 5-11
5-25. Protecting Supplies In Storage 5-12
5-26. Protecting Supplies During Shipment 5-12
5-27. Organizational Maintenance 5-12
=Section VII. Homeland Security Response= 5-13
5-28. Chemical, Biological, Radiological, Nuclear, and
High-Yield Explosive Response 5-13
5-29. Capabilities of Response Elements 5-14
=APPENDIX A. MEDICAL EFFECTS OF NUCLEAR, BIOLOGICAL, AND
CHEMICAL WEAPONS AND TOXIC INDUSTRIAL MATERIAL= A-1
A-1. General A-1
A-2. Physical Effects of Nuclear Weapons A-1
A-3. Physiological Effects of Nuclear Weapons A-4
A-4. Biological Effects of Thermal Radiation A-7
A-5. Physiological Effects of Ionizing Radiation A-8
A-6. Handling and Managing Radiologically Contaminated
Patients A-10
A-7. Radiological Patients in Stability Operations and
Support Operations A-13
A-8. Effects of Biological Weapons A-14
A-9. Behavior of Biological Weapons A-15
A-10. Management of Biological Warfare Patients A-16
A-11. Effects of Chemical Weapons A-17
A-12. Behavior of Chemical Weapons A-17
A-13. Characteristics of Chemical Agents A-19
A-14. Management of Chemical Agent Patients A-23
A-15. Management of Toxic Industrial Material Patients A-23
=APPENDIX B. SAMPLE/SPECIMEN COLLECTION AND MANAGEMENT= B-1
=Section I. Introduction= B-1
B-1. General B-1
B-2. Sample/Specimen Background Information B-2
B-3. Sample/Specimen Collection and Preservation B-3
B-4. Chain of Custody B-8
=Section II. Sampling Techniques and Procedures= B-9
B-5. General B-9
B-6. Expended Material B-11
B-7. Environmental Samples B-11
B-8. Collection of Air and Vapors B-12
B-9. Collection of Water Samples B-13
B-10. Collection of Soil Samples B-15
B-11. Collection of Contaminated Vegetation B-16
B-12. Medical Specimens B-16
B-13. Collection of Medical Specimens B-17
B-14. Post Mortem Specimens B-19
B-15. Reporting, Packaging, and Shipment B-20
B-16. Handling and Packaging Materials B-21
B-17. Collection Reporting B-23
B-18. Sample/Specimen Background Documents B-27
=APPENDIX C. GUIDELINES FOR OPERATIONAL PLANNING FOR HEALTH
SERVICE SUPPORT IN A NUCLEAR, BIOLOGICAL, AND
CHEMICAL ENVIRONMENT= C-1
C-1. General C-1
C-2. Predeployment C-1
C-3. Mobilization C-2
C-4. Establish a Medical Treatment Facility C-3
C-5. Operate a Medical Treatment Facility Receiving
Contaminated Patients. C-4
C-6. Preventive Medicine Services C-5
C-7. Veterinary Services C-6
C-8. Dental Services C-6
C-9. Combat Operational Stress Control C-6
C-10. Medical Laboratory Services C-6
C-11. Health Service Logistics C-7
C-12. Homeland Security C-8
=APPENDIX D. MEDICAL PLANNING GUIDE FOR THE ESTIMATION OF
NUCLEAR, BIOLOGICAL, AND CHEMICAL BATTLE
CASUALTIES= D-1
=Section I. Introduction= D-1
D-1. General D-1
D-2. Medical Planners' Tool D-1
=Section II. Medical Planning Guide for the Estimation of
Nuclear, Biological, and Chemical Battle Casualties
(Nuclear)--AMedP-8(A), Volume I= D-1
D-3. General D-1
D-4. Medical Planning Considerations D-2
D-5. Triage D-3
D-6. Evacuation D-3
D-7. In-Unit Care D-3
D-8. Hospital Bed Requirements D-4
D-9. Medical Logistics D-4
D-10. Medical Force Planning D-4
=Section III. Medical Planning Guide for the Estimation of
Nuclear, Biological, and Chemical Battle Casualties
(Biological)--AMedP-8(A), Volume II= D-4
D-11. General D-4
D-12. Medical Planning Considerations D-6
D-13. Triage D-6
D-14. Evacuation D-6
D-15. In-Unit Care D-7
D-16. Patient Bed Requirements D-7
D-17. Medical Logistics D-7
D-18. Medical Force Planning D-8
=Section IV. Medical Planning Guide for the Estimation of
Nuclear, Biological, and Chemical Battle Casualties
(Chemical)--AMedP-8(A), Volume III= D-8
D-19. General D-8
D-20. Medical Planning Considerations D-10
D-21. Triage D-11
D-22. Evacuation D-11
D-23. In-Unit Care D-11
D-24. Patient Bed Requirements D-12
D-25. Medical Logistics D-12
D-26. Medical Force Planning D-12
=APPENDIX E. EXAMPLE X-__, ANNEX__, TO HSS PLAN/OPERATION
ORDER__, MEDICAL NBC STAFF OFFICER PLANNING
FOR HSS IN AN NBC ENVIRONMENT= E-1
=APPENDIX F. EMPLOYMENT OF CHEMICAL AND BIOLOGICAL
COLLECTIVE PROTECTION SHELTER SYSTEMS BY MEDICAL UNITS= F-1
=Section I. Introduction= F-1
F-1. General F-1
F-2. Types of Collective Protection Shelter Systems F-1
=Section II. Employment of the Chemically and Biologically
Protected Shelter System= F-2
F-3. Establish a Battalion Aid Station in a Chemically
Biologically Protected Shelter F-2
F-4. Division Clearing Station in a Chemically Biologically
Protected Shelter F-4
F-5. Forward Surgical Team in a Chemically Biologically
Protected Shelter F-6
=Section III. Employment of the Chemically Protected
Deployable Medical Systems and Simplified Collective
Protection Systems= F-8
F-6. Collective Protection in a Deployable Medical
System-Equipped Hospital F-8
F-7. Chemically/Biologically Protecting the International
Organization for Standardization Shelter F-11
F-8. Chemically/Biologically Protecting the Vestibules F-12
F-9. Chemically/Biologically Protecting Air Handler Equipment F-12
F-10. Establish Collective Protection Shelter Using the M20
Simplified Collective Protection System F-12
F-11. Casualty Decontamination F-12
=Section IV. Operations, Entry, and Exit Guidelines= F-13
F-12. Operations F-13
F-13. Decontamination of Entrance Area F-13
F-14. Procedures Prior to Entry F-14
F-15. Entry/Exit for the Collective Protection Shelter System F-14
F-16. Resupply of Protected Areas F-17
=APPENDIX G. PATIENT DECONTAMINATION= G-1
=Section I. Introduction= G-1
G-1. General G-1
G-2. Immediate Decontamination G-2
G-3. Patient Decontamination and Thorough Decontamination
Collocation G-2
G-4. Patient Decontamination at the Battalion Aid Station
(Level I) G-5
G-5. Patient Decontamination at the Medical Company Clearing
Station (Level II) G-5
G-6. Patient Decontamination at a Hospital (Level III and IV) G-5
G-7. Prepare Hypochlorite Solutions for Patient
Decontamination G-5
G-8. Classification of Patients G-6
G-9. Patient Treatment G-6
=Section II. Patient Decontamination Procedures= G-7
G-10. Decontaminate a Litter Chemical Agent Patient G-7
G-11. Decontaminate an Ambulatory Chemical Agent Patient G-14
G-12. Biological Patient Decontamination Procedures G-18
G-13. Decontaminate a Litter Biological Agent Patient G-18
G-14. Decontaminate an Ambulatory Biological Agent Patient G-19
G-15. Decontaminate Nuclear-Contaminated Patients G-20
G-16. Decontaminate a Litter Nuclear-Contaminated Patient G-21
G-17. Decontaminate an Ambulatory Nuclear-Contaminated
Patient G-21
=APPENDIX H. FIELD EXPEDIENT PROTECTIVE SYSTEMS AGAINST
NUCLEAR, BIOLOGICAL, AND CHEMICAL ATTACK= H-1
H-1. General H-1
H-2. Protection Against Radiation H-1
H-3. Expedient Shelters for Protection Against Radiation H-2
H-4. Expedient Shelters Against Biological and Chemical Agents H-5
=APPENDIX I. DETECTION AND TREATMENT OF NUCLEAR, BIOLOGICAL,
AND CHEMICAL CONTAMINATION IN WATER= I-1
I-1. General I-1
I-2. Detection of Contamination in Water I-1
I-3. Procedures on Discovery of Contamination in Water I-1
I-4. Treatment of Contaminated Water I-2
=APPENDIX J. FOOD CONTAMINATION AND DECONTAMINATION= J-1
J-1. General J-1
J-2. Protection of Food From Contamination J-2
J-3. Nuclear J-3
J-4. Biological J-4
J-5. Chemical J-5
=GLOSSARY= Glossary-1
=REFERENCES= References-1
=INDEX= Index-1
DISTRIBUTION RESTRICTION: Approved for public release; distribution
is unlimited.
[*] This publication supersedes FM 8-10-7, 22 April 1993. Change 1,
26 November 1996
PREFACE
The purpose of this field manual (FM) is to provide doctrine and
tactics, techniques, and procedures for health service support
(HSS) units and personnel operating in a nuclear, biological,
and chemical (NBC), radiological dispersal device (RDD), and
toxic industrial material (TIM) environment. The manual provides
information for use by commanders, planners, leaders, and
individuals in providing HSS under these adverse conditions.
The use of trade or brand names in this publication is for
illustrative purposes only. Their use does not constitute
endorsement by the Department of Defense (DOD).
The proponent of this publication is the United States (US) Army
Medical Department Center and School (AMEDDC&S). Send comments and
recommendations directly to Commander, US Army Medical Department
Center and School, ATTN: MCCS-FCD, 1400 East Grayson Street, Fort
Sam Houston, Texas 78234-5052.
The use of the term "level of care" in this publication is
synonymous with "echelon of care" and "role of care." The term
"echelon of care" is the old North Atlantic Treaty Organization
(NATO) term. The term "role of care" is the new NATO and American,
British, Canadian, and Australian (ABCA) term.
The use of the term TIM in this publication is inclusive of RDD.
The use of the term "Health Service Support" in this publication
is synonymous with Combat Health Support as used in other
publications. Health Service Support is the term used in Joint
Publications to describe medical support to Joint Forces.
Radiological and chemical detection devices discussed in this
publication are currently being replaced through modernization or
new device developments. The users should adapt the application of
doctrine as described to fit the new devices when issued/authorized.
Unless this publication states otherwise, masculine nouns and
pronouns do not refer exclusively to men.
This publication implements NATO Standardization Agreements
(STANAGs) 2475, Medical Planning Guide for the Estimation of
NBC Battle Casualties (Nuclear)--Allied Medical Publication
(AMedP) 8(A), Volume I; 2476, Medical Planning Guide of NBC
Battle Casualties (Biological)--AMedP-8(A), Volume II; 2477,
Planning Guide for the Estimation of NBC Battle Casualties
(Chemical)--AMedP-8 (A), Volume III. It is also in consonance with
the following NATO STANAGs and ABCA Quadripartite Standardization
Agreements (QSTAGs):
TITLE STANAG QSTAG
Warning Signs for the Marking of Contaminated or
Dangerous Land Areas, Complete Equipments, Supplies
and Stores 2002 501
Emergency Alarms of Hazard or Attack (NBC and Air
Attack Only) 2047 183
Interoperable Chemical Agent Detector Kits 608
Emergency War Surgery 2068
Commander's Guide on Nuclear Radiation Exposure of
Groups 2083 898
Reporting Nuclear Detonations, Biological and Chemical
Attacks, and Predicting and Warning of Associated
Hazards and Hazard Areas--ATP-45(B) 2103 187
Friendly Nuclear Strike Warning 2104 189
Nuclear, Biological and Chemical Reconnaissance 2112
NATO Handbook on the Medical Aspects of NBC Defensive
Operations--AMedP-6(B) 2500
Concept of Operations of Medical Support in Nuclear,
Biological, and Chemical Environments--AMedP-7(A) 2873
Medical Aspects of NBC Defensive Operations 1330
Principles of Medical Policy in the Management of a
Mass Casualty Situation 2879
Medical Aspects of Mass Casualty Situations 816
Guidelines for Air and Ground Personnel Using Fixed
and Transportable Collective Protection Facilities
on Land 2941 2000
Training of Medical Personnel for NBC Operations 2954
CHAPTER 1
NUCLEAR, BIOLOGICAL, AND CHEMICAL WARFARE ASPECT OF THE MEDICAL
THREAT
1-1. General
_a._ After World War II, the Soviet Union represented the
principal threat to the national security interests of the US.
During this period, the military capability of the Soviet Armed
Forces grew enormously. Starting in the later years of the 1980s,
the international security environment has undergone rapid,
fundamental, and revolutionary changes. With the collapse of Soviet
communism, the Soviet Union disintegrated as a viable economic and
political system. The Warsaw Pact dissolved as a political and
military entity. The central Soviet government was replaced by the
Commonwealth of Independent States (CIS), dominated by the Russian
Republic. The cohesion of Soviet strategic military capability has
been fractured by--
· The dissolution of central Soviet control.
· The formation of the CIS.
· The unpredictability associated with uncertain loyalties and
low morale.
The ultimate outcome of these events in terms of US national
security interests is unclear. The military capabilities of CIS
like Russia, Ukraine, Kazakstan, and Belarus remain formidable. The
capabilities include strategic nuclear and impressive conventional,
biological, and chemical warfighting capabilities.
_b._ From a global perspective, the economic power and influence
of developing and newly industrialized nations continue to grow.
Centers of power (global or regional) cannot be measured solely
in military terms. Nation states pursuing their own political,
ideological, and economic interests may become engaged in direct
or indirect competition and conflict with the US. More nations
have acquired significant numbers of modern, lethal, combat weapon
systems; developed very capable armed forces; and become more
assertive in international affairs. In the absence of a single,
credible, coercive threat, old rivalries and long repressed
territorial ambitions will resurface, causing increased tensions
in many regions. Political, economic, and social instability and
religious, cultural, and economic competition will continue to
erode the influence of the US over the rest of the world. This
erosion will also reduce the US influence of traditional regional
powers over their neighbors. This environment will encourage the
continued development, or acquisition, of modern armed forces and
equipment by less influential nations; thus raising the potential
for the use of NBC/RDD weapons during internal conflict and armed
confrontations in developing regions of the world.
_c._ A third dimension to the threat is terrorist, rogue groups,
and belligerents employing a number of chemical and biological
agents and the possible use of TIM to injure or kill US personnel.
The actions may be isolated or may be imposed by groups of
individuals. Most will have the financial backing of nations, large
organizations, or groups that have the desire to cause harm and
create public distrust in our government.
1-2. Medical Threat
Medical threat is the composite of all ongoing or potential enemy
actions and environmental conditions that will reduce combat
effectiveness through wounding, injuring, causing disease, and/or
degrading performance. Soldiers are the targets of these threats.
Weapons or environmental conditions that will generate wounded,
injured, and sick soldiers, beyond the capability of the HSS
system to provide timely medical care from available resources,
are considered major medical threats. Weapons or environmental
conditions that produce qualitatively different wound or disease
processes are also major medical threats. Added to the combat
operational and disease and nonbattle injury (DNBI) medical threats
are adversary use of the following types of weapons, agents, and
devices:
· Biological warfare agents.
· Chemical warfare agents.
· Nuclear weapons.
· Toxic industrial materials.
· Radiological dispersal devices.
· Directed-energy devices/weapons.
· Chemical, biological, radiological, nuclear, and high-yield
explosives.
1-3. Nuclear, Biological, Chemical, and Radiological Dispersal
Device Threats--The Health Service Perspective
_a._ _Nuclear Weapons and Radiological Dispersal Device Threats._
Since the breakup of the Soviet Union, the number of countries
with known nuclear capable military forces has almost doubled.
Available information suggests that a number of countries in the
Middle East, Asia, and Africa have or may have nuclear weapons
capability within the next decade. Table 1-1 lists those countries
known to have, suspected of possessing, or seeking, nuclear
weapons. Planners can expect, as a minimum, 10 to 20 percent
casualties within a division-sized force that has experienced
a nuclear strike. In addition to the casualties, a nuclear
weapon detonation can generate an electromagnetic pulse (EMP)
that will cause catastrophic failures of electronic equipment
components. Radiological dispersal devices, comprised of an
explosive device with radioactive material, can be detonated
without the need for the components of a nuclear weapon. The RDD
can disperse radioactive material over an area of the battlefield
causing effects from nuisance levels of radioactive material to
life-threatening levels without the thermal and, in most cases, the
blast effects of a nuclear detonation. For nuclear weapons effects
see Appendix A.
_Table 1-1. Countries Possessing or Suspected of Possessing Nuclear
Weapons_
========================================================
KNOWN TO POSSESS SUSPECT OR SEEKING
--------------------------------------------------------
UNITED STATES OF AMERICA IRAQ
RUSSIA NORTH KOREA
UKRAINE IRAN
BELARUS LIBYA
KAZAKSTAN ALGERIA
PEOPLE'S REPUBLIC OF CHINA SOUTH AFRICA
FRANCE ISRAEL
UNITED KINGDOM
PAKISTAN
INDIA
========================================================
_b._ _Biological Warfare._
(1) Biological warfare (BW) is defined by the US intelligence
community as the intentional use of disease-causing organisms
(pathogens), toxins, or other agents of biological origin (ABO) to
incapacitate, injure, or kill humans and animals; to destroy crops;
to weaken resistance to attack; and to reduce the will to fight.
Historically, BW has primarily involved the use of pathogens in
assassinations or as sabotage agents in food and water supplies to
spread contagious disease among target populations.
(2) For purposes of medical threat risk assessment, we are
interested only in those BW agents that incapacitate, injure, or
kill humans or animals.
(3) Known or suspect BW agents and ABOs can generally be
categorized as naturally occurring, unmodified infectious agents
(pathogens); toxins, venoms, and their biologically active
fractions; modified infectious agents; and bioregulators. See Table
1-2 for examples of known or suspected BW threat agents. Also,
Table 1-3 presents possible developmental and future BW agents.
_Table 1-2. Examples of Known or Suspect Biological Warfare Agents_
============================================================
PATHOGENS TOXINS
------------------------------------------------------------
_BACILLUS ANTHRACIS_ (ANTHRAX) BOTULINUM TOXIN
_FRANCISELLA TULARENIUS_ (TULAREMIA) MYCOTOXINS
_YERSINIA PESTIS_ (PLAGUE) ENTEROTOXIN
_BRUCELLA SPECIES_ (BRUCELLOSIS) RICIN
_VIBRIO CHOLERAE_ (CHOLERA)
_VARIOLA_ (SMALLPOX)
_VIRAL HEMORRHAGIC FEVERS_
=============================================================
_Table 1-3. The Future of Biological Warfare Agents_
=======================================================================
CURRENT THREAT FUTURE
-----------------------------------------------------------------------
PATHOGENS MODIFIED PATHOGENS
LIMITED NUMBER OF TOXINS EXPANDED RANGE OF TOXINS (ORGANO-TOXINS)
AGENTS OF BIOLOGICAL ORIGIN PROTEIN FRACTIONS
AGENTS OF BIOLOGICAL ORIGIN
=======================================================================
(4) Many governments recognize the industrial and economic
potential of advanced biotechnology and bioengineering. The
same knowledge, skills, and methodologies can be applied to the
production of second and third generation BW agents. Naturally
occurring infectious organisms can be made more virulent and
antibiotic resistant and manipulated to render protective vaccines
ineffective. These developments complicate the ability to detect
and identify BW agents and to operate in areas contaminated by the
BW agents. For biological agent characteristics and effects see
Appendix A. The first indication that a BW agent release/attack has
occurred may be patients presenting at a medical treatment facility
with symptoms not fitting the mold for endemic diseases in the
area of operations (AO). See Appendix B for sampling requirements,
sampling procedures, packaging and shipping, and chain of custody
requirements.
_c._ Chemical Warfare.
(1) Since World War I, most western political and military leaders
have publicly held chemical warfare (CW) in disrepute. However,
evidence accumulated over the last 50 years does not support the
position that public condemnation equates to limiting development
or use of offensive CW agents. The reported use of chemical agents
and biological toxins in Southeast Asia by Vietnamese forces; the
confirmed use of CW agents by Egypt against Yemen; and later by
Iraq against Iranian forces; and the probable use of CW agents by
the Soviets in Afghanistan indicate a heightened interest in CW as
a force multiplier. Also, an offensive CW capability is developed
as a deterrent to the military advantage of a potential adversary.
For a list of common chemical agents, their characteristics,
behavior, and effects see Appendix A. Table 1-4 lists those
countries known or suspected of having offensive chemical weapons.
(2) The Russian Republic has the most extensive CW capability in
Europe. Chemical strikes can be delivered with almost any type of
conventional fire support weapon system (from mortars to long-range
tactical missiles). Agents known to be available in the Russian
inventory include nerve agents (O-ethyl methyl phosphonothiolate
[VX], thickened VX, Sarin [GB], and thickened Soman [GD]);
vesicants (thickened Lewisite[L] and mustard-Lewisite mixture[HL]);
and choking agent (phosgene). Although not considered CW agents,
riot control agents are also in the Russian inventory.
(3) The US is in the process of destroying its stockpiles of CW
weapons. Many weapons have already been destroyed and the storage
facilities have been rendered safe of all CW agent residues.
_Table 1-4. Nations Known or Suspected of Possessing Chemical Weapons_
==================================================================
KNOWN TO POSSESS SUSPECTED OF POSSESSING
------------------------------------------------------------------
UNITED STATES OF AMERICA PEOPLE'S REPUBLIC OF CHINA
RUSSIA NORTH KOREA
FRANCE EGYPT
LIBYA ISRAEL
IRAQ[*] ETHIOPIA
IRAN TAIWAN
SYRIA BURMA
------------------------------------------------------------------
[*] FOLLOWING THE PERSIAN GULF WAR (1990-91), THE UNITED NATIONS
(UN) BEGAN DESTROYING CW MUNITIONS DISCOVERED DURING INSPECTION
VISITS TO IRAQ BY UN ARMS CONTROL INSPECTORS. INCLUDED AMONG THE
CW MUNITIONS DISCOVERED WERE SOME 2,000 AERIAL BOMBS AND 6,200
ARTILLERY SHELLS FILLED WITH MUSTARD AND SEVERAL THOUSAND 122
MILLIMETERS (mm) ROCKET WARHEADS FILLED WITH NERVE AGENT (GB). IRAQ
ALSO DECLARED SURFACE TO AIR MISSILE (SCUD) WARHEADS FILLED WITH
NERVE AGENT (GB AND GF). TABLE 1-5 PROVIDES A LIST OF KNOWN CW
AGENTS.
==================================================================
_Table 1-5. Chemical Warfare Agents_
=======================================================================
NERVE VESICANT INCAPACITATING CHOKING BLOOD
-----------------------------------------------------------------------
TABUN(GA) SULFUR CNS DEPRESSANT(BZ) PHOSGENE (CG) HYDROGEN
MUSTARD (HD) CYANIDE (AC)
GB HL CHLORINE (CL) DIPHOSGENE (DP) CYANOGEN
GD L CHLOROPICRIN (PS) CHLORIDE (CK)
GF PHOSGENE D-LYSERGIC ACID
OXIME (CX)
VX DIETHYLAMIDE (LSD)
=======================================================================
_d. Toxic Industrial Materials._
Toxic industrial materials can present a medical threat for
deployed forces. Toxic industrial materials are comprised of toxic
industrial biologicals (TIB), toxic industrial chemicals (TIC),
and toxic industrial radiological (TIR) materials. These materials
are found throughout the world and are used on a daily basis
for commercial and private purposes. Large storage facilities,
transportation tankers (over the road and railcars), as well as
smaller containers of material, pose a danger to the health of
personnel. Accidental spills or releases and terrorist actions
can all lead to release of these materials into the environment
causing potential casualty producing effects. Medical treatment
facilities and nuclear power plants use radioactive materials
that can pose a health hazard if accidentally released or used
by hostile forces, terrorists, or others to contaminate an area.
Biological materials used in medical research and pharmaceutical
manufacturing may be used by hostile forces, terrorists, or
others to produce casualties. Many TICs produce the same effects
on personnel as CW agents. As a matter of fact, many TICs are of
the same chemical structure as CW agents. However, there is quite
a difference in their potency; in most TICs the potency is much
lower. For example, chlorine used to treat water supplies has also
been used as a CW agent; organophosphate pesticides can cause the
same effects as some nerve agents. Hostile forces, terrorists, or
others may use RDDs to produce casualties as well. For detailed
information on toxic industrial materials see FM 8-500.
CHAPTER 2
COMMAND AND CONTROL
2-1. General
The US forces may be attacked by or exposed to NBC, TIM, lasers,
advanced electronics, high explosives, fuel-air, thermobaric, and
conventional weapons; or a combination of these weapons/materiel.
Mass casualty situations will be the rule and not the exception.
Mass casualty situations can occur anyplace on the battlefield.
Combined NBC and conventional weapons injuries may predominate.
Command and control (C2) will be essential to prevent casualties
and to provide effective HSS. However, C2 (to include HSS
C2) elements may be primary targets. Effective HSS in an NBC
environment can be accomplished, but only if necessary preparations
to survive and to be mission capable are taken. Increased HSS C2
actions are needed to maintain HSS proximity to the supported
force; to clear the battlefield; to move and resupply the HSS
units, while managing multiple simultaneous mass casualty
incidents; and to rapidly evacuate patients. Health service
support C2 units must push HSS augmentation to mass casualty
sites, clear the site, evacuate the patients to Medical Treatment
Facilities (MTFs) that can provide essential care or out of the
AO; decontaminate and extract medical forces from NBC contaminated
areas and redistribute or redeploy the HSS forces. Within medical
units, C2 will be challenged by the use of protective clothing
and equipment, the need to move (either to the patients or out
of the contaminated area), and obtaining additional support.
Health service support advisers and staff officers must provide
guidance to commanders on continued duty for personnel who have
been exposed to NBC weapons/agents and TIM effects. Leaders
must greatly increase coordinating, preplanning, using tactical
standing operating procedures (TSOPs), and establishing multiple
C2 mechanisms. See Appendix C for guidelines on operational
planning for health service support in an NBC or TIM environment.
See Appendix D for medical planning guide on NBC casualties. See
Appendix E for a sample format of a "medical NBC staff officer
appendix to annex Q."
2-2. Health Service Support Command and Control Planning
Considerations
_a._ Battle situational understanding is of great importance on
the NBC battlefield. The number of casualties from each NBC attack
will overwhelm any single medical unit or MTF causing the medical
commander/leader to take action. To the extent possible, the
commander/leader should be prepared for the requirement instead of
reacting to it. To ensure responsive C2 the HSS plan must consider:
· Likely targets (C2 nodes, main supply routes (MSR), supply
nodes, troop concentrations, key terrain features, key forces,
or other high value targets).
· Patient estimates (conventional, NBC, and TIM).
· Availability of HSS resources (preestablished support plans).
· Availability of required nonmedical support (patient
decontamination teams).
· Ability to maintain operations if C2 is lost at any HSS level.
· Ability to maintain C2 operations when normal communication
systems have been disabled due to EMP effects or other system
failures.
· Ability to maintain C2 operations while the unit is operating
in mission-oriented protective posture (MOPP) Level 4 (reduced
audio and visual acuity).
· The requirements for immunizations, pretreatments, barrier
creams, prophylaxis, insect repellents, and other medical
countermeasures to protect the forces.
· The resource requirements for treatment, MEDEVAC, and
hospitalization (including care for enemy prisoners of war
[EPW]).
_b._ Clearing the battlefield will require preplanning and close
coordination at all levels. Early resuscitation, stabilization, and
prompt medical evacuation (MEDEVAC) are mandatory for survival of
the sick and wounded.
_c._ For conventional operations C2 see FM 8-10. Field Manual 8-55
provides HSS planning for conventional operations.
_d._ Provisions for emergency medical care of civilians, consistent
with the military situation. All non-DOD civilian care must
be approved by the AO Commander in Chief/senior official and
coordinated with the civil affairs unit and/or country team. For
eligibility of care determinations guidance, see FM 8-10.
_e._ For additional information on planning operations in an NBC
environment see FMs 8-10, 4-02.10, 4-02.4, 4-02.6, 4-02.283,
8-9, 8-10-6, 8-10-26, 8-284, and 8-285. Higher headquarters must
distribute timely plans and directives to subordinate units to
ensure that the subordinate unit's HSS plan supports their plan.
2-3. Health Service Support Command and Control Appraisal of the
Support Minion
The HSS personnel make an appraisal of the supported mission
to determine the expected patient load. Once the appraisal has
been accomplished, HSS personnel prepare for the HSS mission by
assigning personnel responsibilities. Using triage and EMT decision
matrices for managing patients in a contaminated environment
improves treatment proficiency. See Figure 2-1 for a sample
decision matrix. Training HSS personnel in the use of simple
decision matrices should enhance their effectiveness and contribute
to a more efficient battlefield HSS process. Prior training
for designated nonmedical personnel in patient decontamination
procedures will enhance their effectiveness in the overall patient
care mission. See Appendix D for planning factors on the estimation
of NBC casualties.
2-4. Health Service Support Units
Health service support units must plan, train, and routinely
practice mass casualty management. The NBC attack or TIM event will
likely be in conjunction with enemy conventional operations. But,
the TIM event may be caused by terrorist or belligerent action.
There will likely be increased conventional casualties in addition
to the NBC/TIM related casualties. The supply and transportation
units will be using the MSR in support of the combat commander's
requirements; thus, impacting on patient MEDEVAC and HSS unit
resupply. Communications will be disrupted. Therefore, HSS C2 must
plan and prepare for conducting operations with limited or no
communications with other HSS organizations.
+------------------------------------+
| GATHER DATA |
| NERVE AGENT SYMPTOMS |
| (VISUAL/TACTILE--VERBAL/NONVERBAL) |
+----------------+-------------------+
|
+--------+--------+
| CHECK MOPP GEAR |
+--------+--------+
|
+--------------+--------------+
| |
+-------+------+ +-------+------+
| NOT INTACT | | INTACT |
+-------+------+ +-------+------+
| |
+-------+------+ +-------+------+
| ADMINISTER | | ADMINISTER |
| ANTIDOTE | | ANTIDOTE |
+-------+------+ +-------+------+
| |
+-------+------+ +------+-----+
| SECURE | | |
| MOPP GEAR | +-----+----+ +-----+----+
+-------+------+ |INDIVIDUAL| |INDIVIDUAL|
| | CAN | | CANNOT |
+------+-----+ | FUNCTION | | FUNCTION |
| | +-----+----+ +-----+----+
| | | |
+----+-----+ +----+-----+ +----+---+ +-----+------+
|INDIVIDUAL| |INDIVIDUAL| | RTD | | CHECK FOR |
| CAN | | CANNOT | +--------+ | OTHER |
| FUNCTION | | FUNCTION |---------------->| INJURIES |
+-----+----+ +----------+ +-----+------+
| |
+-----+----+ +-------+-------+
| RTD | | |
+----------+ +------+------+ +-----+------+
| NO INJURIES | | INJURIES |
+------+------+ +------+-----+
| |
+------+------+ +------+-----+
| EVAC | | PROVIDE |
+-------------+ | EMT |
+------+-----+
|
+------+-----+
| EVAC |
+------------+
_Figure 2-1. Sample triage and emergency medical treatment decision
matrix._
2-5. Movement/Management of Contaminated Facilities
Operations in a contaminated area require the HSS commander/leader
to operate with contaminated or potentially contaminated assets.
The following provides guidance in determining how to operate with
contaminated facilities:
_a. Fulfill Health Service Support Principles._ In making his
decision to move or continue to operate with contaminated
facilities, the commander/leader must apply the principles of
conformity, proximity, flexibility, mobility, continuity, and
control. The unit's operation must conform to the tactical
commander's operation plan (OPLAN). Health service support must
be provided to the tactical unit as far forward as possible; this
ensures prompt, timely care. Additionally, the HSS commander/leader
must be flexible; his support must be tailored to meet the
supported commander's OPLAN requirements. Therefore, HSS assets
must be as mobile as the unit they support. Finally, the HSS
commander/leader must control his assets. Dispersion on the
integrated battlefield may enhance unit survivability; but the HSS
commander/leader may not be able to maintain control of his assets,
they may become compromised.
_b. Decision to Move._ The HSS commander/leader (when deciding
to move his unit to an uncontaminated area or in support of the
tactical commander's plan) must base his decision to move on
several factors.
(1) _Protection available._ What type of protection is available
in the new area? Will he need to establish the units' collective
protection shelter (CPS) systems, or are indigenous shelters
available (for example, buildings, tunnels, caves)? Does the unit
have sufficient individual protective equipment for unit personnel?
(2) _Persistency._ If his unit has been in a contaminated area,
is the contamination persistent or nonpersistent? Is the area he
will move to contaminated or clean? Persistency determines the
MOPP level; the degree of threat; and performance decrement caused
by the protective measures used. The level of contamination will
determine whether employment of CPS is viable. The MTF may be able
to continue to operate at the location by employing CPS. Personnel
and patient decontamination must be accomplished before processing
into the CPS.
(3) _Patients._ Before moving the entire facility, the HSS
commander/leader must consider the number and types of patients
at the MTF; his ability to redirect en route patients to the new
MTF location; and his ability to evacuate the patients currently
on hand. All patients should be stabilized before movement; but,
MEDEVAC must be continued.
(4) _Alternate facilities._ Alternate facilities may be used
(if the facility can be configured to ensure continuity of care
or provide a protected area for patients) until the relocating
activity is up and operating. This is a viable consideration when
CPS is not available or the current location is contaminated with a
persistent agent. Patient decontamination cannot be performed in an
area heavily contaminated with a persistent agent.
(5) _Medical evacuation._ Consideration must always be given to the
patient. Routes of MEDEVAC must be disseminated to supported and
supporting units. The ability to evacuate patients during the move
must continue. All MEDEVAC considerations must be addressed before
any move.
(6) _Mobility._ An MTF that is not 100 percent mobile requires
movement support. Thus, the commander/leader must coordinate
movement support requirements with higher headquarters.
(7) _Mission._ The primary consideration is the support mission of
the MTF. The tactical commander requires continuous HSS for his
personnel; when a move jeopardizes the quality of care, the move
may be delayed.
(8) _Sustainability._ Hand-in-hand with the mission is
sustainability (the ability of the unit to continue its support
mission). If the current location of the MTF hinders the unit's
ability to sustain its support mission, then the MTFs support to
the unit is in question. Similarly, if moving the MTF will result
in a disruption of support, then the move may not be viable.
(9) _Decontamination._ When a nonpersistent agent hazard exists and
a CPS is not available, patients may be directed to another MTF
until the hazard is gone; or the MTF can move to a contamination
free area. Certain facilities may be decontaminated, patient
protection procedures applied, and the operation continued.
However, an MTF contaminated with a persistent agent requires
time-consuming and resource-intensive decontamination operations;
it may include replacement of contaminated shelters.
_c. Management of Contaminated and "Clean" Facilities._ Facilities
contaminated with a persistent agent may be too resource intensive
to decontaminate. Operating with a combination of contaminated
assets and "clean" assets may be necessary. Mark contaminated
assets with standard warning tags. Use these assets in contaminated
environments and along contaminated routes. Keep clean assets in
operation in clean areas. Of primary importance is proper marking
and the avoidance of cross contamination.
_d. Medical Supplies and Equipment for Patient Treatment._ Are
sufficient medical supplies and equipment available to perform the
anticipated mission? Does the unit have special medical equipment
sets available (chemical agent patient decontamination and chemical
agent patient treatment medical equipment sets)?
2-6. Leadership on the Contaminated Battlefield
_a._ Operating on a contaminated battlefield will stress
leadership. Heat stress from being in higher levels of MOPP for
long periods of time may lead to dehydration. The commander/leader
must ensure that his personnel rest, drink, and eat sufficiently
to allow them to continue with the mission. In the midst of
activity, rest, hydration, and nutrition are often overlooked;
however, a good leader will ensure that his personnel needs
are met. See FM 21-10 for work/rest cycles and water drinking
requirements. Individuals may suffer hyperventilation because
of the enclosed feelings. Personnel remaining in MOPP Level 4
around the clock may suffer from increased sleep loss. Use of CPS
can reduce this problem by allowing the personnel to rest out of
their MOPP gear. Leaders must share leadership responsibilities
and delegate responsibilities as much as possible so that each
one gets sufficient rest to maintain unit effectiveness. Further,
leaders should concentrate on supervision or unit mission, rather
than on generation of new procedures during and after an attack.
The NBC battlefield will, therefore, require more proactive and
dedicated leaders who can balance the needs of their personnel and
the mission. Further, leaders will be challenged by an additional
logistics burden of providing nontraditional respiratory protection
for personnel against TIMs. For detailed information on combat
operational stress control (COSC) see FM 8-51 and FM 22-51.
+---------------------------------------------------+
| DANGER |
| |
| The standard NBC protective mask will not protect |
| personnel from most TICs. |
+---------------------------------------------------+
_b._ Leadership must plan for and establish procedures to maintain
personnel performance during NBC operations. Personnel performance
while wearing MOPP is degrading. At MOPP Level 3 or 4, all but
the most basic patient care procedures may have to be suspended
because--
· Wearing gloves reduces the ability to grasp and manipulate
small items (fine motor skill).
· MOPP impedes the ability to move about (gross motor skills).
· The mask reduces visual fields and acuity (visual skills).
· The mask and hood greatly reduces vocalization and hearing
abilities (auditory skills).
· The MOPP creates significant heat and mental stress
(stamina). Heat injuries can occur in a very short period of
time.
2-7. Homeland Security
Commanders and leaders must plan for and be prepared to support
homeland security efforts; especially, for response to chemical,
biological, radiological, nuclear, and high-yield explosive (CBRNE)
events. Depending upon the location of the event, the response
may be to a military installation in support of the weapons of
mass destruction--installation support team (WMD-IST) or to an
event site off a military installation. Response to a CBRNE event
off a military installation will normally require a request
for Department of Defense support to the event from the first
responders to the event (usually from the incident commander or
lead federal agency [Federal Bureau of Investigation or Federal
Emergency Management Agency]). See Appendix C for planning
considerations.
CHAPTER 3
LEVELS I AND II HEALTH SERVICE SUPPORT
3-1. General
_a._ The use of NBC weapons is a condition of battle and HSS
personnel must prepare to operate in these environments. Added
is the dimension of TIM releases/incidents in the operational
area. The importance of preventive medicine (PVNTMED) measures
and first aid (self-aid, buddy aid, and combat lifesaver [CLS]
support) are even more critical. Heat and stress injuries related
to MOPP wear are issues for the HSS leadership as well as the force
he is supporting. The stress load on personnel is increased by
the concerns of being exposed to TIM releases. Considering that
staffing of HSS units is based upon the minimum required to provide
support on a conventional battlefield, they will be challenged to
provide the same level of HSS in these environments.
_b._ The HSS leadership must quantify the HSS capability to
their commanders. The medical staff must review OPLANS and make
recommendations to reduce the number of patients. Medical NBC
training programs must stress the essential imperative of immediate
decontamination, the need to monitor your buddy for NBC and heat
or combat/operational stress injury effects, and the proper use of
NBC defense prophylaxis, pretreatments, insect repellents, barrier
creams, and immunizations.
_c._ Maintaining close proximity to the supported force has been
a major tenet of HSS doctrine and a critical factor in reducing
the mortality rate. Maintaining this proximity and finding a
place clean enough to provide necessary care requires intense
coordination with the supported force. Alternate casualty
collection points, decontamination sites, medical treatment
sites, and MEDEVAC routes must be established, coordinated and
communicated to the lowest level practical. Communication will be
much more difficult, but must be maintained. Timely reports through
the HSS technical channels will allow an optimal HSS response.
Replacements for HSS front line losses must be rapidly filled after
NBC weapons are employed.
_d._ Contamination (NBC and TIMs) can significantly hinder
HSS operations. To maximize the unit's survivability and HSS
capabilities and to avoid such contamination, leaders must use--
· Contamination avoidance techniques.
· Alarms and detection equipment.
· Unit dispersion techniques.
· Overhead shelter, shielding material, protective cover, and
buildings of opportunity. However, these shelters may not
provide protection from chemical vapor or BW hazards.
· Collective protection shelters, if available. See Appendix F.
· Chemical agent resistant coatings on equipment.
_e._ On the NBC battlefield, as on the conventional battlefield,
HSS is focused on keeping soldiers in the battle. Effective and
efficient PVNTMED measures, triage, emergency medical treatment
(EMT), decontamination, advanced trauma management (ATM), and
contamination control in the AO saves lives, assures judicious
MEDEVAC, and maximizes the return to duty (RTD) rate.
3-2. Level I Health Service Support
_a._ Level I (unit-level) HSS may consist of a combat medic
section, a MEDEVAC section, and a treatment squad. The treatment
squad operates the Level I MTF (battalion aid station [BAS]). Level
I HSS is supported by first aid in the form of self-aid/buddy aid
and the CLS. See FM 4-02.4 for detailed information on conventional
Level I HSS.
_b._ When operating under an NBC threat or when NBC attack is
imminent, the BAS must prepare for continuation of its mission.
Should an attack occur or a downwind hazard exist, the BAS must
seek out a contamination free area to establish a clean treatment
area, or must establish collective protection to continue the
mission. Some BASs have Chemically Biologically Protected
Shelter (CBPS) Systems. When available, these systems serve as
the primary shelter for the BAS; they are operated in the full
chemical/biological (CB) mode when attack is imminent or has
occurred. See Appendix F for information on establishing a BAS
in a CBPS system. When operating in the CB mode only patients
requiring life- or limb-saving procedures are allowed entry at
the BAS. Patients that have minor injuries that can be managed
in the contaminated EMT area of the patient decontamination site
will receive treatment in this area. After treatment, these
patients will have the integrity of their MOPP restored by taping
the damaged area and returned to duty. Patients with injuries
that require further treatment, but who can survive evacuation
to the Level II MTF will have their MOPP spot decontaminated,
their injuries managed, the integrity of their MOPP restored,
and be directed to an evacuation point to await transport to the
Level II MTF (example, an individual with a splinted broken arm).
When patients or personnel are contaminated or are potentially
contaminated, they must be decontaminated before admission into
the clean treatment area (see FM 3-5 for personnel decontamination
procedures and Appendix G for patient decontamination procedures).
3-3. Level II Health Service Support
_a._ In the brigade, Level II HSS consists of--
· Evacuating patients from the BAS and MEDEVAC on an area
support basis from within the brigade support area (BSA).
· Providing area support Level I medical treatment.
· Operating the medical company clearing station (hereafter
referred to as the division clearing station [DCS]), which
provides a patient holding capability for up to 40 patients for
72 hours. See FM 4-02.6 and FM 8-10-24 for detailed information
on Level II conventional operations.
· Providing limited dental service.
· Providing limited PVNTMED support in the areas of medical
surveillance, occupational and environmental health
surveillance, food service sanitation, water quality control
(including NBC contamination surveillance), and communicable
disease control.
· Providing limited COSC; these patients are returned to duty
as far forward as their condition permits.
_b._ In the division, HSS is the same as for the brigade, except
patients may be evacuated from the BSA DCS, but not evacuated from
the BAS.
_c._ When operating under an NBC threat or when NBC attack is
imminent, the DCS must prepare for continuation of its mission.
Should an attack occur or a downwind hazard exist the DCS must
seek out a contamination free area, or must establish collective
protection to continue the mission. The DCS in some medical
companies have four CBPS Systems; they are complexed to provide
space for DCS operations. These systems are operated in the
CB mode when attack is imminent or has occurred. See Appendix
F for information on establishing a DCS in CBPS Systems. When
operating in the CB mode only patients requiring life- or
limb-saving procedures are allowed entry. Patients with minor
injuries that can be managed in the contaminated EMT area of the
patient decontamination site will receive treatment in this area.
After treatment, these patients will have the integrity of their
MOPP restored by taping the damaged area and returned to duty.
Patients with injuries that require further treatment, but who
can survive evacuation to the Level III MTF will have their MOPP
spot decontaminated, their injuries managed, and be directed to an
evacuation point to await transport to the Level III MTF (example,
an individual with a splinted broken arm). When personnel and
patients are contaminated or are potentially contaminated, they
must be decontaminated before admission into the clean treatment
area (see FM 3-5 for personnel decontamination procedures and
Appendix G for patient decontamination procedures).
3-4. Forward Surgical Team
Forward surgical teams (FST) are either organic to divisional and
nondivisional medical units or are forward deployed in support of
divisional or nondivisional medical companies to provide a surgical
capability. Field Manual 8-10-25 describes FST operations. However,
when forward deployed and NBC contamination is imminent the FST
must employ collective protection in order to continue their
support mission. When operating in a contaminated area the FST
CBPS Systems must be complexed with the DCS CBPS. The FST cannot
operate in an NBC environment without the support of the DCS. They
do not have the capability to decontaminate patients. All patients
are decontaminated in the DCS patient decontamination area. They
are then processed into the EMT section of the DCS; where they
are triaged and routed to the FST for surgery, if required. See
Appendix F for FST employment of collective protection procedures.
3-5. Actions Before a Nuclear, Biological, or Chemical Attack
_a._ Given the disruption of transportation, communications, and
operations during and following an NBC attack, it should be clear
that preparation is the key to survival and effectively providing
HSS. Preparing a simple and complete TSOP and HSS plan that really
integrates NBC is the first step. Critical training for medical
personnel before an NBC attack is how to--
· Survive the attack individually and as a unit.
· Operate the Level I or Level II MTF in the environment.
· Effectively care for NBC patients.
_b._ Even minimal site preparation (nuclear hardening or CB
protecting) may improve survival, greatly reduce contamination,
and maintain the ability to continue to provide HSS. See the
discussion below for more information on each environment. As
with other military personnel, HSS personnel must keep their
immunizations current; use available prophylaxis against suspect CB
agents; use pretreatments for suspect chemical agents; use insect
repellents, and have antidotes and essential medical supplies
readily available for known or suspected NBC effects. The best
defense for HSS personnel is to protect themselves, their patients,
medical supplies, and equipment by applying contamination avoidance
procedures. They must ensure that stored medical supplies and
equipment are in protected areas or in their storage containers
with covers in place. One method of having supplies and equipment
protected is to keep them in their shipping containers until
actually needed. When time permits and warnings are received that
an NBC attack is imminent, or that a downwind hazard exists,
HSS personnel should employ their CPS (see Appendix F) or seek
protected areas (buildings, tents, or other ABOVE ground shelters
for biological or chemical attack; culverts, ravines, basements, or
other shielded areas for nuclear) for themselves and their patients.
_c._ Other tasks include:
· Verifying NBC defense HSS inventories are complete.
· Reviewing supported units NBC plans, procedures, casualty
collection points, decontamination sites, and resources
available to support the HSS mission.
· Coordinating with the S2/G2, S3/G3 and S4/G4 of the supported
unit to develop the medical courses of action; to obtain
necessary materiel to support extended operations without
resupply (MSR contamination or transportation support not
available).
· Coordinating with supported units for at least eight
nonmedical personnel for patient decontamination augmentation
at the Level I and II MTFs.
3-6. Actions During a Nuclear, Biological, or Chemical Attack
While it is possible that the NBC attack will be discrete short
events, the more likely scenario is the enemy will use NBC
throughout the conflict. The warning and reporting system will
provide as much notice as is possible. Using the information
provided, HSS personnel will continue their mission by using the
best available protected areas. If warned of a nuclear attack, they
take up positions within the best available shelter; movement out
of these positions will be directed by leadership when it is safe
to do so.
3-7. Actions After a Nuclear, Biological, or Chemical Attack
All personnel must survey their equipment to determine the
extent of damage and their capabilities to continue the mission.
Initially, patients from nuclear detonations will be suffering
thermal burns or blast injuries. Also, expect patients and HSS
personnel to be disoriented. Nuclear blast and thermal injuries
will immediately manifest, most radiation-induced injuries
will not be observed for several hours to days. Chemical agent
patients will manifest their injuries immediately upon exposure
to the agent, except for blister agents. Biological agent
patients may not show any signs of illness for hours to days
after exposure, except for trichothecene (T_{2}) mycotoxins. All
patients arriving at Levels I and II MTFs must be checked for NBC
contamination. Patients are decontaminated before treatment (see
Appendix G) to reduce the hazard to HSS personnel, unless life- or
limb-threatening conditions exist. Patients requiring treatment
before decontamination are treated in the EMT area of the patient
decontamination station. Examples of patient conditions that may
require treatment at the contaminated treatment station of the
patient decontamination area--
· Massive hemorrhage.
· Respiratory distress.
· Severe shock.
3-8. Logistical Considerations
_a._ Health service logistics (HSL) personnel must train and
prepare to operate in all battlefield situations. Operating in an
NBC environment requires the issue of chemical patient treatment
medical equipment set and chemical patient decontamination medical
equipment set. Expect disruption of MSR and communications systems
and plan accordingly. See FM 4-02.1 and FM 8-10-9 for details on
HSL operations.
_b._ The medical platoon (Level I) is authorized two chemical
agent patient treatment medical equipment sets and one chemical
agent patient decontamination medical equipment set. Each chemical
agent patient treatment medical equipment set has enough supplies
to treat 30 patients. Each chemical agent patient decontamination
medical equipment set has enough consumable supplies to
decontaminate 60 patients.
NOTE
The chlorine granules in the chemical agent patient
decontamination set are used to prepare the hypochlorite
solutions for use to decontaminate patients.
_c._ The brigade, divisional, and nondivisional medical companies
are authorized five chemical agent patient treatment medical
equipment sets and three chemical agent patient decontamination
medical equipment sets. These medical equipment sets are for use at
the DCS patient decontamination station.
3-9. Personnel Considerations
During NBC actions, HSS personnel requirements increase; thus,
HSS reinforcement or replacements are necessary. Plans for HSS
in a NBC battlefield must include efforts to conserve available
HSS personnel and ensure their best use. HSS personnel will be
fully active in providing EMT or ATM care; they will provide
more definitive treatment as time and resources permit. However,
to provide care they must be able to work in a shirt-sleeved
environment, not in MOPP Levels 3 or 4. Nonmedical personnel
conduct search and rescue operations for the injured or wounded;
they provide immediate first aid and decontamination. See FM 3-5,
for detailed information on personnel and equipment decontamination
operations. See FMs 4-02.283, 8-284, and 8-285 for detailed
information on treatment of NBC patients.
3-10. Disposition and Employment of Treatment Elements
_a._ Select sites for the BAS and DCS that are located away from
likely enemy target areas. Cover and concealment is extremely
important; they increase protection for operating the MTF.
_b._ Operating a CBPS System in the CB mode at the BAS requires
at least eight medical personnel. The senior NCO performs patient
triage and limited EMT and minor injury care in the patient
decontamination area. One trauma specialist supervises patient
decontamination and manages patients during the decontamination
process. Two trauma specialists work on the clean side of the hot
line and manage the patients until they are placed in the clean
treatment area or are sent into the CBPS for treatment. They also
manage the patients that are awaiting MEDEVAC to the DCS. The
physician, physician assistant, and two trauma specialists provide
ATM in the clean treatment area or inside the CBPS. See Appendix F
for CPS entry/exit procedures.
_c._ When the BAS or DCS are receiving NBC contaminated patients,
they require at least eight nonmedical personnel from supported
units to perform patient decontamination procedures. These
facilities are only staffed to provide patient care under
conventional operational conditions. Without the augmentation
support, they can either provide patient decontamination or patient
care, but not both.
_d._ A patient decontamination station is established to handle
contaminated patients (see Appendix G). The station is separated
from the clean treatment area by a "hot line" and is located
downwind of the clean treatment area or CPS. Personnel on
both sides of the "hot line" assume a MOPP level commensurate
with the threat agent employed (normally MOPP Level 4). The
patient decontamination station should be established in a
contamination-free area of the battlefield. However, it may be
necessary to establish a patient decontamination station that is
collocated with an MTF that is employing a CBPS, in a chemical
vapor hazard area in order to decontaminate patients and clear the
battlefield before moving the MTF to a clean area. When CPS systems
are not available, the clean treatment area is located upwind 30
to 50 meters of the contaminated work area. When personnel in the
clean working area are away from the hot line, they may reduce
their MOPP level. Chemical monitoring equipment must be used on the
clean side of the hot line to detect vapor hazards due to slight
shifts in wind currents; if vapors invade the clean work area, HSS
personnel must re-mask to prevent low-level CW agent exposure and
minimize clinical effects (such as miosis).
3-11. Civilian Casualties
Civilian casualties may become a problem in populated or built-up
areas, as they are unlikely to have protective equipment and
training. The BAS and DCS may be required to provide assistance
when civilian medical resources cannot handle the workload.
However, aid to civilians will not be undertaken without command
approval, or at the expense of health services provided to US
personnel.
3-12. Nuclear Environment
_a._ The HSS mission must continue in a nuclear environment;
protected shelters are essential to continue the support role.
Well-constructed shelters with overhead cover and expedient
shelters (reinforced concrete structures, basements, railroad
tunnels, or trenches) provide good protection from nuclear attacks
(see Appendix H). Armored vehicles provide some protection against
both the blast and radiation effects of nuclear weapons. Patients
generated in a nuclear attack will likely suffer multiple injuries
(combination of blast, thermal, and radiation injuries) that will
complicate medical care. Nuclear radiation patients fall into three
categories:
· The _irradiated_ patient is one who has been exposed to
ionizing radiation, but is not contaminated. They are not
radioactive and pose no radiation threat to medical care
providers. Patients who have suffered exposure to initial
nuclear radiation will fit into this category.
· The _externally contaminated_ patient has radioactive dust
and debris on his clothing, skin, or hair. This radioactive
debris can cause burns if not removed quickly. This usually
presents a "housekeeping" problem to the MTF, similar to the
lice-infested patient arriving at a peacetime MTF. However,
an accumulation of radioactive debris, from several patients
admitted to the MTF, may present a threat to other personnel.
The externally contaminated patient is decontaminated at the
earliest time consistent with required medical care. Lifesaving
care is always rendered, when necessary, before decontamination.
· The _internally contaminated_ patient is one that has
ingested or inhaled radioactive material, or radioactive
material has entered the body through an open wound. The
radioactive material continues to irradiate the patient
internally until radioactive decay and/or biological
elimination removes the radioactive isotope. Attending medical
personnel are shielded, to some degree, by the patient's
body. Inhalation, ingestion, or injection of quantities of
radioactive material sufficient to present a threat to health
care providers is highly unlikely.
_b._ Medical units operating in a radiation fallout environment
will face three problems:
· The MTF may be immersed in fallout, requiring decontamination
and relocation efforts.
· Patients may continue to be produced from continued radiation
exposure.
· The contaminated environment hinders MEDEVAC.
_c._ Decontamination of most radiological contaminated patients and
equipment can be accomplished with soap and water. Soap and water
will not neutralize radioactive material. However, it will remove
the material from the skin, hair or material surface. See Appendix
G for specific patient decontamination procedures. The waste can
become a concentrated point of radiation and must be managed and
monitored.
_d._ Commanders and leaders must consider the radiation exposure
levels for themselves, their staffs, and patients when operating
in or determining if the unit will enter a radiologically
contaminated area. The commander and leader must establish
an operational exposure guide for their unit and personnel.
The operational exposure guide (OEG) is established for either
battlefield exposures as shown in Table 3-1 or for exposures in
stability operations and support operations as shown in Table 3-2.
The tables present radiation exposure status (RES) categories;
however, they can be used to establish OEGs based on the same
exposure criteria.
_Table 3-1. Radiation Exposure Status Categories for Tactical
Operations_
===============================================================
=RES-O= THE UNIT HAS HAD NO RADIATION EXPOSURE.
=RES-1= THE UNIT HAS BEEN EXPOSED TO GREATER THAN 0 cGy BUT
LESS THAN OR EQUAL TO 75 cGy.
=RES-2= THE UNIT HAS BEEN EXPOSED TO GREATER THAN 75 cGy BUT
LESS THAN OR EQUAL TO 125 cGy.
=RES-3= THE UNIT HAS BEEN EXPOSED TO GREATER THAN 125 cGy.
===============================================================
_Table 3-2. Radiation Exposure Status Categories During Stability
Operations and Support Operations_
=================================
=RES-O= <0.05 cGy
=RES-1A= 0.05 TO 0.5 cGy
=RES-1B= 0.5 TO 5 cGy
=RES-1C= 5 TO 10 cGy
=RES-1D= 10 TO 25 cGy
=RES-1E= 25 TO 75 cGy
=================================
3-13. Medical Triage
Medical triage is the classification of patients according to the
type and seriousness of illness or injury; this achieves the most
orderly, timely, and efficient use of HSS resources. However, the
triage process and classification of nuclear patients differs from
conventional injuries. See FM 4-02.283 for nuclear patient triage
and treatment procedures.
3-14. Biological Environment
_a._ A biological attack (such as the enemy use of bomblets,
rockets, spray or aerosol dispersal, release of arthropod vectors,
and terrorist or insurgent contamination of food and water) may be
difficult to recognize. Frequently, it does not have an immediate
effect on exposed personnel. All HSS personnel must monitor for BW
indicators such as--
· Increases in disease incidence or fatality rates.
· Sudden presentation of an exotic disease.
· Other sequential epidemiological events.
_b._ Passive defensive measures (such as immunizations, good
personal hygiene, physical conditioning, using arthropod
repellents, wearing protective mask, and practicing good
sanitation) will mitigate the effects of many biological agent
intrusions.
_c._ The HSS commanders and leaders must enforce contamination
control to prevent illness or injury to HSS personnel and to
preserve the facility. Incoming vehicles, personnel, and patients
must be surveyed for contamination. Ventilation systems in MTFs
(without CPS) must be turned off if BW exposure is imminent.
_d._ Decontamination of most BW contaminated patients and equipment
can be accomplished with soap and water. Soap and water will not
kill all biological agents; however, it will remove the agent from
the skin or equipment surface. See Appendix G for specific patient
decontamination procedures.
_e._ Treatment of BW agent patients may require observing and
evaluating the individual to determine necessary medications,
isolation, or management. See FM 8-284 for specific treatment
procedures for BW agent patients.
_f._ Medical surveillance is essential. Most BW agent patients
initially present common symptoms such as low-grade fever, chills,
headache, malaise, and coughs. More patients than normal may be
the first indication of biological attack. Daily medical treatment
summaries, especially DNBI, need to be prepared and analyzed.
Trends of increased numbers of patients presenting with unusual or
the same symptoms are valuable indicators of enemy employment of
BW agents. Daily analysis of medical summaries can provide early
warnings of BW agent use, thus enabling commanders to initiate
preventive measures earlier and reduce the total numbers of troops
lost due to the illness. See FM 4-02.17 for information of medical
surveillance procedures. See FM 8-284 for preventive, protective,
and treatment procedures.
3-15. Chemical Environment
_a._ Consider that all patients generated in a CW agent environment
are contaminated. The vapor hazards associated with contaminated
patients may require HSS personnel to remain at MOPP Level 4 for
long periods. The MTF must be set up in clean areas or employ
CPS. If there is liquid agent contamination, or a continued vapor
hazard, the MTF should be moved and be decontaminated, mission
permitting.
_b._ Initial triage, EMT, and decontamination are accomplished on
the "dirty" side of the hot line. Life-sustaining care is rendered,
as required, without regard to contamination. Normally, the senior
health care sergeant performs initial triage and EMT at the BAS.
Secondary triage, ATM, and patient disposition are accomplished on
the clean side of the hot line. When treatment must be provided
in a contaminated environment outside the CPS, the level of care
may be greatly reduced because medical personnel and patients
are in MOPP Level 3 or 4. However, lifesaving procedures must be
accomplished. See FM 8-285 for specific treatment of CW agent
patients.
_c._ Decontamination of most chemically contaminated patients
and equipment requires the use of materials that will remove and
neutralize the agent. See FM 3-5 for equipment decontamination
procedures and Appendix G for specific patient decontamination
procedures.
3-16. Operations in Extreme Environments
Enemy employment of NBC weapons or TIMs in the extremes of climate
or terrain warrants additional consideration. Included are the
peculiarities of urban terrain, mountains, snow and extreme cold,
jungle, and desert operations in an NBC environment with the
resultant NBC-related effects upon medical treatment and MEDEVAC.
For a more detailed discussion on NBC aspects of urban terrain,
mountain, snow and extreme cold, jungle, and desert operations, see
FMs 3-06.11, 31-71, 90-3, 90-5, and 90-10.
_a._ In mountain operations, passes and gorges may tend to channel
the nuclear blast and the movement of chemical and biological
agents. Ridges and steep slopes may offer some shielding from
thermal radiation effects. Close terrain may limit concentrations
of troops and fewer targets may exist; therefore, a lower patient
load may be anticipated. However, the terrain will complicate
patient evacuation and may require patients to be decontaminated,
treated, and held for longer periods than would be required for
other operational areas.
_b._ The effects of extreme cold weather combined with NBC-produced
injuries have not been extensively studied. However, with traumatic
injuries, cold hastens the progress of shock, providing a less
favorable prognosis. Thermal effects will tend to be reinforced by
reflection of thermal radiation from snow and ice-covered areas.
Care must be exercised when moving chemically contaminated patients
into a warm shelter. A CW agent on the patient's clothing may
not be apparent. As the clothing warms to room temperature, the
CW agent will vaporize (off-gas), contaminating the shelter and
exposing occupants to potentially hazardous levels of the agent. A
three-tent system is suggested for processing patients in extreme
cold operations. The first tent (unheated) is used to strip off
potentially contaminated clothing. The second (heated) is used to
perform decontamination, perform EMT and detect off gassing. The
third (heated) is used to provide the follow on care and patient
holding.
_c._ In rain forests and other jungle environments, the overhead
canopy will, to some extent, shield personnel from thermal
radiation. However, the canopy may ignite and create forest fires
and result in burn injuries. By reducing sunlight, the canopy may
increase the persistency effect of CW agents near ground level.
The canopy also provides a favorable environment for BW agent
dispersion and survival.
_d._ In desert operations, troops may be widely dispersed,
presenting less profitable targets. However, the lack of cover and
concealment exposes troops to increased hazards. Smooth sand is a
good reflector of nuclear thermal and blast effects; generating
increased numbers of injuries. High temperatures will increase the
discomfort and debilitating effects on personnel wearing MOPP,
especially heat injuries.
3-17. Medical Evacuation in a Nuclear, Biological, and Chemical
Environment
_a._ An NBC environment forces the unit leadership to consider to
what extent he will commit MEDEVAC assets to the contaminated area.
If the battalion or task force is operating in a contaminated
area, most or all of the organic medical platoon MEDEVAC assets
will operate there. However, efforts should be made to keep
some ambulances free of contamination. For conventional MEDEVAC
operations see FM 8-10-6 and FM 8-10-26.
_b._ We have three basic modes of evacuating patients (personnel
[litter bearers], ground vehicles, and aircraft). Using litter
bearers to carry the patients involves a great deal of stress.
Cumbersome MOPP gear, added to climate, increased workload, and the
fatigue of battle, will greatly reduce personnel effectiveness.
If personnel must enter a radiologically contaminated area, an
OEG must be established (see Table 3-1). Radiation exposure
records are maintained by the NBC NCO and made available to the
commander, staff, and medical leader. The exposure is entered into
the individual's medical record. Based on the OEG, the commander
and leaders will decide which MEDEVAC assets will be sent into
the contaminated area. Again, every effort is made to limit the
number of MEDEVAC assets that are contaminated. Medical evacuation
considerations should include the following:
(1) A number of ambulances will become contaminated in the
course of battle. Optimize the use of resources; use those
already contaminated (medical or nonmedical) before employing
uncontaminated resources.
(2) Once a vehicle or aircraft has entered a contaminated area, it
is highly unlikely that it can be spared long enough to undergo
thorough decontamination. However, operational decontamination
should be performed to the greatest extent possible. This will
depend upon the contaminant, the tempo of the battle, and the
resources available to the MEDEVAC unit. Normally, contaminated
vehicles (air and ground) will be confined to dirty environments.
See FM 3-5 for details on decontamination procedures.
(3) Use ground ambulances instead of air ambulances in contaminated
areas; they are more plentiful, are easier to decontaminate, and
are easier to replace. However, this does not preclude the use of
aircraft. If an air ambulance is deployed into a contaminated area,
use it for repeated MEDEVAC missions rather than sending other
clean aircraft into the area.
(4) The relative positions of the contaminated area, forward line
of own troops (FLOT), and threat air defense systems will determine
where helicopters may be used in the MEDEVAC process. One or more
helicopters may be restricted to contaminated areas; use ground
vehicles to cross the line separating clean and contaminated
areas. The ground ambulance proceeds to an MTF with a patient
decontamination station (PDS); the patient is decontaminated and
treated. If further MEDEVAC is required, a clean ground or air
ambulance is used. The routes used by ground vehicles to cross
between contaminated and clean areas are considered dirty routes
and should not be crossed by clean vehicles, if mission permits.
Consider the effects of wind and time upon the contaminants; some
agents will remain for extended periods of time.
(5) Keep the helicopter rotor wash in mind when evacuating
patients, especially in a contaminated environment. The intense
rotor wash will disturb the contaminants and further aggravate
the condition. The aircraft must be allowed to land and reduce to
flat pitch before patients are brought near. This will reduce the
effects of the rotor wash. Additionally, a helicopter must not land
too close to a decontamination station (especially upwind) because
any trace of contaminants in the rotor wash will compromise the
decontamination procedure.
_c._ Immediate decontamination of rotor wing aircraft and ground
vehicles is accomplished to minimize crew exposure. Units include
decontamination procedures in their standing operating procedures
(SOP). A sample aircraft decontamination station that may be
tailored to a unit's needs is provided in FM 3-5.
_d._ Evacuation of patients must continue, even in an NBC
environment. The HSS leader must recognize the constraints NBC
places on operations; then plan and train to overcome these
deficiencies.
_e._ To minimize the spread of contamination inside the MEDEVAC
aircraft, plastic sheeting should be placed under the litter to
catch any contaminant that drips off the patient or litter. The
plastic sheeting can be removed with the patient, removing any
contamination with it. When plastic sheeting is not available,
placing a blanket under the litter will reduce the amount of agent
that makes contact with the inside of the aircraft.
NOTE
The key to mission success is detailed preplanning. A HSS plan
must be prepared for each support mission. Ensure that the HSS
plan is in concert with the tactical plan. Use the plan as a
starting point and improve on it while providing HSS.
_f._ Medical evacuation by United States Air Force (USAF) aircraft
will be severely limited until runway repairs and decontamination
has occurred. Aerial flights from contaminated areas into
uncontaminated airspace and destinations may be impossible for
extended periods of time; some nations will not allow patients
from contaminated areas to travel through or over their country.
Therefore, patient holding on-site (or in theater) for an extended
period of time must be anticipated.
_g._ Patient protection during evacuation must be maintained.
Patients that have been decontaminated at the PDS at an MTF will
have had their MOPP ensemble removed. The forward deployed MTFs
will not have replacement MOPP ensembles for the patients. These
patients must be placed in a patient protective wrap (PPW) before
they are removed from the clean treatment area for evacuation (see
the PPW instruction sheet/PPW label for use of the PPW). The PPW
provides the same level of protection as the MOPP ensemble. The
patient does not have to wear a protective mask when inside the
PPW. The patient is placed inside the PPW that is on a litter. The
PPW may also have a battery-operated blower that can provide a
reduction of the body heat load and reduce the carbon dioxide level
within the PPW. The PPW will provide protection for the patient for
up to 6 hours and is a one-time use item. The blower is reusable,
remove it and the attachment devices from the used PPW and return
it to the patient movement items inventory. See FM 4-02.1 for a
discussion on patient movement items.
+----------------------------------------------------------+
| =WARNING= |
| |
| DO NOT place contaminated patients in the PPW. It is for |
| use with uncontaminated/decontaminated patients only. |
+----------------------------------------------------------+
CHAPTER 4
=LEVELS III AND IV HOSPITALIZATION=
4-1. General
_a._ Many factors must be considered when planning for Levels III
and IV hospital support on the integrated battlefield. The hospital
staff must be able to defend against threats by individuals or
small groups (two or three) of infiltrators and survive NBC
strikes or TIM incidents while continuing their mission. This
threat may include the introduction of NBC or TIM in the hospital
area, the water or food supplies; and the destruction of equipment
and/or supplies. On the larger scale of surviving NBC strikes and
continuing to support the mission, operating in a contaminated
environment will present many problems for hospital personnel. The
use of NBC weapons or TIM release can compromise both the quality
and quantity of health care delivered by medical personnel due to
the contamination at the MTF; constrain mobility and evacuation;
and contaminate the logistical supply base. While providing
hospital support, consider the following assumptions:
(1) Their location, close to other support assets, makes them
vulnerable to NBC strikes and release/dispersion of TIMs.
· Command, control, communications, computers, and intelligence
(C4I) infrastructure, logistical nodes, and base clusters are
high value targets.
· Most NBC weapons are designed for wide-area coverage.
Chemical and biological agents may present a hazard some
distance downwind from the area of attack; also, residual
radiation may extend for hundreds of kilometers (km) from
ground zero.
· The large signature (size, heat, infrared) of a hospital
makes it easy to find and target (the assumption is that the
hospital is very near the intended targets).
· Hospitals located near road networks and airfields for access
to evacuation routes increase their exposure to tactical
strikes of NBC weapons and exposure to TIM releases.
· There are ever-increasing numbers of countries and
individuals with the ability to manufacture and deliver NBC
weapons/agents. This activity increases their use potential at
all levels of conflict.
NOTE
When using existing civilian hospitals, the materials for an
RDD may be at these hospitals. Exploding the material in place
is very practical for a small team of terrorists.
(2) Large numbers of casualties are produced in a short period
of time. Many of these casualties may have injuries that are
unfamiliar to hospital personnel. These injuries may include--
· Radiation casualties.
· Biological casualties.
· Chemical casualties.
· Toxic industrial biological casualties (release of material
from biological research facilities).
· Toxic industrial chemical casualties.
· Toxic industrial radiological casualties.
· Chemical agent antidote overdose casualties.
· Combined conventional and NBC injuries.
· Stress casualties mimicking all the above.
(3) In addition to the wounding effects of NBC weapons on troops,
their use will have other effects upon the patient care delivery
system.
· Follow-on treatment may have to be delayed due to the need
for patient and faculty decontamination.
· The arrival of contaminated patients at the hospital will
require hospital personnel to perform triage; administer EMT
procedures in the patient decontamination area; supervise
augmentation personnel performing patient decontamination;
and constantly monitor the hospital for contamination. The
combat support hospital [CSH] requires at least 20 nonmedical
personnel from units within the geographic area/base cluster
of the hospital to perform patient decontamination under
medical supervision. See Appendix G for patient decontamination
procedures.
· Patients may have been triaged and decontaminated at a Level
I or Level II MTF. However, all patients must be triaged and
checked for contamination as they arrive at the hospital
ambulance drop off point. Triage ensures patients receive
life- or limb-saving care in a timely manner. If patients are
arriving from a suspected NBC contaminated area, they must
be decontaminated before admission into the clean treatment
area of the hospital. The patient decontamination area is
established on the downwind side of the hospital. When the
hospital does not have collective protection, the patient
decontamination point must be at least 50 yards downwind of
the hospital entry point. When the hospital is located inside
a base cluster, the patient decontamination area may have to
be established some distance from the hospital to prevent
contamination of other units in the area. Should this be the
case, the patients may have to be transported by ambulance or
other vehicle from the clean side (hot line) of the patient
decontamination area to the receiving point of the hospital.
· Conditions may mandate the use of nonmedical vehicles to
transport casualties to the MTF. The use of these vehicles
limits or prohibits en route medical care, but may be the only
way to clear the battlefield and ensure timely care of patients
at the hospital.
(4) Mission-oriented protective posture reduces the efficiency of
all personnel.
(5) Without CPS systems, hospitals may operate for a limited
time in a nonpersistent agent environment, but are incapable of
operating in a persistent agent environment.
· Chemical/biological filters for fixed site hospital
ventilation systems will be a critical item of supply.
Controlled entry and exit point with sufficient space to permit
placement of litter patients and/or numbers of personnel
that permit purge of vapors will have to be established. All
windows, doors, and other points that may have air leaks will
have to be sealed (use tape and plastic sheeting) to enable the
facility to have a positive overpressure to keep CB agents out.
· Liquid chemical agents can penetrate the TEMPER in about 6
hours or general purpose (GP) tentage in a shorter period of
time. These agents will penetrate the wrappings on medical
supplies and equipment; especially, sterilized equipment and
supplies, paper-wrapped cotton sponges, and open or lightly
closed medications/solutions. They can also contaminate
water/food supplies. Therefore, equipment and supplies must be
stored in protected areas or under protective coverings.
· Without a CPS system, treatment procedures involving open
wounds or the respiratory tract in the presence of a CB agent
hazard is limited. Exposing open wounds and the respiratory
tract to the agent increases the effects of these agents on the
patient.
· Without hardened protection, the hospital, staff, and
patients are susceptible to the effects (blast, thermal,
radiation, and missiling) of nuclear weapons.
· Hospital electrical and electronic medical equipment is
vulnerable to the effects of the EMP produced by nuclear
weapons. The EMP is not harmful to humans, animals, or plants,
but is very damaging to electronic equipment.
· Hospital equipment is very difficult to decontaminate. Aging
(allowing the agent to off-gas) may be the only means of
decontamination.
· Hospitals are not kept in reserve. All personnel and
equipment losses due to NBC contamination or radiation will
have to be replaced.
_b._ There are currently two force modernization initiative
hospital systems in the force structure. The Medical Force 2000
(MF2K) system consists of the CSH, the field hospital (FH), and the
general hospital (GH). The Medical Reengineering Initiative (MRI)
consists of only one hospital system--the CSH. The MF2K CSH is a
corps asset, whereas, the FH and GH are the echelon above corps
hospital systems. The MRI CSH will be located in the corps and at
echelons above corps. The MRI CSH will replace the FH and GH at
echelons above corps. See FM 4-02.10, FM 8-10-14, and FM 8-10-15
for detailed information on these hospital systems.
4-2. Protection
_a._ Protection of hospital assets requires intensive use of
intelligence information and careful planning. The limited
mobility of hospitals makes their site selection vital to minimize
collateral damage from attacks on other units.
· Hospitals must be located as close to the supported units as
possible to provide responsive care in support of the tactical
commander's plan. However, their limited mobility must be
considered when selecting their locations.
· Protective factors (distance from other support units and
interposed terrain features) must be balanced against the
operational factors (accessibility and time required for
patient transport).
· Depending on the weapon systems used, local topography, and
meteorological conditions, relatively large portions of the
tactical area may remain uncontaminated.
_b._ Many defensive measures will either impede or preclude
performance of the hospital mission. Successful hospital defense
against an NBC threat is dependent upon accurate, timely receipt of
information via the nuclear, biological, and chemical warning and
reporting system (NBCWRS). This information will allow the hospital
to operate longer without the limitations and problems associated
with the use of the CPS and personnel assuming MOPP Levels 3 and
4. The detailed information (provided in the NBC 5 and 6 reports
respectively) on the areas affected and the types of agents used
allows the hospital staff to--
· Project the number and types of patients to be expected.
· Establish a patient decontamination area.
· Request patient decontamination assistance.
(1) _Protective procedures._
(_a_) Because most hospital sections operate in sheltered areas
(tentage or hard-walled shelter), some protection is provided
against vapor, liquid, and particulate (fallout) hazards. Sealing
all openings can increase the temporary protection from such
hazards; all entries and exits must be curtailed while operating
in this mode. Liquid agents will eventually seep through the tent
fabric and create a vapor hazard inside the shelter. Locating
equipment, such as trucks, under trees or other cover provides
similar effects. Setting up hospitals in existing structures
(concrete or steel buildings) provides greater protection from
hazards and eliminates many decontamination problems. However,
without means to seal openings, chemical agent vapors can enter the
structure. The addition of CB filtration systems with air locks,
that provide overpressure, can provide maximum protection for
occupants. Entry and exit procedures must be established to prevent
contamination being introduced by personnel and patients entering.
See Appendix F for entry/exit procedures when CB filters and air
locks are in use.
(_b_) Concealment and good operations security (OPSEC) will help
prevent identification of a unit.
(_c_) Dispersion is a defensive measure employed by tactical
commanders; however, hospital operations limit the value of this
technique. One technique that may be used is locating sections of
the hospital, such as the motor pool, personnel billets, laundry,
and logistical storage, a greater distance from the hospital
complex than normal. This will increase dispersion without severely
compromising the hospital mission.
(_d_) The MOPP ensemble does not protect against all radiation
effects of nuclear weapons. However, it provides some protection
against alpha and beta radiation burns. By covering all body
surfaces, especially hairy areas, MOPP greatly expedites the
decontamination process.
(2) _Nuclear._
(_a_) Most protective measures for hospitals against nuclear attack
require engineer and/or intensive logistic support. This support
includes placing sandbag walls around tents; digging trenches for
patient occupation; or constructing earthen berms (see Appendix
H). Occupying existing structures, depending upon their strength
and potential flammability, may be the best protection against
the effects of a nuclear strike. The remainder of this section
presents factors to consider when selecting the protective posture
for the hospital against a nuclear attack. Leaving equipment packed
and loaded until actually needed for operations will help protect
materiel in an NBC environment. In any event the unit must have
established an OEG, implemented radiation monitoring, and have
contingency plans if these radiation levels are approached or
exceeded.
(_b_) Personnel and patient protection requirements will depend
upon the threat (blast, thermal, immediate radiation, or fallout
effects). The MOPP ensemble will not protect against internal
radiation, but will provide some protection from external
radiological contamination.
· If the threat is nuclear fallout, the hospital structure
provides protection; the fallout can be brushed or washed
off. This allows protection while permitting patient care
to continue virtually uninterrupted. A need to relocate the
hospital will depend upon the degree of contamination; the
amount of decontamination possible; and the projected stay
before a normal move in support of operations.
· Hospital tentage alone offers little protection against blast
and missiling effects. If the patients are to remain in the
tents, they are placed on the floor. Place all equipment on
the ground or as low as possible and secure all loose objects.
In GP tents, sandbags can be piled around the base of the tent
poles to add stability. The tent poles and patient beds should
keep the canvas off the ground enough (if the tent collapses)
to continue minimal patient care and evacuation; however, be
aware of possible tent pole breakage.
· Hospital units are very susceptible to the thermal effect
of a nuclear detonation. Tents will not provide protection
against the thermal pulse. If the thermal effect (fire) is an
impending threat, patients and personnel in tentage must move
to trenches, bunkers, or other nonflammable areas.
· Protection factors that can reduce the overall radiation
exposure rate for hospital personnel and patients are--
· Time. Reducing the exposure time to the radiation reduces
the overall exposure proportionally (cut the time of
exposure in half and the overall exposure is cut in half).
EXAMPLE: An exposure time of 60 minutes to a dose rate
of 100 centigray (cGy) is cut in half (30 minutes) to an
exposure rate of 50 cGy.
· Distance. Increasing the distance from the radiation
source reduces the exposure in an inverse square
relationship (double the distance factor by 2 decreases the
exposure factor by 4).
· Shielding. Placing material between personnel and patient
and the radiation source decreases the dose (the reduction
factor is dependent on the type of radiation and the
density of the shielding material). Placement of sandbags
(two feet wide) around the hospital tents and shelters
provides adequate shielding for protection from gamma and
x-ray radiation; the thicker the sandbag stacks the greater
the protection factor. Tent material is a good shield for
alpha particles and adequate shielding from beta particles.
See Appendix H for field expedient shielding techniques.
(3) _Biological._ The most likely use of a biological agent (such
as anthrax) is releasing the agent as an aerosol. While such agents
may produce large numbers of casualties, initially patients may
be seen at the MTF in small numbers, but the number of patients
will rapidly increase within a few hours to days. When a trend
is identified, the enemy use of a biological agent is suspected.
General protective measures are the same as for any infectious
disease; specific protective measures are used once the vector or
method of transmission has been identified. Designating a single
hospital to care for these patients (from a patient care or disease
transmission standpoint) may not be necessary. However, if the
agent is communicable, consolidating them all at one facility
maximizes the use of limited assets and aids in limiting the
spread of the disease. Protective measures against biological
attack are the same as those for chemical agents when bombs,
sprays, or gases are used; see (4) below. The difficulty in rapidly
identifying biological agents may force the use of protective
measures for longer periods of time. Faced with this situation, a
careful evaluation of the mask-only posture is necessary before
implementing any level of MOPP. See FM 8-284 for additional
information on prevention, protection, and treatment of biological
casualties.
(4) _Chemical._
(_a_) _Individual protection._ When CPS systems are not available,
using the correct MOPP level is essential in hospital mission
performance. The level of MOPP assumed depends upon the level of
threat. An alternative approach for the hospital commander is the
use of the mask-only posture. This posture is acceptable when
the hazard is from vapor only (except mustard). See FM 3-4 for a
description of each MOPP level and mask-only procedures.
· _Hospital warning system._ The hospital must have a warning
system that alerts all personnel of impending or present
hazards. This system must include visual and auditory signals;
the signals must operate inside and outside the hospital
complex. There are numerous problems associated with warning
personnel; they include--
· The wide area covered by the hospital operations.
· Some personnel will be asleep at all times of the day or
night (two or three shifts).
· The considerable noise from mechanical support equipment;
such as the power generation and environmental control
equipment.
· Tentage and equipment interrupts line of sight.
· _Hospital personnel response._ When NBC alarms are activated,
all personnel (including off duty personnel) report to their
duty stations as soon as they are in the designated MOPP level.
This allows for 100 percent personnel accounting and provides
additional personnel to secure patients and materiel.
· _Unprotected hospital areas._ Areas of the hospital without
CPS are at their best posture with all openings secured and
the ventilation systems turned off. For nonpersistent agents
(vapor hazards), personnel and patients stay at the designated
MOPP level until the all clear signal is given; then normal
operations are resumed.
NOTE
Patients with injuries that prevent their assuming a protective
posture must be placed in a PPW or immediately evacuated to a
clean MTF.
_(b) Environmental protection._ As noted previously, hospital
complexes without CPS offer some protection against liquid or
fallout contamination, but little protection against vapor hazards.
· When MOPP Level 1 must be assumed, close and secure all tent
flaps, vents, and doors to prevent the entrance of liquids or
particles. All hospital personnel outside of shelters assume
MOPP Level 4. Cover or move all equipment and supplies into
shelters (tents, hard-walled shipping containers), if possible.
Placement under thick foliage trees is better than left out in
the open. The best policy is to keep all equipment and supplies
not immediately needed covered or in closed containers.
· When MOPP Level 3 or mask-only posture is assumed, shut down
the hospital's ventilation system to prevent drawing vapors
or fallout contamination into the hospital. This measure also
provides some protection of the internal environment during the
time required for the vapor to penetrate the tentage.
_(c) Patient protection._
· Patient protection depends upon prior planning and timely
warning of the chemical threat. Each patient's protective mask
must be available and serviceable. If the patient came from
a contaminated area, the mask must be decontaminated and the
filters changed. The mask decontamination and filter change
may have to be performed by hospital personnel. If ambulatory
patients' medical conditions permit (minimal care ward), they
may be able to perform this task. The hospital supply staff
must ensure that mask filters are available at the supporting
logistics support facility and can be requisitioned to meet
this requirement. Check all masks for serviceability as soon as
the mission permits, but always before they are needed. Do not
wait until the warning has been received to begin checking the
mask. Each area must have an established plan for operations
(to include assisting patients assuming MOPP or other
protective posture) in the NBC environment. Appendix F provides
additional information on patient protection.
+--------------------------------------------------------+
| CAUTION |
| |
| Remember, personnel must assume MOPP Level 4 before |
| beginning any decontamination process or risk becoming |
| a casualty themselves. |
+--------------------------------------------------------+
· Hospital staff always mask themselves first, then assist
patients in masking. On minimal care wards, most patients
can put on their masks. For those who cannot, other patients
can assist them after putting on their own masks. On the
intermediate care wards, some patients will be able to put on
their masks, but many will require assistance. Intensive care
and emergency room staff will have to assist their patients in
masking.
· Many patients with head and neck wounds or who are on
life-support devices will be unable to wear their individual
protective masks; these patients must be placed in a PPW. While
the PPW has two ports for intravenous or blood infusion lines,
the staff may have to adapt for other devices (Foley catheters,
traction devices, and cardiac monitor) by using tape and other
means to seal the gaps created in the seal around the edge of
the PPW. Patients requiring assisted ventilation are at extreme
risk, unless their air supply is protected. The sequence of
protecting everyone is mask yourself first; assist those
patients who can wear their protective masks; and then place
patients in the PPW.
_(d) Materiel protection._ Protection of materiel, especially
expendable supplies, requires covers and barriers. All materiel not
required for immediate use is kept in shipping containers, medical
chests, or under cover (tentage, plastic sheeting, and tarpaulin)
for protection against particulate or liquid hazard. Protection
against vapor hazard may require multiple barriers through which
the vapor must penetrate. For example, intravenous solutions are in
their individual plastic bags, in the cardboard shipping box, on a
covered pallet, in a hard-walled shelter; such as a military-owned
demountable container (MILVAN). This presents four barriers against
the vapor hazard. These principles should be used to the maximum
extent practical.
4-3. Decontamination
_a._ Decontamination of nuclear-contaminated personnel, equipment,
and the operational site is as follows:
(1) Monitoring equipment is used to detect contamination; the
contamination is then removed by brushing or scraping with brooms,
brushes, or tree branches. Flushing hard surface contaminated areas
with water is also effective in removing nuclear contamination.
However, there remains a problem of containing and removing the
contaminated water. The best method of containment is to trench
the area into a sump for collection of the contamination. This
will reduce the area of contamination; however, the level of
concentrated radiation may be such that there is an increased
hazard to personnel. The collection area must be clearly marked
using the standard nuclear hazard signs.
(2) Nuclear contamination of the site may require relocating the
hospital. Scraping 1 or 2 inches of topsoil from the area, or
covering the area with 1 or 2 inches of uncontaminated dirt will
not be practical. A need to relocate the hospital will depend
upon the degree of contamination; the amount of decontamination
possible and the projected stay before a normal move in support
of operations. If the hospital is immersed in a high level of
radioactivity, the best option may be to abandon it for 48 to
72 hours. After this period the area should be checked and if
the radioactivity has decayed sufficiently the hospital may be
reoccupied and continue operations or moved to a clean area. The
command OEG must be followed if reoccupying or moving the facility.
_b._ Suspect biological agents should be removed from equipment as
quickly as possible, In the absence of agent-specific guidance,
clean exposed surfaces using a 5 percent hypochlorite solution or
copious quantities of soap and water (preferably hot). Liberally
apply the hot, soapy water and scrub all surfaces with a brush.
Then rinse the surfaces with hot water. As previously discussed,
the soapy water used is contaminated and must be controlled
and removed to a safe area. Supertropical bleach (STB) and
decontaminating solution Number 2 (DS2, US Army) are effective
against most known biological agents because of their caustic
nature. If anthrax (or other spore formers) is suspected, repeat
the entire decontamination process again to remove the spores.
Other standard biological decontamination agents are described in
FM 3-5.
+------------------------------------------------------------------+
| CAUTION |
| |
| 1. Keep liquid decontaminants out of equipment with electronic |
| or electrical circuits. Unplug electrical devices before |
| attempting to decontaminate them; prevent electric shock. Some |
| electronic devices maintain an electric charge, even after being |
| unplugged, use extreme care to prevent shock. |
| |
| 2. Soap and water only mechanically remove BW agents. The |
| soap and water solution must be contained to prevent spreading |
| the agent to other personnel, thus causing more casualties. |
+------------------------------------------------------------------+
_c._ Decontamination of chemical contamination is as follows:
(1) Personnel use their soldier skills and their M295 Individual
Equipment Decontamination Kit to decontaminate their personal
equipment. The M13, decontamination apparatus, portable, is used to
decontaminate vehicles, trailers, and International Organization
for Standardization (ISO) shelters. This apparatus uses DS2
(a highly caustic, flammable solution that cannot be used to
decontaminate tentage). The DS2 must be washed off after sufficient
time has passed for decontamination (see FM 3-5 for details).
Water used for NBC decontamination purposes becomes contaminated;
therefore, it must be contained in sumps. Dig shallow trenches to
channel the water into sumps. This will be difficult in hospital
areas because relatively flat sites are needed for hospital
complexing, but must be accomplished to reduce the contamination
levels in the hospital area.
(2) When hospital tentage becomes contaminated, decontamination
operations must be considered immediately. Spot decontamination
may be effective for small areas; however, gross contamination of
TEMPER and GP tentage is best decontaminated by aging. Without
CPS and with persistent agent contamination that absorbs into
the tentage and presents a continuing vapor hazard, the hospital
stops receiving patients and evacuates all patients as quickly as
possible. When large portions of the hospital are contaminated,
personnel decontaminate all equipment possible and relocate to
a new site, leaving the contaminated equipment to age or to be
decontaminated by a specialized unit. When small portions of the
hospital are contaminated, the contaminated portions are removed
to another location for decontamination; hospital operations are
continued, but at a lower operational level. For detailed equipment
decontamination procedures, see FM 3-5.
NOTE
Liquid decontamination material must not be used on electrical
or electronic components of equipment. Liquid decontaminants
can damage the equipment; thus making it inoperable and not
available for patient care or transport. The use of liquids
to decontaminate electronic equipment could also potentially
result in injury or electrocution of personnel.
(3) Each US Army hospital is issued =five= chemical agent patient
treatment MES and =three= chemical agent patient decontamination
MES, Chemical Agents Patient Decontamination, for use in
decontaminating patients. Each hospital must decontaminate and
treat its own personnel who become casualties; chemical casualties
from units in its general area; or contaminated patients received
from lower level MTFs. See Appendix G for patient decontamination
procedures and for establishment of a patient decontamination and
treatment station.
4-4. Emergency Services
_a._ Providing emergency services will be complicated by several
factors:
· Varying levels of treatment received prior to arrival at the
hospital.
· Caring for combined conventional wounds and NBC agent effects.
· Managing heat-related complications associated with MOPP/PPW
use.
· Controlling psychological effects caused by biological and
chemical agents, the impact of NBC weapons, or the isolation of
MOPP gear or PPWs.
· Having EMT personnel working at the arrival point,
decontamination site, and in the hospital EMT area.
· Conducting triage and providing patient care while in MOPP
gear.
· Supervising supported units decontamination augmentation
personnel. These personnel will most likely be of any military
occupational specially (MOS), except medical. They will use
hospital equipment and supplies to decontaminate patients.
_b._ Contaminated patients must be triaged in the decontamination
area that is established at the hospital. Contaminated patients
=WILL NOT= be brought into the clean EMT area until decontaminated.
All patients are screened for contamination. Based on the findings,
the patient is routed to the contaminated triage station, or to
the clean triage station. Contaminated patients are triaged,
then routed to the decontamination area, or to the contaminated
treatment area. Patient admission to the clean treatment area may
be delayed; however, life- or limb-saving care is provided in the
contaminated treatment area before decontamination.
4-5. General Medical Services
The provision of general medical services in the hospital will be
continued with minimal interruptions in the NBC environment. The
noninvasive nature of these services allows their continuation at
most MOPP levels. However, some general medical services will be
constrained by MOPP Levels 3 and 4 and the mask-only posture. These
constraints may include, but not be limited to--
· Communication limitations.
· Loss of the oral route for administering medications to
patients.
· Limited ability to accurately evaluate the eyes, nose, and
mouth of patients wearing a protective mask.
· Reduced ability to perform examination/assessment of patients
in PPW or MOPP Levels 3 and 4.
· Inability to provide oxygen therapy or ventilator support
to a patient in a vapor hazard environment, unless a CB
filter-supported respirator is available.
· Logistical constraints based upon the fact that key areas
such as dietetics, supply, and laundry are not in the
CPS. These services may be reduced or delayed in the NBC
environment. See Appendix F for Information on patient feeding
under NBC conditions.
4-6. Surgical Services
_a._ Surgical services will be severely limited in the NBC
environment. At any level above MOPP Level 0, without a CPS system
surgical services are halted except for life- or limb-saving
expedient procedures. Surgery cannot be safely performed outside a
CPS due to a variety of factors including--
· Lack of protected ventilation for patients during and after
surgery.
· Inability to maintain a sterile field while using MOPP gear.
· Direct access for agents through open wounds to the
circulatory and respiratory systems.
· Decreased dexterity and vision resulting from MOPP gear use.
· Inability to quickly place the patient in a PPW should the
need arise.
_b._ Due to the relatively high number of trauma cases, hospital
services may be severely constrained by NBC contamination. The
hospital location and the possible need for relocation are two
major planning considerations for the command staff.
_c._ Patient accounting and medical regulating are critical factors
in the transfer of patients from a hospital without a CPS that
must move out of an NBC environment. Hospitals without CPS stop
receiving patients when a persistent hazard is identified; patients
on hand are protected and transferred to a clean MTF.
4-7. Nursing Services
Providing nursing care in a hospital without CPS is influenced by
the amount of protective gear worn by the nursing staff and the
patients. The patients may be in their MOPP gear, in a PPW, or
wearing only their protective mask; any of which will interfere
with care. The nursing staff will wear the same level of protection
as the patients.
_a._ Direct assessment of a patient's vital signs is extremely
limited at MOPP Levels 3 or 4; however, a carotid artery pulse can
be taken by palpating the neck area. The patient's respiratory rate
and level of consciousness may be assessed visually. Palpitation
of the blood pressure through a PPW may be possible if it is
relatively strong, or at least in the normal range. The patient's
temperature cannot be monitored; this is an area of concern due to
the possibility of heat stress.
_b._ Only gross neurological signs can be assessed through the PPW
or when the patient is in MOPP Levels 3 or 4. However, even this
assessment is complicated by the presence of miosis and by the
health care provider's mask. Urinary output and cardiac monitoring
is continued uninterrupted for patients wearing a mask only and for
patients in the PPW.
_c._ Oral hygiene and bathing are postponed until a safe
environment is available (MOPP Level 2 or less). All toileting will
occur within the hospital complex using ISO contained latrines,
chemical toilets, bedpans, urinals, buckets, or containers with
plastic liners. Waste from improvised containers must be placed in
containers with covers or in plastic bags and sealed to control
odors and prevent spread of infectious material within the
facility.
_d._ At MOPP Levels 3 and 4, feeding must be postponed. A
nutritional assessment is needed to determine how long each patient
can tolerate a fasting state when MOPP Level 3 or Level 4 remains
in effect for over 24 hours.
_e._ Intravenous (IV) medications are mixed in a clean area and
then transported in a protective wrap (multilayers of plastic,
medical chest, or layered cardboard) to the user. However, IV
solutions, blood, and injections can be given to patients on an
unprotected ward. Normally, oral medications are only given at MOPP
Level 2 or lower.
_f._ Treatment procedures that have the potential of contaminating
the patient's pulmonary or circulatory systems are conducted only
at MOPP Level 2 or below. However, EMT procedures may have to
be performed in the contaminated treatment area, or the patient
decontamination area.
_g._ Continuous oxygen therapy requires a collective protection
environment or a CB filter supported respirator.
_h._ Delivery of nursing care at MOPP Level 3 or Level 4 is limited
due to the sensory restrictions of MOPP gear. Time is taken to
reassure the patients on a personal basis, as much as possible,
and by routinely monitoring the ward environment. Communications
are difficult and identities are masked. Maintain the identity of
personnel by using handwritten name tags for staff and patients
(including patients in PPW).
_i._ As with all procedures, the time required for record-keeping
rises markedly at MOPP Level 3 or Level 4. Contaminated paperwork
cannot be evacuated with the patient. Transcribe essential
information onto uncontaminated documents for evacuation with the
patient. A record of patient exposure time to a contaminated area
is prepared to assess the cumulative risk to the patient.
4-8. Conventional Operations
For conventional operations of hospitals in a field environment see
FM 4-02.10, FM 8-10-14, and FM 8-10-15.
CHAPTER 5
OTHER HEALTH SERVICE SUPPORT
Section I. PREVENTIVE MEDICINE SERVICES
5-1. General
On the integrated battlefield, PVNTMED services will be in greater
demand than at any other time, especially under BW conditions.
Preventive medicine personnel will be called upon to assist the
commander in determining the health hazards associated with nuclear
fallout; the safety of drinking water in an NBC environment;
as well as determining when to use prophylaxis, pretreatments,
immunizations, and other PVNTMED measures (PMM) associated with
NBC warfare. Preventive medicine personnel must be aware of the
medical threat in the AO. They must continually update their
medical surveillance activities to identify disease trends (endemic
and epidemic), potential disease vectors, and the susceptibility
of troops to these diseases. Under NBC conditions, diseases may
manifest that exist in the area, but were not being transmitted to
personnel. However, due to the reduced health status of personnel
from exposures to or from stress-related NBC conditions, the
troops begin to suffer their effects. The appearance of diseases
or arthropods not known to exist in the AO are indicators that BW
agents have been used. For details on PVNTMED operations, see FM
4-02.17.
5-2. Disease Incidence Following the Use of Nuclear, Biological,
and Chemical Weapons
_a._ _Determining Factors._ Factors of prime importance in
determining the nature and severity of the disease effects are--
· Immunization status of personnel.
· Population density.
· Degree of industrialization in the operational area.
· Availability of food supplies.
· Availability of water.
· Climate.
Finally, the manner and situation in which nuclear weapons are used
are of importance. A single weapon detonated in a socially stable
area will have far less serious effects than a detonation in an
area where combat has already disrupted the social stability. At
Hiroshima and Nagasaki, Japan (excellent examples of the first
type of situation), the survivors who could get away were able
to obtain food, shelter, and care from surrounding intact areas.
With prolonged combat operations, such intact areas would not be
available, resulting in no food, shelter, or care for survivors.
There will be a breakdown in social order and there will be a lack
of effective medical support; including PVNTMED functions and
facilities.
_b._ _Disease Incidence._ Without PVNTMED capabilities, increased
incidence and morbidity from diseases will follow. Some diseases
will predominate in incidence, depending upon the geographical
areas involved and the endemic diseases present.
(1) In urban areas in temperate climates, several diseases are
epidemic threats. These epidemic threats may include--
· Dysentery (due to a variety of pathogens).
· Rickettsial diseases, particularly typhus and scrub typhus.
· Hepatitis.
· Tuberculosis.
· Sexually transmitted diseases.
· Malaria and cholera (in many parts of the world).
(2) There are several reasons for the increased risk of disease
including, but not limited to--
· Crowding of surviving populations with limited sanitary
facilities, such as was seen in Europe at the end of World War
II.
· A lack of prophylaxis and immunizations with resultant
increases in the susceptible faction of a given population.
· A lack of pest management.
· The effect of irradiation on susceptibility to infection.
With the high levels of fallout covering wide areas, a large
number of people will sustain sublethal whole-body doses of
irradiation. The interaction of irradiation with infections
is not clear; but it may be the result of latent infections
manifesting and decreased resistance to infection. The result
is an increased incidence of disease.
· The ecological imbalance and host-parasite relationship
following the use of nuclear weapons. Each class and order of
animals has marked differences in sensitivity to irradiation.
Arthropods, for example, are much more resistant than are
vertebrates. The normal balance between arthropods and
birds that prey upon them in a given area may be severely
upset, producing a marked overgrowth of the arthropods. If
the arthropods include vectors of disease there would be a
serious increase in disease hazards. If there is an increase
in arthropods that destroy vegetation there would be a serious
destruction of food crops.
· The introduction of a BW agent in an AO in which the disease
organism is endemic or epidemic can increase the risk level for
exposed personnel.
5-3. Preventive Medicine Section
The PVNTMED sections of the brigade, divisional, and nondivisional
medical companies perform analysis on water sources and supplies
to determine the presence or absence of NBC/TIM contamination; see
Appendix I for additional information. Based upon their findings,
the water is released for consumption, or is restricted from use
until it is treated (usually by water production personnel using
the reverse osmosis water purification unit [ROWPU]). They also
collect water samples for suspect biological agent contamination
for supporting medical laboratory analysis (see Appendix B). They
conduct medical surveillance activities, to include occupational
and environmental health threat surveillance. They conduct
limited entomological surveys to determine the existence of
disease-vectoring arthropods in the AO. They inspect food service
facilities to determine the extent, if any, of NBC contamination.
They evaluate the unit's--
· Immunization status.
· Use of prophylaxis for specific diseases (such as
antimalarial tablets) (see FM 4-02.33), for nuclear radiation
exposure (such as granisetron for nausea and vomiting) (see
FM 4-02.283), and for BW agents (such as Ciprofloxacin for
postexposure chemoprophylaxis for Anthrax) (see FM 8-284).
· Use of nerve agent pyridostigmine pretreatment tablets (see
FM 8-285), if warranted.
· Application of personal hygiene and field sanitation
procedures (FM 21-10/MCRP 4-11.1D).
Based upon their findings, they provide recommendations for
corrective actions to the commanders. They assist in training
US Army unit field sanitation teams (FM 4-25.12); they are not
members of the unit field sanitation team. They conduct medical
surveillance activities for their command (FM 4-02.17).
5-4. Preventive Medicine Detachment
The PVNTMED detachment provides PVNTMED services on an area support
basis to units within their assigned AO. These services include,
but are not limited to--
· Conducting water surveillance, including NBC contamination.
Collecting water samples suspected of NBC/TIM contamination for
analysis by supporting medical laboratory (see Appendix B).
· Performing food service sanitary inspections.
· Conducting medical surveillance and providing epidemiological
consultation.
· Conducting pest (arthropod and rodent) surveys and
surveillance.
· Conducting arthropod control operations. The aerial spraying
missions are dependent upon availability of helicopter support.
· Conducting occupational and industrial hygiene surveys.
· Advising commanders on the application of PMM.
· Training the supported units' field sanitation teams.