when available. When these containers are not available, Mylar bags
may be used. When using a glass bottle, jar, or Teflon^{TM} jar,
seal the cap with either pressure-sensitive or Teflon^{TM} tape,
and mark for identification. When using Mylar bags, place each
sample in a separate bag, push excess air out, and seal by folding
the open end over two to three times and wrapping the bag with
tape. Insert the first bag into a second bag, seal, tape, and mark
for identification. If possible, place the samples in a piglette.
+-----------------------------------------------------------+
| CAUTION |
| |
| Avoid direct contact with the sample to prevent exposing |
| yourself to the suspect agent (MOPP 4 is required). |
+-----------------------------------------------------------+
_c._ Collect samples as soon as possible when directed, upon
detection of a suspect substance, or after the alleged incident.
B-11. Collection of Contaminated Vegetation
As with soil samples, vegetation is also a suitable medium to
collect as samples for toxic organic compounds.
_a._ Collect samples of vegetation that appear to be different
from normal. Select leaves that have wilted or appear to have been
chemically burned. Collect samples of vegetation that appear to
have liquid or solid substances deposited on their surfaces (this
may be noticed as a shiny or moist area).
_b._ Collect samples of vegetation at several locations within the
suspected contaminated area. Using a cutting tool or any sharp
object, cut several affected leaves and/or a handful of grass
whenever possible. Do not crush the sample. Place the sample into a
Mylar or reclosable bag. Squeeze excess air out of the bag and seal
it. Fold the open end of the Mylar bag over two to three times, and
wrap it with tape. The minimum size for a sample is three leaves or
three handsful of grass. One leaf is of little value, but is better
than nothing. Bark is acceptable but not preferred. Mark the bag
for identification. Take a control sample of similar material from
an unaffected (uncontaminated) area. Fold, seal, tape, and mark the
control sample in the same manner as the actual sample.
_c._ When it is possible to determine a probable center of attack
in an area, collect vegetation samples near the center of the area,
about 100 meters upwind of the area, and in several 100-meter
increments downwind of the area. If the collector can discern a
contamination pattern in the area, this should be reported.
B-12. Medical Specimens
_a._ Just as blood and urine specimens are taken from humans who
were allegedly exposed in an attack, also collect specimens from
individuals who claim not to be affected by a toxic agent and
are from the same group as exposed personnel. The purpose is the
same as collecting environmental control specimens; that is, to
determine if a toxic substance is present in the individuals'
natural environment or if it has been artificially introduced.
_b._ Selection of humans for control sampling is somewhat more
complicated than selection of environmental control samples. This
is because ethnic diets, racial differences, physiological makeup,
and actual living conditions of persons who are outwardly similar
may introduce potentially large deviations. Each of these factors
must be accurately considered before selecting subjects as controls.
_c._ Consideration of ethnic diets is important because of unique
foods or methods of food preparation that may exist. As an example,
individuals in settled areas may purchase beer that has been
carefully filtered and sterilized, while individuals in a nearby
unsettled area may ferment their own beer by burying home crafted
jugs in the ground and extracting the product little by little over
several months.
_d._ Racial differences can account for differences in mortality
and morbidity rates in specific populations. One example of this
could be the high rate of hemophilia in a population versus the
rarity of the disease in another.
_e._ Physiological makeup is critical because of the differences in
hormone balance and tissue composition in males, females, adults,
and juveniles. For this reason, medical control specimens should be
drawn from individuals of the same gender and approximate age as
specimens from exposed personnel, if possible.
_f._ Differences in the actual living conditions of people also
require a close look. The point here is that conditions in
remote, semicivilized camps are seldom the same as those in a
well-established camp that has access to modern amenities.
_g._ The bottom line in selecting subjects for medical control
sampling is that they be as similar in all aspects as possible.
B-13. Collection of Medical Specimens
_a._ Trained medical technicians or physicians should collect
medical specimens (human or animal); however, Special Forces NBC
Reconnaissance team personnel are trained to do this procedure.
Remember, the collector must have express permission (authority)
to collect medical specimens from the dead, because of religious
beliefs in many cultures. To obtain such specimens without
permission may result in unnecessary mission complications. Ensure
all personnel handling or collecting medical specimens have
received proper immunizations for their own protection. They must
be inoculated IAW The Surgeon General's guidance.
_b._ Medical specimens collected during an investigation include
blood, urine, sputum, nasal swabs, and tissue specimens from living
victims and blood and urine specimens from unexposed persons
(background control specimens).
_c._ Collect blood specimens using either a standard 10 cc
disposable syringe with a 1- to 1½-inch needle (20 to 22 gauge),
or by using a Vacutainer^{TM} system. When using a Vacutainer^{TM}
system, ensure that multiple specimen needles and "red top" vacuum
tubes are used. Ten cc of blood is sufficient for analytical
testing. Do not take more than 5 cc from small, malnourished
children. After blood is collected, it should be transferred to
a polypropylene-type container and sealed with parafilm before
transporting.
All body fluids should be collected without violating antiseptic
techniques. Also, prior to transporting specimens, collectors
need to check specimen containers for paper labels IAW guidelines
for labeling medical specimens. Collect blood specimens using the
following materials equipment:
· Gloves.
· 10 cc sterile, disposable syringe.
· 1- to 1.5-inch sterile needle (20 to 22 gauge).
· Vacutainer^{TM} device (adapter with needle).
· Constricting band.
· Disinfectant pads, Betadine, or alcohol.
· Sterile 2×2-inch gauze pads.
· Labels.
NOTE
Gloves should be worn whenever handling medical specimens. Do
not freeze liquid blood and urine specimens (ideal cooling
temperature is between 35° and 40°F [2° to 4°C].)
_d._ Collect urine specimens using either a standard urine cup or
by a urine catheter and urine cup. When collecting the specimen
directly into a urine cup, the person must urinate into the cup
until sufficient fluid is collected (40 cc of urine is preferable,
although 10 cc can support analytical testing). When the person is
unable to urinate, the catheterization technique is preferable.
The catheterization technique is best performed in a clinical
environment. As with other body fluids collected, urine must be
kept cold. Do not freeze.
NOTE
For correct procedures on catheterization refer to STP
8-91W15-SM-TG.
_e._ Collect tissue specimens using sterile scissors and forceps or
as directed by the attending physician.
(1) When casualties have unidentified skin lesions, photographs
of the lesion(s) and overall photos of the extent of the
lesion(s) should be taken, using color film before biopsy. A
specimen of the lesion should be obtained. This is done by
surgically removing a portion of the skin with a sterile pair
of scissors and forceps.
(2) Place tissue specimens in a Teflon^{TM} container filled
¼ inch from the bottom with a preservative, (formalin 10%)
for preservation of the specimen until it reaches its proper
destination. Seal the container and lid with parafilm. As with
any other medical specimens, tissue specimens are refrigerated
prior to shipment; but do not freeze tissue specimens.
_f._ Collect nasal swabs by using a cotton-tipped swab. Place the
swab with collected specimen in a Teflon^{TM} container filled ¼
inch from the bottom with a preservative for preservation of the
specimen until it reaches its destination. Seal the container and
lid with parafilm. Refrigerate the specimen for shipment, but do
not freeze.
_g._ Collect sputum by having the patient discharge the sputum into
a small, sterile screw-top jar or urine specimen cup. Seal the
container and refrigerate the specimen for shipment, but do not
freeze.
B-14. Post mortem Specimens
Post mortem specimens should be collected by individuals trained in
forensics. When forensics-trained individuals are not available,
the most qualified medical person should collect human specimens.
Specimens from animals should be collected by veterinary personnel.
In either case, the following specimens are collected:
· =Blood.= Use a 50 to 60 cc sterile syringe with an 18-gauge,
5-inch (large bore) needle to collect blood from the heart, and
urine directly from the bladder. Use a spinal needle to collect
cerebral spinal fluids. Three of each type of specimens must be
collected.
· =Lungs.= A biopsy needle is needed to properly collect lung
tissue specimens. After collecting specimens from the lungs,
place specimens in a plastic or Teflon^{TM} container filled
with 10% formalin (preservative) and seal the container for
transporting to its destination.
· =Liver.= If possible collect liver core specimens, using a
large-gauge needle (18-gauge, 5-inch long) via intercostal
or abdominal puncture. Or, if the family consents, perform
a minilaparotomy and obtain one or two 2×2×2 cm sections of
liver. Store and package the specimen as directed for tissue
specimens. For suspect biological agents, see Table B-1 for
specific types of specimens, amount, collection medium, and
from whom to collect.
NOTE
Before attempting any of the above procedures, collector must
be certified by a qualified person (medical doctor) on the
correct procedures to collect specimens from cadavers.
_Table B-4. Standard Sizes of CB Samples/Specimens to be Collected_
========================================================================
TYPE SIZE NOTES
------------------------------------------------------------------------
=CHEMICAL WARFARE SAMPLES=
SOIL (10 CM X 5 CM X 1 CM) CIGARETTE-PACK SIZE OR LARGER
AREA IS MORE USEFUL THAN
GREATER DEPTH
DILUTE AGENT 10 ML
WATER 500 ML (MAXIMUM)
C18 SEP-PAK^{TM} 200 ML
VEGETATION (EQUIVALENT TO 3 LEAVES DEPENDS ON AMOUNT OF CONTAMIN-
OR 3 HANDSFUL OF GRASS) ATION. BEST SAMPLES WILL BE
FOUND NEAR THE RELEASE POINT
------------------------------------------------------------------------
=BIOLOGICAL WARFARE SAMPLES=
SOIL (10 CM X 5 CM X 1 CM) CIGARETTE-PACK SIZE OR LARGER
AREA IS MORE USEFUL THAN
GREATER DEPTH
LIQUID 25 TO 50 ML DO NOT USE C18 SEP-PAK^{TM}
WITH MEDICAL SPECIMENS
VEGETATION SIZE OF SOFT DRINK CAN BEST SAMPLES DEPEND ON THE
AMOUNT OF CONTAMINATION
FOUND NEAR THE RELEASE POINT
------------------------------------------------------------------------
=MEDICAL SPECIMENS=
URINE 20 TO 50 ML MUST OBTAIN CONSENT TO COLLECT
SPECIMENS FROM OTHER THAN US
CASUALTIES
WHOLE BLOOD OR 5 ML MUST OBTAIN CONSENT TO COLLECT
SERUM SPECIMENS FROM OTHER THAN US
CASUALTIES
CEREBRAL SPINAL 2 ML MUST OBTAIN CONSENT TO COLLECT
FLUID SPECIMENS FROM OTHER THAN US
CASUALTIES
ORGAN TISSUE 30 G (MINIMUM)
MEDIASTINAL 2 SHOULD BE REMOVED BY A SURGEON
LYMPH NODES DURING AN AUTOPSY
========================================================================
B-15. Reporting, Packaging, and Shipment
Although a sample/specimen collected from an alleged attack area
can be significant, it can become useless if proper steps are
not taken to record critical information about its collection
or if it is improperly packed and breaks during shipment to an
analysis center. This section discusses the information needed when
acquiring samples/specimens and the preferred methods for handling
and packing samples/specimens for shipment.
_a._ A complete background information history of the circumstances
about each sample's/specimen's acquisition must be provided to the
agency analyzing the sample/specimen.
_b._ Critical background information includes--
· Circumstances of acquisition. How the sample/specimen was
obtained, where it was found, and how it was collected.
· Physical description. The physical state (solid, liquid,
powder, apparent viscosity), color, approximate size, identity
of the specimen (such as military nomenclature), dirt, leaves,
or so forth.
· Circumstances of agent deposition. The type of delivery
system, a description of how the weapon functioned, how the
agent acted on release, sounds heard during dissemination, a
description of any craters or shrapnel found associated with
a burst, and colors of smoke, flames, or mist that may be
associated with the attack.
_c._ Provide information on the agent effects on vegetation for
soil or environmental samples. A description of the general area
(jungle, mountain, grassland) and changes in the vegetation after
agent deposition (such as color change, wilting, drying, dead) in
the main attack and fringe areas.
_d._ Provide information on the agent effects on humans for medical
specimens. Describe how the agent affected personnel in the main
attack area versus fringe areas; the duration of agent effects;
peculiar odors that may have been noticed in the area prior to,
during, and/or after an attack; measures taken that alleviated or
deteriorated the effects; and the approximate number of victims and
survivors, to include their ages and genders.
_e._ Describe the agent effects on animals. Provide information on
the types of animals that were or were not affected by an attack
and of how they were affected.
B-16. Handling and Packaging Materials
Materials used for packaging samples/specimens primarily consist of
Mylar collection bags, Teflon^{TM} specimen jars and tubes, pigs
and piglettes, ice chests, sealing materials, and wrapping and
cushioning supplies.
_a._ _Collection Bag._ Use the Mylar bag as the initial container
for such samples as protective masks and filter canisters,
individual antidote and decon kits, munition fragments, and other
items too large to place in a specimen jar. Use it also to package
sample/specimen containers to ensure a vapor barrier in case the
container is broken in transit. The bag acts as an initial or
secondary vapor barrier to prevent air from leaking inward and
toxic material outward. Follow the procedures below when using the
bag.
· If packaging a specimen container or nonenvironmental
sample/specimen, first, verify it has a sample/specimen number.
Carefully place the sample/specimen in a bottom corner of the
Mylar bag.
· Squeeze all the air out of the bag and seal it by removing
the adhesive's protective strip, and pressing the two sides
together.
· Place a piece of 2-inch-wide fiber or cloth tape across the
end of the bag that you just sealed to reseal the Mylar bag
on the outside. This serves as extra insurance in case the
internal seal is broken.
· With the bag lying in front of you and the seal at the top,
fold the bag across its width to as small a size as possible
without damaging the sample/specimen. At this point, use tape
to hold the fold. Next, fold the bag from the top down to the
bottom of the bag to as small a size as possible. The sealing
of the bag is the most critical step during the packaging
process.
· At this point, turn the bag over and use a marker or file
label to put the sample/specimen number on the outside of
the bag so that analysis center personnel can identify the
sample/specimen.
· Place the folded Mylar bag in a clear plastic reclosable
bag, if available. Following the same steps you used for
the Mylar bag, fold and seal the plastic bag. When this has
been completed, again mark the sample/specimen number on the
exterior of the bag.
_b._ _Glass Specimen Jars and Polypropylene Tubes._ Use glass
containers to hold small environmental samples, water samples, and
medical and post mortem specimens. Use polypropylene containers
to hold medical specimens such as blood or urine. Polypropylene
containers may be used for post mortem specimens if required;
however, glass containers are preferred. The use of glass rather
than plastic containers is preferred for environmental samples
because toxic agents may leach chemicals from plastics into a
sample, introducing contamination and confusing the analysis
efforts.
· If the container has a screw-on lid, place Teflon^{TM}
plumber's tape (NSN 8030-00-889-3535; Tape, Antiseize) on the
threads of the container before putting on the lid. This helps
to limit the leakage of liquids and vapor from the container
and to assure the lid will not fall off while in transit. If
the lid has a cardboard liner, remove the liner and replace it
with one or two layers of parafilm (a laboratory sealant film).
· Once the lid is on, stretch parafilm around the outside of
the container at the junction of the lid and the glass. Two
wraps of the film are enough to provide a leakage barrier and
more assurance that the lid cannot fall off.
· At this point, ensure the sample/specimen number is on the
outside of the container. Use a diamond etching pencil or
an adhesive label to put the sample/specimen number on the
exterior of the container.
_c._ _Six-Pound Metal Can._ Use metal cans as the external
container for packaging small items that have been sealed in Mylar
bags, specimen jars, and polypropylene tubes containing medical
specimens. The metal can helps absorb shock from rough handling
during shipment and eliminates the spread of contamination if a
specimen container is broken. The six-pound metal can is capable
of holding more than one sample/specimen (depending upon size of
samples/specimens).
· Before placing samples/specimens in the can for shipping,
ensure a sample/specimen number is assigned and is visible on
each item.
· Place about 1 to 2 inches of packing material in the bottom
of the can.
· Wrap jars and tubes in plastic bubble wrap or ⅛- to
¼-inch-thick foam rubber sheeting, secure the wrap with tape or
a rubber band, and place the wrapped item in the can.
· If bubble wrap or foam rubber is not available, use
newspaper. The guiding principle is that the sample/specimen
containers should fit snugly and not be able to move in the can.
_d._ _Ice Chest._ Standard polyethylene or metal ice chests are
the most easily procured items used for transworld shipment of CB
samples/specimens. The most easily used size is about 24 inches
long by 18 inches high by 15 inches deep. This size permits the
sender to ship two or three 6-pound metal cans in each chest with
sufficient dry ice to maintain freezing temperatures for about four
days. Also, each chest remains at a weight that one individual can
handle.
_e._ _Transport Container._ When the samples/specimens must be
transported on commercial aircraft, an IATA-approved sample
transport container must be used for shipment/delivery to the CONUS
laboratory.
_f._ _Coolants._ Samples/specimens submitted for laboratory
analysis must be properly packaged, labeled, and shipped to
ensure they arrive in an analytically acceptable condition.
All samples should be maintained at a temperature of 1° to 4°C
during transport. Ideally, samples/specimens should arrive at
the in-theater laboratory within 6 hours of collection. The
samples/specimens should be delivered to the CONUS laboratory
within 24 to 48 hours. If the samples/specimens cannot be delivered
to the CONUS laboratory within this time, then they should
be flash frozen to -165°C, if capabilities are available. If
available, dry ice should be used when flash freezing cannot be
accomplished. If the samples/specimens cannot be delivered to the
CONUS laboratory within 24 hours, the supporting laboratory should
subculture the samples/specimens and send the subculture with the
samples/specimens to the CONUS laboratory. The subculturing date
should also be provided.
_g._ _Internal Insulation._ While a commercial ice chest provides
good insulation of both the samples/specimens and the coolant, it
is best to place extra insulation and cushioning around the metal
cans inside the chest. Newspapers, plastic bubble wrap, and foam
rubber may all be used with almost equally good results except
newspapers and standard ice do not mix well.
B-17. Collection Reporting
_a._ The collector must provide a formatted message for
transmission as soon as possible to report acquisition and shipment
of samples/specimens. During special operations in a theater in
which a Special Forces Group (SFG) is deployed, the message is
transmitted by the fastest means through the fewest channels to the
NBC control (NBCC) center. If a NBCC center has not been deployed
to the area of operations, as in low-sample/specimen volume
peacetime NBC sampling operation, the message is transmitted
by the fastest means through the fewest channels to the message
addressees below. In addition, a written report accompanies each
sample/specimen or batch of samples/specimens. The collector
ensures that the acquisition message has been properly classified.
_b._ The collection report includes at least the following
addressees:
SECSTATE WASHDC
SECDEF WASHDCHOSD-ISA/OUS-DREH
JCS WASHDC//J-3/J-5H
CIA WASHDCHOSWR-STD-LSBNIC-NIO(STP)H
DIA WASHDC//DT-3B/DT-5A//
DIR AFMIC FT DETRICK MD//AFMIC-CR/AFMIC-SA//
DA WASHDC//DAMI-FIT/DAMO-SWC//
CMDT USACMLS FT LEONARD WOOD MO//ATSN-CM-CO//
CDR SBCCOM APG
MDHSMCCR-OPF/SMCTE-OPE-RA-ID2H
CDR FSTC CHARLOTTESVILLE VA//AIAST-RA-ID2H
CDR USAMRIID FT DETRICK MD (For suspect biological
samples/specimens only.)
_c._ A collection message contains the following information:
· The sample/specimen identification number is part of the
subject line if only a single sample/specimen is referred to in
the text. Otherwise, refer to the sample/specimen number within
the message body with its background information.
· The shipment date, mode of transportation, courier
identification, air bill of lading number, flight number
destination, and estimated time of arrival are included if
the sample/specimen is to be shipped immediately. Also, the
material courier receipt form (DD Form 1911) should be used to
maintain chain of custody.
· Background information on the sample/specimen. Questionable
circumstances surrounding acquisition of a sample/specimen.
The name of another country or agency that acquired a
sample/specimen from the same event or area and is not shown on
the message address.
· A recommended priority and rationale for analysis to guide
the analysis center on the assessment of the potential value of
the sample/specimen.
· All details relating to the collection of the
sample/specimen, regardless of how insignificant they may seem
to the collector.
_d._ Ship all samples/specimens by the fastest, safest means,
preferably by a technical escort unit (TEU) to the theater
Chemical-Biological Sampling Control Element (CBSCE) or to a
location the CBSCE designates. If there is no CBSCE in the theater,
send the samples/specimens IAW preplanned instructions from the
Chemical-Biological Sampling Control Center (CBSCC) at CBDA,
Aberdeen, Maryland. The CBSCC uses the following criteria to
determine the final destination of each sample:
· Is the sample/specimen chemical or biological in content?
· Is the sample/specimen content completely unknown?
· Is the sample/specimen a possible biological material?
(1) In any case, the NBCC center must be notified in advance of
shipment of the sample so additional instructions or deviations
from standard instructions can be given. Figure B-l shows an
example of a shipping notification message. The NBCC center
will direct, in advance, that samples be sent to one or more
of the following locations, depending on the category of the
samples. Prior to shipment of samples/specimens, contact must
be made with--
Commander
Technical Escort Unit
ATTN: SMCTE-OPE
Aberdeen Proving Ground, MD 21010
DSN: 584-4381 (Duty hours) DSN: 584-2773 (After duty hours)
(2) This unit controls the transport of samples/specimens
to their final destination(s). Do not ship suspected toxic
samples/specimens or munition systems to CONUS technical
centers or intelligence agencies without coordination and prior
approval by the recipient.
NOTE
Suspect CB samples/specimens are first delivered to the
supporting medical laboratory in the AO for in-theater
analysis before they are transported out of the AO. The
supporting laboratory will withdraw an aliquot of selected
samples/specimens for analysis. The supporting medical
laboratory is responsible for providing the AO commander
confirmatory identification within the AO. The CONUS-based
reference laboratory is responsible for providing confirmatory
identification for President and Secretary of Defense purposes.
FM AMEMBASSY DDTTTTZ JAN 02
TO CDR TEU APG MD//SMCTE-OPE//
SECSTATE WASHDC
SECDEF WASHDC//OSD-ISA/OUS-DRE//
INFO CIA WASHDC//OSWR-STD-LSB/NIC-NIO(STP)//
JCS WASHDC//J-3/J-5//
DIA WASHDC//DT-3B/DT-5A//
DIR NSA FT MEADE MD
DIR AFMIC FT DETRICK MD//AFMIC-CR/AFMIC-SA//
DA WASHDC/DAMI-FIT/DAMO-SWC//
CDR FSTC CHARLOTTESVILLE VA//AIAST-RA-ID2//
CDR CBDA APG MD//SMCCR-OPF//
CDR USACMLS FT MCCLELLAN//ATZN-CM-CU//
CLASSIFICATION
SECSTATE FOR...
SECDEF FOR...
CIA FOR...
JCS FOR J-3/J-5 FOR...
DA FOR DAMO-SWC FOR...
AFMIC FOR...
CBDA FOR FIO...
FSTC FOR AMXST-FW...
USACMLS FOR THREAT MGR...
E.0.12356: DECL: OADR (Note: This is included if the message is
classified.)
TAGS: ...
Subject: Shipment of CB Samples/Specimens
REF(S): TEU MSG #, (DTG DDTTTT [time zone] JAN 02)
1. (W) SHIPPING INFORMATION:
A. DATE SHIPPED: JANUARY 11, 2002.
B. MODE OF TRANSPORTATION: AIR EXPRESS, AIR BILL NUMBER RPT
C. FLIGHT SCHEDULE: TO TYO BY JAL XXX, JANUARY 11, 2002. TO JFK
BY JAL YYY, JANUARY 12, 2002. TO IAD BY DEC ZZZ,
JANUARY 12, 2002.
D. DESTINATION: DULLES INTERNATIONAL AIRPORT.
E. ESTIMATED TIME OF ARRIVAL: 2010 HOURS, JANUARY 12, 2002.
2. SPECIAL HANDLING REQUIREMENTS: DRY ICE ENCLOSED AS COOLANT.
3. SHIPMENT CONSISTS OF TWO ICE CHESTS (1 FOR CRDEC AND 1 FOR AFMIC)
CONTAINING SIX SAMPLES/SPECIMENS. ALL LIQUID SAMPLES/SPECIMENS ARE
IN POLYPROPYLENE TUBES AND HAVE BEEN CAREFULLY PACKED TO AVOID
BREAKAGE. THE FOLLOWING SAMPLES ARE INCLUDED IN THE SHIPMENT:
SAMPLE/SPECIMEN NUMBER MESSAGE REFERENCE
TH-850102-001AG THRU TH-850102-005AG BANGKOK DDTTTTZ JAN 02
4. USDAO HAS STATED THAT THIS SHIPMENT IS PARTIAL FULFILLMENT OF CIR.
_Figure B-l. Sample shipping notification message._
B-18. Sample/Specimen Background Documents
The sample/specimen background document allows a collector
to note the most relevant details associated with pre- and
post-sample/specimen collection conditions. Do not consider the
report to be all-inclusive. The information collected should
include at least the items listed in Figure B-2. Interviews should
be conducted with individuals exposed to the CB agent as well as
individuals not exposed (see Figure B-3).
1. ID NUMBER___________
2. COLLECTION (DATE/TIME):______________________
3. COLLECTOR/UNIT:_______________________________
4. TYPE: ENVIRONMENTAL___ BIOMEDICAL___ SINGLE___ MULTIPLE___
5. PURPOSE: ATTACK___ CHEM/BIO ALARM___ CHEM DETECT___
RECON ILLNESS/DEATH___ OTHER___
6. POSTEXPOSURE: HOURS___ DAYS___ WEEKS___ UNKNOWN___
7. LOCATION: TOWN_______________ COORDINATES__________________________
A. TERRAIN: FLAT___ HILLS___ MOUNTAIN___ DESERT___ JUNGLE___
SPARSE TREES___ GRASS___ BODY OF WATER/TYPE___
B. WEATHER: CLEAR___ CLOUDY___ RAIN___ FOG___ SNOW___ DUST___
C. WIND: LIGHT___ HEAVY___ GUSTY___ NONE___
D. ODOR: SWEET___ FRUITY___ PEPPER___ FLOWER___ IRRITATING___
CHANGING___ NONE___ OTHER_____
E. TEMPERATURE AT TIME OF ATTACK:_____ TEMPERATURE AT TIME OF SAMPLE
COLLECTION:_____
8. COMMENTS:
______________________________________________________________________
______________________________________________________________________
9. ATTACK: DATE/TIME_______ METHOD: ARTILLERY___ ROCKET___ AIRCRAFT___
MORTAR___ RPG/GRENADE___ OTHER, DESCRIBE:__________________________
A. EXPLOSION: AIR_______ (HEIGHT)_______ GROUND_________ SIZE_______
DISTANCE_________ DESCRIBE:____________________
B. CONSISTENCY: SMOKE___ MIST___ DUST___ RAIN___ GEL___
INVISIBLE, DESCRIBE:_______
10. ENVIRONMENTAL SAMPLE: SOIL__ WATER__ VEGETATION__ AIR__ OTHER___
11. BIOMED SPECIMEN: ACUTE___ CONVALESCENT___ EXPOSED___ NOT ILL___
POSTMORTEM___ CONTROL, EXPLAIN:_________________ BLOOD___ LIVER___
LUNG___ SPLEEN___ BRAIN___ SKIN___ KIDNEY___ URINE___
OTHER, DESCRIBE:_________________________
12. COMMENTS:
__________________________________________________________________
13. CASUALTY: SSN_______________ UNIT_______________________ SEX______
14. SIGNS/SYMPTOMS: ONSET__ DURATION__
A. HEAD: FEVER___ CHILLS___ HEADACHE___ FLUSHED___ DIZZINESS___
UNCONSCIOUSNESS___ COMA___ HALLUCINATIONS___
B. EYES: SUNLIGHT SENSITIVE___ PAINFUL___ BURNING___
DROOPY EYELIDS___ DOUBLE VISION___ BLURRED VISION___
LARGE PUPILS___ PINPOINT PUPILS___
C. NOSE: RUNNY___ BLEEDING___
D. THROAT: SORE___ DRY___ SALIVATING___ BLOODY SPUTUM___
HOARSENESS___ DIFFICULTY SPEAKING___
E. RESPIRATION: DIFFICULTY BREATHING___ CHEST/PAIN DISCOMFORT___
WHEEZING (IN/OUT)___ COUGHING___ LABORED BREATHING___
F. HEART POUNDING OR RUNNING___ IRREGULAR HEARTBEAT___
G. GI: LOSS OF APPETITE___ NAUSEA___ FREQUENT VOMITING___
FREQUENT DIARRHEA___ VOMITING BLOOD___ DIARRHEA WITH BLOOD___
H. URINARY: BLOODY URINE___ UNABLE TO URINATE___
I. MUSCULOSKELETAL: NECK PAIN____ MUSCLE TENDERNESS___
MUSCLE TREMBLING/TWITCHING___ WEAKNESS___
PARALYSIS, DESCRIBE:_____________________ CONVULSIONS___
TREMORS___ MUSCLE ACHES___ BACK PAIN___ JOINT PAIN___
J. SKIN: RASH___ REDDENING___ ITCHING___ BLISTERS___ PAIN___
NUMBNESS___ PROFUSE PERSPIRATION___
15. COMMENTS:
______________________________________________________________________
16. ANIMALS AFFECTED: YES___ NO___ DESCRIBE:__________________________
17. RELATED SPECIMENS_________________________________________
ID NUMBER_____________________________________
DESCRIPTION__________________________________
18. COLLECTOR
SIGNATURE____________________________
NAME___________________________
PHONE NUMBER______________________
E-MAIL________________________
19. REVIEWER
SIGNATURE
NAME
PHONE NUMBER_________________
E-MAIL_________________
_Figure B-2. Sample/specimen background document._
CB INCIDENT INTERVIEW
DATE:_____________________ INTERVIEWER: ______________________________
SUBJECT'S NAME: ______________________________________________________
ALIAS #1_____________________________ #2______________________________
AGE:____________ SEX: ____ M ____F YEAR OF BIRTH:__________
NATIONALITY:__________________________________________________________
SUBJECT'S ADDRESS:____________________________________________________
IDENTITY CARD #:______________________________________________________
DELIVERY METHODS:
TYPE: ____UNKNOWN _____GROUND ____AIR _____ARTILLERY/ROCKET ____MINE
OTHER, DESCRIBE:______________________________________________________
HEIGHT: ______(M)
SIZE: _____________ (AFFECTED AREA IN METERS)
DISTANCE: __________(M)
AGENT CHARACTERISTICS
ODOR: _____NONE _____SWEET _____FRUITY _____IRRITATING _____PEPPER
_____FLOWER _____CHANGING _____OTHER, DESCRIBE:_______________________
COMMENTS:_____________________________________________________________
______________________________________________________________________
CONSISTENCY:
______SMOKE ______MIST _____DUST _____RAIN ______GEL ______DRY
____VISIBLE ____INVISIBLE ____OTHER, DESCRIBE:________________________
COLOR:_____________ DESCRIBE DEVELOPMENT OF COLOR:____________________
AREA COVERAGE:________________________________________________________
PHYSICAL DISSEMINATION/COVERAGE (i.e., DROPLET SIZE AND DISTRIBUTION):
WRITE OR DRAW_________________________________________________________
SYMPTOMS:_____________________________________________________________
______________________________________________________________________
INDIVIDUAL'S ACTIONS:
DURING ATTACK:________________________________________________________
______________________________________________________________________
AFTER ATTACK:_________________________________________________________
______________________________________________________________________
PROTECTIVE MEASURES:__________________________________________________
TREATMENT RECEIVED:___________________________________________________
______________________________________________________________________
ENVIRONMENTAL EFFECTS: VEGETATION CHANGE? ___YES ___NO
DESCRIBE:_____________________________________________________________
______________________________________________________________________
ANIMALS AFFECTED? ___YES ___NO
DESCRIBE:_____________________________________________________________
OTHERS AFFECTED:
NAME AGE SYMPTOMS RESOLUTION
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_Figure B-3. Chemical/biological incident interview._
FM AMEMBASSY DDTTTTZ JAN 02
1.00
SHIPPING
TO CDR TEU APG MD/SMCTE-OPEI/
SECSTATE WASHDC
SECDEF WASHDC//OSD-ISA/OUS-DRE//
INFO CIA WASHDC//OSWR-STD-LSB/NIC-NIO(STP)//
JCS WASHDC//J-3/J-5//
DIA WASHDC//DT-3B/DT-5A//
DIR NSA FT MEADE MD
DIR AFMIC FT DETRICK MD//AFMIC- CR/AFMIC-SA//DA WASHDC//
DAMI-FIT/DAMO-SWC//
CDR FSTC CHARLOTTESVILLE VA//AIAST-RA-ID2//
CDR CRDEC APG MD//SMCCR-OPE//
CDR USACMLS FT LEONARD WOOD MO//ATSN-CM-CO//
CDR USAMRIID FT DETRICK MD// (FOR SUSPECT BIOLOGICAL
SAMPLES/SPECIMENS ONLY)
CLASSIFICATION
SECSTATE FOR...
SECDEF FOR
CIA FOR
JCS FOR J-3/J-5 FOR
DA FOR DAMO-SWC FOR
AFMIC FOR
CRDEC FOR FIO
FSTC FOR AMXST-FM
USACMLS FOR THREAT MGR
E.O. 12356: DECL: OADR (NOTE: This is included if the message is
classified.) TAGS:
=SUBJECT: SHIPMENT OF CB SAMPLES=
REF(S): TEU MSG, #______. (DTG DDTTTT [time zone] Jan 02)
1. INFORMATION:
A. DATE SHIPPED: JANUARY 11.2002.
B. MODE OF TRANSPORTATION: AIR EXPRESS. AIR BILL NUMBER RPT
C. FLIGHT SCHEDULE: TO TYO BY JAL XXX JANUARY 11, 2002. TO JFK BY
JAL YYY, JANUARY 13, 2002. TO IAD BY DEC ZZZ, JANUARY 12, 2002.
D. DESTINATION: DULLES INTERNATIONAL AIRPORT
E. ESTIMATED TIME OF ARRIVAL; 2010 HOURS. JANUARY 12, 2002.
2. SPECIAL HANDLING REQUIREMENTS: DRY ICE ENCLOSED AS COOLANT.
3. SHIPMENT CONSISTS OF TWO ICE CHESTS (1 FOR CRDEC AND 1 FOR AFMICO)
CONTAINING SIX SAMPLES/SPECIMENS. ALL LIQUID SAMPLES/SPECIMENS ARE
IN POLYPROPYLENE TUBES AND HAVE BEEN CAREFULLY PACKED TO AVOID
BREAKAGE. THE FOLLOWING SAMPLES/SPECIMENS ARE INCLUDED IN THE
SHIPMENT:
SAMPLE/SPECIMEN NUMBER MESSAGE REFERENCE TH-8501
1AG THRU TH-850102-005AG BANGKOK DDTTTTZ JAN 0202-00
4. USDAO HAS STATED THAT THIS SHIPMENT IS PARTIAL FULFILLMENT OF CIR.
_Figure B-4. Sample/specimen shipping report._
APPENDIX C
GUIDELINES FOR OPERATIONAL PLANNING FOR HEALTH SERVICE SUPPORT IN A
NUCLEAR, BIOLOGICAL, AND CHEMICAL ENVIRONMENT
C-1. General
As the HSS unit prepares for its support role, NBC, TIM, and CBRNE
considerations must be included. This appendix provides guidelines
for HSS planning, preparing for, and conducting operations in an
NBC environment and responding to a homeland defense CBRNE event.
C-2. Predeployment
When preparing the unit's mobilization plan and TSOP, include
the supplies and equipment that will be required for the unit
to operate in an NBC environment. DO NOT wait until ordered to
mobilize to begin preparation for the mission. A well-prepared
and trained unit stands a much better chance of surviving and
accomplishing their assigned mission. At a minimum include the
following:
· Nerve agent pretreatment and antidotes (see FM 8-285).
· Blister agent antidote/treatment (see FM 8-285).
· Incapacitating agent treatment (see FM 8-285).
· Lung-damaging agents (choking agents) treatment (see FM
8-285).
· Blood agent (cyanogen) treatment (see FM 8-285).
· Biological agent immunizations and chemoprophylaxis (see FM
8-284).
· Biological agent treatment (see FM 8-284).
· Nuclear and radiological treatment (see FM 4-02.283).
· Protective mask with hood for each individual (see FM 3-4).
· Replacement filters for protective mask (see FM 3-4).
· Two sets of MOPP per individual assigned to unit (see FM 3-4).
· All authorized radiation detection equipment.
· All authorized chemical agent detection equipment.
· All authorized NBC alarm systems.
· Biological agent detection equipment, if available.
· Sample/specimen collection, packaging, and shipping supplies
for suspect NBC agents.
· Decontamination equipment and supplies (DS2, STB, pails,
sponges, mops, decontaminant application apparatus, individual
skin decontamination kits, and individual equipment
decontamination kits [see FM 3-5]).
· Material for covering supplies and equipment (such as plastic
sheeting, tape, and tarpaulins).
· Material for preparing improvised protection in shelters
(such as plastic sheeting, tarpaulins, tape, and sandbags).
· Collective protection shelter systems with repair parts, if
available.
· Chemical agent patient decontamination Medical Equipment Set
(MES). The MES can also be used to decontaminate nuclear and
biological patients, if authorized.
· Chemical agent patient treatment MES. Some components may
also be used to treat nuclear and biological patients, if
authorized.
· Water supply for patient decontamination, if required.
· Shovels, picks, and axes.
· Lightweight decontamination system M17 and other
decontamination apparatuses.
· Applicable references (Army Regulations [ARs], Joint
publications, FMs, technical manuals [TMs], training circulars
[TCs], and TSOPs).
C-3. Mobilization
During mobilization the unit must ensure that all supplies and
equipment are on hand and are serviceable. Commanders and leaders
must also ensure that--
· Movement plans are prepared.
· Transportation support requirements are identified and
requested.
· Load plans include provisions for the transportation of NBC
supplies and equipment (medical and nonmedical).
· A MOPP level has been established for the movement, if
applicable.
· A checklist of training shortfalls is prepared and a training
plan is in place.
C-4. Establish a Medical Treatment Facility
Plans for establishing a BAS, DCS, or FST for operating in a
NBC environment must include employment of CBPS systems. When
establishing a hospital using Deployable Medical Systems (DEPMEDS),
the chemically protected (CP) DEPMEDS must be set up as the
conventional shelters are being set up. Once the conventional
shelter has been set up and is operational, CP DEPMEDS cannot be
established without first taking down the existing shelter. Follow
the technical manual provided with the CP DEPMEDS system issued to
your unit. Plans for operating a DEPMEDS equipped hospital in the
NBC environment should include, but not be limited to--
· Coordinating with the supported unit to ensure unit casualty
collecting points and patient decontamination points are on the
HSS template. If possible, integrate HSS units/elements into
local units NBC detection systems and communications systems.
· Surveying the AO. Survey the area to ensure contamination is
not present before establishing the MTF.
· Establishing detection stations on the unit's perimeter.
· Determining direction of prevailing wind. All contaminated
patients, ambulances, and helicopters must arrive on the
downwind side of the MTF; this must be done with or without CPS.
· Setting up the contaminated triage, patient decontamination,
and contaminated treatment areas (including overhead cover).
· Establishing the contaminated ambulance point.
· Establishing the contaminated helicopter landing area.
· Preparing the contaminated waste dump.
· Establishing the clean ambulance point.
· Establishing the clean helicopter landing area.
· Marking the hot line and preparing the shuffle pit.
· Employing CP DEPMEDS system (close shelter, turn on CB
filtration units, close air locks, and maintain overpressure),
if available.
· Establishing the clean treatment area 30 to 50 yards (meters)
upwind of hot line, when CPS is not available.
· Ensuring provisions for overhead cover at the patient
decontamination area.
· Requesting patient decontamination personnel from supported
units for the BAS and DCS, or from units located within the
geographic area for hospitals.
· Requesting issue of chemical patient treatment and chemical
patient decontamination MESs, if not on-hand.
· Establishing contamination monitoring procedures in CPS.
· Establishing control procedures for personnel crossing the
hot line (through the shuffle pit).
· Establishing CPS entry and exit control procedures (see
Appendix F).
· Making improvisations; if the MTF must operate in a
nuclear/radiological environment. For optional improvisations,
see Appendix H.
C-5. Operate a Medical Treatment Facility Receiving Contaminated
Patients
Individuals should have decontaminated themselves or have been
decontaminated by unit personnel; however, an MTF must plan for
and be prepared to receive contaminated patients. The patients may
not have been decontaminated at the unit, or they may have become
contaminated en route to the MTF. Selected CSHs may be designated
as the primary NBC MTF and be augmented with additional supplies
and medical staff. When designated as such, plans must be prepared
designating the location of the CSH that can best support the
forward deployed MTFs. All actions listed in paragraph C-4 must be
taken. During operations, actions that must be taken are--
· Establishing a MOPP level commensurate with the operation.
· Requiring all ambulances and helicopters with contaminated
(or suspected) patients to stay downwind of the MTF.
· Conducting initial triage, decontamination, and contaminated
treatment downwind of the clean treatment area (Appendixes F
and H).
· Ensuring all personnel crossing the hot line are
decontaminated.
· Monitoring personnel entering clean area to ensure that they
are contamination free.
· Monitoring for contamination in the clean treatment area
(with or without CPS).
· Establishing an internal monitoring program to periodically
verify that the MTF is contamination free.
· Monitoring CPS for entry of contamination.
· Providing protection for patients if contamination enters the
MTF.
· Ensuring personnel drink sufficient quantities of water to
prevent heat injury (see FM 21-10).
· Providing protection for personnel and patients in a
cold environment. Use sheltered/heated area for patient
decontamination.
· Providing protection of personnel and patients in a hot
environment.
· Controlling contaminated waste.
· Isolating biological agent patients, if necessary, to control
spread of agent/disease (see FM 8-284).
· Protecting supplies and equipment from contamination.
· Providing medical resupply to clean areas.
· Providing food service for personnel and patients in CPS.
· Providing latrine facilities in CPS.
· Providing drinking water in CPS.
· Providing waste disposal support. Remove waste from the CPS
at least two times dally. More frequently if large amounts are
collected or if odors become a problem.
· Collecting suspect BW agent specimens from patients.
Packaging, preparing chain of custody document, and shipping
specimens to supporting medical laboratory.
C-6. Preventive Medicine Services
Plans for providing preventive medicine services must include
monitoring water supplies for contamination. To perform this
mission, equipment and supplies must be available and operational.
Essential equipment and supplies include--
· Radiation detection equipment such as AN/PDR77, AN/PDR27,
AN/VDR2.
· Preventive Medicine Water Quality Control Set.
· M272 Chemical Agent Detection Set.
· Biological sample collection kit, shipping containers,
refrigerant, and chain of custody forms.
C-7. Veterinary Services
Plans for veterinary services must include provisioning for
treatment to government-owned animals and quality control of
food supplies. To perform their mission, essential supplies and
equipment include--
· Treatment for NBC injured animals. Especially, antidotes and
treatment for CB agents.
· Radiation detection equipment.
· M272 Chemical Agent Detection Set.
· Biological sample/specimen collection kit, shipping
containers, refrigerant, and chain of custody forms.
C-8. Dental Services
Most dental services at the dental treatment facilities will have
to be suspended in NBC contaminated areas due to a lack of CPS.
Plans must include for emergency dental services to be provided
in a clean area or in an MTF with a CPS. Essential supplies and
equipment include--
· Dental treatment set for maxillofacial injuries.
· Material for covering and protecting supplies and equipment.
C-9. Combat Operational Stress Control
Although specific supplies and equipment are not required for
COSC, plans must be prepared to provide these services under NBC
conditions. The COSC staff must locate clean areas to conduct COSC
activities or manage the COSC patients in a MOPP level commensurate
with the command MOPP guidance.
C-10. Medical Laboratory Services
Planning for medical laboratory support must include plans for
conducting analysis on suspect NBC samples/specimens. Designated
supporting medical laboratories must be prepared to analyze and
provide confirmation/identification on specimens/samples of suspect
NBC agents from humans, water sources, food supplies, and the
environment (air and soil). The samples/specimens may be collected
by MTF personnel, chemical corps personnel, PVNTMED personnel,
veterinary personnel, or other services personnel. To perform this
mission, supplies and equipment should include--
· General supplies and equipment.
· Biological sample/specimen collection kits and supplies. To
provide capabilities for others to collect samples/specimens
(in the event that they do not have these items otherwise
available).
· Biological test kits or apparatus.
· Microbiology services.
· Immunology/serology MES.
· Microbiology MES.
· Laboratory, general MES.
· Veterinary services.
· Laboratory, veterinary MES.
· Veterinary postmortem field MES.
· Preventive medicine services.
· Water, biological sampling and analysis supplies and
equipment.
· Radiation protection MES.
· Entomology MES.
· Alpha/beta detectors.
· Microscope, phase.
· Ambient air analyzer.
· Epidemiology MES.
C-11. Health Service Logistics
Plans must include health service logistics support to continue
under NBC conditions. To continue this role, all supplies must be
protected from contamination. Materials required include--
· Detection equipment.
· Plastic sheeting.
· Tape.
· Tarpaulins.
· NBC detection equipment such as, M8 chemical agent detection
paper, M9 chemical agent detection tape, radiation detection
equipment, and biological agent sample/specimen collection
supplies.
NOTE
This guideline contains items that are required specifically
for HSS operations in an NBC environment. The items are in
addition to supplies and equipment required for conventional
operations. This guideline is not all inclusive, but is
a starting point for HSS units to develop their specific
guidelines.
C-12. Homeland Security
Health service support units and installation medical
activities/centers must be prepared to provide support in the
event that CBRNE are used on the United States. Medical commanders
and leaders should develop plans on how the provision of medical
support will be provided to a CBRNE event. The plan should include,
but not be limited to--
· Number and type of units required to respond.
· Medical equipment and supplies required.
· Personal protective equipment required for medical response
personnel.
· Time required to prepare unit/personnel to respond.
· Length of time response support is required.
· Sources for food, shelter, local transportation, and resupply
of expended or lost equipment and supplies.
APPENDIX D
MEDICAL PLANNING GUIDE FOR THE ESTIMATION OF NUCLEAR, BIOLOGICAL,
AND CHEMICAL BATTLE CASUALTIES
Section I. INTRODUCTION
D-1. General
The primary purpose of the Medical Planning Guide for the
Estimation of Nuclear, Biological, and Chemical Battle
Casualties--AMedP-8(A), a three-volume publication for NBC, is to
assist medical planners, medical logisticians, and medical staff
officers in predicting NBC warfare contingency requirements for
HSS personnel, medical materiel stockpiles, patient transport
or evacuation capabilities, and facilities needed for patient
decontamination, triage, treatment, and supportive care. The
optional use of these guides is for projecting medical NBC
operational estimates at brigade, division, corps, and EAC.
NOTE
The use of "the guide" in this appendix refers to AMedP-8(A),
Volume I, II, or III. The AMedP-8(A), Volume I, II, or III, is
the text for each of the STANAGs. The contents of this appendix
are extracts from Sections 1, 2, and 3 of the guide.
D-2. Medical Planners' Tool
Medical planners' estimates (such as casualty, logistics,
evacuation, and personnel cross leveling) must be modified for
the NBC environment. Estimates of NBC medical workload can be
found in AMedP-8(A). A compact disk containing these documents
and an automated version of AMedP-8(A), the Casualty Requirements
Estimation Tool (CREST), can be obtained from Headquarters,
Department of the Army, ATTN: DASG-HCZ-FD, 5109 Leesburg Pike,
Falls Church, VA 22041-3258. The CREST is primarily an Army tool
focusing on corps, brigades, and battalions, but also models aerial
ports of debarkation, seaports of debarkation, and other units.
+--------------------------------------+
| This Section Implements STANAG 2475. |
+--------------------------------------+
Section II. MEDICAL PLANNING GUIDE FOR THE ESTIMATION OF NUCLEAR,
BIOLOGICAL, AND CHEMICAL BATTLE CASUALTIES (NUCLEAR)--AMedP-8(A),
VOLUME I
D-3. General
_a._ Volume I of the guide provides estimates of casualties and
remaining operational strength after a nuclear detonation in a
brigade-sized unit during an out-of-area contingency operation.
These estimates include the numbers, injury type (initial nuclear
radiation, blast, and thermal injuries), and injury severity of
nuclear patients based on several brigade scenarios. The scenarios
include three different brigade-sized units, in warned or unwarned
posture, which have single detonation of 5, 20, or 50 KT in the
unit area.
_b._ The guide is organized into 10 sections. Section 1
introduces the guide and presents background and medical planning
considerations. Section 2 provides information on the methodology
used to develop the estimates of fatalities, casualties, and
effectiveness of individuals remaining in the unit. Section 3
explores the use of the casualty prediction tables based on combat
effectiveness decrements and estimates of the number of casualties
categorized by insult level. Sections 4 through 10 contain tables
of casualty estimates.
_c._ A sample of this information is graphically depicted in
Tables 1-1 and 1-2 of the guide. The casualty estimates used to
prepare these tables are presented in the guide as Tables 6-4
and 10-4 in Sections 6 and 10 respectively. The use of these
tables is explained in paragraphs 3.1 through 3.6 of the guide.
Paragraphs 3.7 and 3.8 of the guide discuss how to use the guide
for situations not explicitly addressed.
_d._ The effects of residual radiation on personnel are not
included in the guide. AMedP-6 and AMedP-7 provide information
on planning, operations, and treatment for a residual radiation
situation. Also not included is the impact of tumbling; impact
of glass shards from windows of vehicles or buildings; crushing
deaths from building failure; or COSC casualties; thus causing
underestimations on the number of patients. Further, there will be
personnel who get radiation doses or burns and do not seek medical
care.
_e._ A nuclear detonation may introduce new levels of destruction
to the battlefield. There is very little experience with nuclear
effects and there is certainly no experience with these weapons
on a modern, highly technological battlefield. Therefore, there
is little historical data on which to base estimates of personnel
injured. Computer simulations are generally used to estimate
numbers of personnel injured. Although these estimates may include
significant uncertainty, they provide the best estimates to date.
D-4. Medical Planning Considerations
_a._ For effective mass casualty management, key medical and
related considerations must be well planned and practiced. These
include on-site triage and emergency care, communications, health
service logistics, evacuation by ground and air resources, and
personnel training in self-aid/buddy aid. Plans need to be made
for requirements that may differ from the usual combat situation.
For example, in combat situations, severe burn injuries in large
numbers are relatively uncommon. Therefore, no special planning
for the care of large numbers of burn patients is required. In a
nuclear environment, this may not be true, and consideration must
be given to the increased need for medical support that would
result from a high incidence of burn patients.
_b._ Prior to an attack, the data may be used by medical planners
to augment the requirements for conventional combat as appropriate
for the nuclear situation. The tables can be used to prepare
estimates of the number of patients at all echelons.
_c._ After an attack, the effectiveness and adequacy of the medical
support effort during the first 24 hours are critical. Commanders
should be informed rapidly of the estimated medical load in order
to provide rescue and treatment resources or request assistance
from higher headquarters, adjacent units, or allied units. These
estimates should be updated postattack based on aerial or ground
reconnaissance and survey.
_d._ In addition to casualties, a nuclear weapon detonation can
generate an EMP that may cause catastrophic failures of electronic
equipment components and may adversely affect the capability of
all units in the area of the detonation. Electromagnetic pulse has
no direct effect on personnel and is not further addressed in this
publication.
D-5. Triage
Since a nuclear detonation may produce mass casualties, plans for
a triage system must be in place. Paragraphs 3.4 through 3.5 of
the guide describe patient categories by injury severity and may
be used to estimate the number and injury severity of patients
for a particular operational scenario. The guide does not,
however, provide estimates of the number of patients by triage
classification.
D-6. Evacuation
_a._ An efficient and flexible evacuation plan is absolutely
essential for the preservation of life and to retain the mobility
of forward medical resources. In a potential mass casualty
situation, the full range of evacuation assets should be considered.
_b._ The extended hospital time of nuclear casualties will
influence levels of evacuation or hospitalization. In addition,
estimates of the different types of casualties can be a
consideration in evacuation planning. In planning for evacuation,
estimates provided in the guide can be used as a starting point
from which to estimate evacuation resources.
D-7. In-Unit Care
_a._ Some personnel within the military unit may not be classified
medically as casualties, but will require some self-aid and buddy
aid. A casualty is defined as anyone entering the medical system.
Paragraph 2.5 of the guide further describes the basis for casualty
calculation.
_b._ Nuclear detonations will produce a large number of blast,
burn, and projectile injuries that initially must be treated by
individual soldiers trained in first aid procedures. The physical
damage to the surrounding area as a result of a nuclear detonation
will increase delays in medical assistance and evacuation. Training
in self-aid/buddy aid will improve casualty survival rates and
conserve medical resources. The guide can be used to provide a
conservative estimate of the numbers of injured that will require
first aid. The tables in Sections 4 through 10 of the guide,
showing the status of unit personnel by time period, can be used
to indicate the numbers of personnel who are injured (but not
casualties) who may require first aid.
D-8. Hospital Bed Requirements
The data provided in the guide can be used to determine immediate
additional bed requirements resulting from a nuclear detonation.
In addition to the numbers of patients who will need beds, the
data provided in the guide can also indicate the increased
hospitalization time of nuclear casualties. Long-term bed
requirements, greater than 30 days, are not provided. Based on the
theater evacuation policy specified for the operation, the hospital
bed days may be in theater or in CONUS.
D-9. Medical Logistics
The data provided in the guide can assist in estimating the needed
supplies. The supply system must be prepared for increased demands
for certain types of medical and general supplies and equipment,
kits, dressings, and antibiotics. The treatment of combined
injuries will not require any special types of supplies, although
demands for certain types of supplies will increase.
D-10. Medical Force Planning
The assignment of medical support is normally based upon the
total military population and the expected conventional casualty
rate. The data provided in the guide may be used to assess the
requirement for additional medical units. The planning guidance
presented in this document can (and should) be modified to reflect
the needs of the anticipated operation, including operational
tempo, national/coalition priorities, medical resource allotment,
and so forth. When trying to augment personnel, consider that
the use of a nuclear weapon in a tactical situation could be an
indication of an increased tempo of warfare. Therefore, even though
a unit may be targeted with a nuclear detonation, that unit may
not be the site where the highest numbers of casualties are being
produced, and another unit may have priority of support.
+--------------------------------------+
| This Section Implements STANAG 2476. |
+--------------------------------------+
Section III. MEDICAL PLANNING GUIDE FOR THE ESTIMATION
OF NUCLEAR, BIOLOGICAL, AND CHEMICAL BATTLE CASUALTIES
(BIOLOGICAL)--AMedP-8(A), VOLUME II
D-11. General
The guide, AMedP-8(A), Volume II, provides estimates of casualties,
and remaining operational strength, after single BW attacks on
tactically deployed, brigade-sized land force units, offshore naval
and marine forces, and selected strategic targets in rear areas.
These worst-case casualty estimates are for personnel within
both the targeted and the downwind hazard areas of the attacked
forces. They assume that all affected personnel will be unsheltered
and unwarned. To further estimate worst-case outcomes, the guide
assumes that exposed individuals have not been vaccinated against
any of the evaluated agents, nor have they undergone any type
of medical prophylactic treatment prior to exposure. The tables
included in the guide are designed to show numbers of expected
casualties; expected fatalities; personnel at different performance
levels; and times after exposure. In selected scenarios, the guide
provides a method for estimating casualties among collocated
civilians based on local population density.
_a._ The guide presents casualty estimates for all possible
combinations of the following conditions:
· Eleven operational scenarios.
· Seven biological agents.
· Four types of delivery systems.
· Three attack intensities.
_b._ The guide is subject to limitations of extent and content.
Since there are many more possible attack variables than those
considered, the guide presents a limited number of estimates and
provisional guidance for estimating cases not modeled. These
estimates are based upon the best available medical data, but
such data result in qualified estimates. Therefore, for more
authoritative medical descriptions, medical planners and staff
personnel should use FM 8-9, NATO Handbook on the Medical Aspects
of NBC Defensive Operations, AMedP-6(B), Part II--Biological.
Users of the guide must amplify or modify these estimates to meet
emergent requirements such as injuries resulting from combined
biological and conventional attacks.
_c._ Computer models that integrate available information have been
used to predict the effects of future biological attacks. These
resultant estimates may include substantial uncertainties when
applied to specific situations. However, they provide the best
estimates available to date.
_d._ The guide is also organized into 10 sections. Section 1
introduces features of the guide, and then presents background and
medical planning considerations. Section 2 provides information on
the methodology used to develop the estimates. Section 3 describes
how to use the tables presented in the guide. Sections 4 through 10
of the guide contain tables of casualty estimates, with one section
for each of the seven biological agents.
_e._ Biological attacks are likely to have a significant impact on
the medical system. As detailed elsewhere in the guide, victims
may number in the hundreds or even thousands. Demand for medical
care may quickly overwhelm available resources; this problem will
be exacerbated if medical personnel themselves become victims of
the attack. Local civilian populations will be victimized as well,
limiting host-nation support and potentially adding to the demands
on the military medical system.
_f._ A variety of medical responses to BW attacks are available,
depending on the agent used and whether medical countermeasures are
employed prior to attack or after exposure has already occurred.
For many agents, immunization or pre-exposure prophylaxis with
antibiotics may prevent illness in those subsequently exposed.
After exposure, disease can often be prevented or ameliorated via
immunization and therapeutic use of antibiotics, antiviral drugs,
and hyperimmune gammaglobulins.
D-12. Medical Planning Considerations
_a._ Effective mass casualty management requires careful planning.
The guide is designed to support such planning by providing medical
planners and staff personnel with a systematic means for estimating
the number of biological casualties. However, casualty management
also involves practice of self-aid and buddy aid, on-site triage
and emergency care, decontamination, transport to medical
facilities, infection control measures, communications, health
services, logistics, and evacuation by ground or air transportation.
_b._ Medical requirements resulting from attacks with biological
agents may be substantially different from those resulting from
conventional, nuclear, or chemical combat. There would be no
indication of the presence of biological agents in most tactical
situations. Units downwind from an attack area may be unexpectedly
exposed to biological agents. In some cases, there will also be a
risk of secondary infection and subsequent epidemics amongst troops
and/or the local population. Additionally, use of biological agents
may generate reservoirs within the local animal population that may
serve as a further source of infection.
_c._ Often the first indication of an attack with a biological
agent will be the development of symptoms in exposed personnel.
Diagnosis and treatment are complicated by the fact that many
of the agent-induced diseases described in the guide begin with
symptoms associated with common illnesses, such as influenza. In
such cases, biological agent attacks may generally be distinguished
from naturally occurring epidemics by the sudden onset of disease,
the large number of personnel presenting with similar symptoms, and
the concentration of those personnel in geographically contaminated
areas.
D-13. Triage
_a._ Since a biological attack may produce mass casualties,
preparations for a triage system should be in place before the
attack. Paragraph 3.3.8 of the guide describes patient categories
by illness severity. For a particular described operational
scenario, this information may be used to estimate the number
of patients with specified levels of illness. The guide does
not provide estimates of the number of patients by triage
classification or usual medical descriptions.
_b._ Decontamination of patients must be considered before further
evacuation.
D-14. Evacuation
_a._ An efficient and flexible evacuation plan is essential for
adequate casualty treatment and to retain mobility of forward
medical resources. For an assessment of a potential mass casualty
situation, the medical planner should consider the full range of
evacuation assets, limitations, and obstacles. After an attack,
the medical staff may need to estimate the number of casualties
that could require evacuation at given postexposure times.
_b._ Evacuation requirements will vary with the type of biological
agent used. Casualties resulting from some agents may not be
evacuated because the time course of effects is relatively short.
For others, like botulinum toxin, casualties may require evacuation
to a facility where they can receive care for weeks or even months.
Estimates provided in the guide can be used as a starting point
from which to plan for evacuation resources, including those
required for decontamination of personnel and transportation assets.
D-15. In-Unit Care
The casualty estimates in the guide are presented without
allowance for in-unit care. However, there may be need for rapid
intervention. Delays in obtaining medical care may occur because of
physical damage or contamination of the surrounding area. Soldiers
trained in first aid procedures may be the first to provide aid
to biological agent casualties. The guide provides a conservative
estimate of the numbers of exposed personnel who will require first
aid. The tables described in paragraphs 3.3.2 through 3.3.4 of the
guide give the time courses of effects that may apply to estimation
of in-unit care and delayed medical requirements.
D-16. Patient Bed Requirements
Bed requirements can be estimated using the tables described in
paragraphs 3.3.2 through 3.3.4 of the guide. The latter type of
table is useful after an attack since it shows gains and losses
of casualties over time. The type of table described in paragraph
3.3.5 of the guide may be more useful for long-range planning. It
shows maximum numbers of personnel by illness severity category.
The tables in the guide only provide estimates for the first 35
days after attack. Based on the theater evacuation policy specified
for the operation, hospital days may be in theater or in the
national area.
D-17. Medical Logistics
_a._ The estimates provided in the guide are intended to support
projections of medical materiel and logistical requirements.
Increased demands may occur for certain types of medical and
general supplies, including equipment, kits, antibiotics,
disinfectants, and other critical medical materiel. Demands may
also increase for items unique to the prevention and treatment of
biological agent casualties, such as vaccines, antibiotics, and
antisera, as well as items adapted to contaminated environments.
Tables showing maximum numbers of personnel by illness severity
category can provide useful input for logistical planning.
_b._ Often the first indication of an attack with a biological
agent will be the development of symptoms in exposed personnel.
Diagnosis and treatment are complicated by the fact that many
of the agent-induced diseases described in the guide begin with
symptoms associated with common illnesses, such as influenza. In
such cases, biological agent attacks may generally be distinguished
from naturally occurring diseases.
D-18. Medical Force Planning
_a._ The assignment of medical support is normally based upon the
total military population and the expected conventional casually
rate. The guide may be used to assess requirements for additional
medical units.
_b._ Although a specific unit may be the target of a biological
attack, more casualties could be suffered by other units downwind.
Accordingly, a unit other than the targeted one may have priority
for support. The tables presented in the guide can be used in
planning for either situation. Some tables show estimated maximum
numbers of personnel by illness severity category. Such estimates
should be combined with a comprehensive array of other available
information to increase the effectiveness of medical force planning.
+--------------------------------------+
| This Section Implements STANAG 2477. |
+--------------------------------------+
Section IV. MEDICAL PLANNING GUIDE FOR THE ESTIMATION OF NUCLEAR,
BIOLOGICAL, AND CHEMICAL BATTLE CASUALTIES (CHEMICAL)--AMedP-8(A),
VOLUME III
D-19. General
_a._ The primary purpose of Volume III is to assist medical
planners, logisticians, and staff officers in predicting CW
contingency requirements. Requirements include medical personnel,
medical materiel stockpiles, patient transport or evacuation
capabilities, and facilities needed for patient decontamination,
triage, treatment, and supportive care. An optional purpose is to
support medical operational estimates.
_b._ The guide provides medical worst-case estimates of casualties
and remaining operational strength after a single CW attack on
a tactically deployed, brigade-sized land force units, with
protection available and protection unavailable. These worst-case
casually estimates are for personnel located within both the
targeted and the downwind hazard areas of the brigade. It is
assumed that all targeted personnel will be unsheltered and without
medical pre-exposure prophylactic treatment. Tables in the guide
are designed to show total numbers of--
· Casualties with different types and severities of injury at
various times after exposure.
· Personnel at different performance levels and times after
exposure.
· Fatalities at specified times after exposure.
_c._ The guide presents estimates of personnel status at specific
time points. These range from 1 to 3 hours to 7 to 30 days after an
attack, depending on the type of agent considered. Such estimates
are projected from all possible combinations of the following
conditions:
· Seven operational scenarios involving three types of units:
heavy brigade, support brigade, and light infantry brigade.
· Three chemical agents: the nerve agents GB and VX, and the
blister agent HD.
· Three types of munitions delivering the agents: aerial bombs,
tactical ballistic missiles, and rounds from multiple launch
rocket systems/artillery batteries--
· Three attack intensities for each type of munition: light,
moderate, and heavy.
· Two postures of individual physical protection against the
attacks: unavailable and available.
_d._ An index to essential information and four sample problems
to illustrate use of this information are at the end of the guide
(see Section 11). Section 11 provides a planning guide overview,
describes applications, and presents a brief explanation of
modeling methods used to prepare estimates.
_e._ The guide is subject to limitations of extent and content.
Since there are many more possible attack variables than those
considered, the guide presents a limited number of estimates.
These estimates are based upon the best available toxicological
values, but such values are qualified estimates. Therefore, medical
planners and staff personnel should use FM 8-9, NATO Handbook on
the Medical Aspects of NBC Defensive Operations, AMedP-6 (B), Part
III--Chemical, for more authoritative medical descriptions and
information on effects of longer duration.
_f._ The guide is most value to the user who needs to know what
kinds of casualties to expect, relative numbers of each, and the
time frames in which they are likely to appear. To assist the
user, who lacks experience in actual CW, the guide describes types
of injury, relevant factors, general magnitudes of effects, and
effects of time courses on chemical casualty numbers. The casualty
estimates are appropriate for training exercises. However, this
initial attempt to provide complex estimates has limitations for
battlefield use. The limitations are described as follows:
· The guide provides estimates for a few of many possible
chemical attacks. Each estimate is based upon computer modeling
of the consequences of specified conditions. This is like
saying that the numbers of men who sneeze, after inhaling
an allergic flower pollen, might be predicted if specific
information (EXAMPLE: The wind speed and direction, the current
weather, altitude, time of day, and sites of concentrated
flower growth) is known for the specific geographic location
of a particular brigade on a given mountain. If such estimates
are made for a few widely different mountains, a user of the
estimates may be able to guess the numbers of sneezing men in
his own brigade, located on a separate mountain. However, if
the conditions on both mountains are not nearly identical, the
user will need to estimate a scaling factor and apply it to
adjust the number predicted for a different environment.
· It is unlikely that exactly identical conditions will exist
for any two mountains or chemical attacks. The user of the
guide must decide which scenario best represents his conditions
(or interpolate from two scenarios), then use or adjust the
estimates. Therefore, each user must recognize any differences
from modeled conditions that might require him to increase, or
decrease, an estimate. The user may need to apply a commander's
guidance on acceptable risk levels, or consider restrictions
of available resources, before accepting, interpreting, or
modifying the relevant planning guide numbers. The most
difficult problem for the user will be to determine how much to
increase, or decrease, planning guide numbers to fit the user's
situation. This problem is discussed in paragraph 3.4 of the
guide.
· The user should be aware that medical worst-case targeting
selects for maximal numbers of survivors entering the medical
system, not for maximal operational losses. The tabulated
estimates are very highly sensitive to the degree of clustering
of personnel and their assumed location within a standardized
brigade area. Accordingly, use of this targeting method leads
to large variations that are based upon the probabilities of
hitting clustered personnel, not evenly or widely distributed
personnel. Therefore, these estimates do not provide a good
basis for estimating the most likely outcomes for a series of
"average" attacks, or for comparing a scenario with an actual
attack. Although the tabular format of the guide suggests
that the listed numbers are exact, the user should understand
that different targeting could readily produce other numbers.
Selection of a scaling factor Is discussed in paragraph 3.4 of
the guide.
D-20. Medical Planning Considerations
_a._ The guide provides medical planners and staff personnel
with a systematic means for estimating chemical casualties in
various-sized units, without regard to composition. This document
provides more accurate and detailed estimates and is based upon
detailed operational scenarios for brigade-sized units. Both
chemical planning guides support estimates of combat performance
from individuals remaining in the unit.
_b._ Effective mass casualty management requires careful planning.
The guide is designed to support such planning by providing medical
planners and staff personnel with a systematic means for estimating
the number, type, and time-related status of chemical casualties.
NOTE
Each user is advised to consult any available national military
NBC defense doctrinal publications of similar nature.
_c._ Medical requirements during CW may be substantially different
from those for the usual combat situation. There may be no
indication of the presence of chemical agents in some tactical
situations. Unprotected units downwind from an attack area, or
those entering contaminated areas in an unprotected posture, may
be unexpectedly exposed to chemical agents. However, casualty
management also involves practice of self-aid and buddy aid,
on-site medical triage and emergency care, transport to medical
facilities, communications, health services, logistics, and
evacuation by ground or air transportation.
_d._ The signs and symptoms of chemical agent exposure may be
sudden and intense, or delayed and subtle, depending on the
agent used and the level of exposure. Individuals may not reach
the first level of care for 15 to 60 minutes after the onset of
effects. Decontamination may delay medical treatment. Stabilization
should occur before casualties leave emergency care areas, but
contamination of these areas may delay the stabilization process.
However, effects of decontamination or secondary contamination
on estimated doses and effects are not considered in the guide.
For medical planning, users of the guide need to consider the
various qualifications of its casualty estimates, as discussed in
paragraphs 3.4 and 3.4.2 of the guide.
_e._ A chemical burn caused by HD can require more care than a
same-sized burn induced by conventional munitions. Therefore, the
initial prognosis may require revision after treatment is underway,
and estimates of percent capable by performance band may require
adjustment.
D-21. Triage
Since a chemical attack may produce mass casualties, preparations
for a triage system should be in place before the attack. Paragraph
2.5.1 of the guide describes patient categories by injury severity.
For a particular described operational scenario, this information
may be used to estimate the number of patients with specified
levels of injury. The guide does not provide estimates of the
number of patients by triage classification or usual medical and
toxicological descriptions.
D-22. Evacuation
_a._ An efficient and flexible evacuation plan is essential for
adequate casualty treatment and to retain mobility of forward
medical resources. For assessment of a potential mass casualty
situation, the full range of evacuation assets, limitations, and
obstacles should be considered by the medical planner. After an
attack, the medical staff may need to estimate the number of
casualties that require evacuation resources at given postexposure
times.
_b._ Evacuation requirements will vary with the type of chemical
agent used. Nerve agent casualties may not be evacuated because
the time course of severe effects is relatively short. Depending
upon exposure conditions, HD casualties may or may not require
evacuation to a facility where they can receive care for several
days, or possibly 6 to 9 months. Estimates provided in the guide
can be used as a starting point from which to plan for evacuation
resources.
D-23. In-Unit Care
The casualty estimates in the guide are presented with no allowance
for in-unit care such as self-aid or buddy aid. Soldiers trained in
first aid procedures may be the first to see chemical injuries. The
guide can provide an estimate of the numbers of injured personnel
who will require first aid. However, there may be need for rapid
augmentation, support, or other intervention. Delays in obtaining
medical care may occur because of physical damage or contamination
of the surrounding area. The tables described in paragraphs 3.3.2
and 3.3.3 of the guide give the time courses of effects that may
apply to estimation of in-unit and delayed medical requirements.
D-24. Patient Bed Requirements
Requirements for patient beds and hospitalization time may be
greater after chemical exposures than after a conventional attack.
Such increases are particularly important for agents, such as
HD, that produce injuries followed by a long recovery period.
Bed requirements can be estimated using the tables described in
paragraphs 3.3.2 and 3.3.3 of the guide. Casualties Occurring by
Time Period tables (see paragraph 3.3.3) in the guide are useful
after an attack since they show gains and losses of casualties
over time. Personnel by Injury Category tables (as described in
paragraph 3.3.4) in the guide may be more useful in long-range
planning. They show maximum numbers of personnel by injury severity
category. The tables in the guide only provide estimates for the
first 30 days after attack. Depending upon the theater evacuation
policy specified for the operation, hospital days may be either in
theater or in the national area.
D-25. Medical Logistics
The estimates provided in the guide are intended to support
projections of medical materiel and logistical requirements.
Increased demands may occur for certain types of medical and
general supplies. These may include specific equipment, kits,
dressings, antibiotics, and other critical medical materiel.
Demands may also increase for items unique to the chemical
battlefield (such as nerve agent antidote autoinjectors), as
well as items adapted to chemical environments (including IV
systems and special self-contained intensive care units). Tables
showing maximum numbers of personnel by injury severity category
(see paragraph 3.3.4 in the guide) can provide useful input for
logistical planning.
D-26. Medical Force Planning
_a._ The assignment of medical support is normally based upon the
total military population and the expected conventional casualty
rate. The guide may be used to assess requirements for additional
medical units. The use of chemical weapons in tactical situations
could be one indication of an increased tempo of warfare and need
for additional personnel.
_b._ Although a unit may be targeted for chemical attack, that
unit might not be located where the highest number of casualties
could occur (as in a downwind hazard area). Accordingly, another
unit might have priority for support. The tables presented in the
guide can be used in planning for either situation. Some tables
(see paragraph 3.3.4 in the guide) show estimated maximum numbers
of personnel by injury severity category. Such estimates should be
combined with a comprehensive array of other available information
to increase the effectiveness of medical force planning.
_c._ The guide is organized into 11 sections. Section 1
introduces the guide and presents background and medical planning
considerations. Section 2 provides information on the methodology
used to develop the estimates of fatalities, casualties, and
effectiveness of individuals remaining in the unit. Section 3
explores the use of the casualty prediction tables based on combat
effectiveness decrements and estimates of the number of casualties
categorized by insult level. Sections 4 through 10 contain tables
of casualty estimates. Section 11 is a tutorial on use of the tool.
_d._ These medical worst-case casualty estimates (see paragraph
2.1.2 through 2.1.7 in the guide) are for personnel in the
chemical-targeted and downwind hazard areas of the brigade sector.
The actual areas presenting chemical agent hazards to personnel
are relatively small and localized when compared to the entire
brigade sector. These estimates are not valid for acute effects
from repeated exposures, possible delayed effects of low dosage
exposures, operational worst-case targeting, targets with different
numbers or distributions of exposed personnel, or attacks involving
different conditions (of meteorology, terrain, protective status,
and so forth) than are modeled. Although the guide is primarily
designed to support medical force planning for future CW defense,
it may be used to anticipate short-term requirements. For example,
delayed requirements of HD victims for care or evacuation resources
may be predicted from tables that give estimates of casually
numbers by injury type at given times after a CW attack (see
paragraphs 3.3.2 and 3.3.3 in the guide).
APPENDIX E
Example X-__, ANNEX__, TO HSS PLAN/OPERATION ORDER__, MEDICAL NBC
STAFF OFFICER PLANNING FOR HSS IN AN NBC ENVIRONMENT
1. PURPOSE. Establish standardized procedures for medical NBC
staff officers planning, preparing for, detecting, reporting, and
providing preventive/protective measures for NBC/TIM hazards.
Establish planning procedures for conducting HSS in NBC/TIM
environments. Also, establish procedures for providing technical
guidance/support to leadership before, during, and after an NBC/TIM
event.
2. PROCEDURES
_a._ Medical NBC staff officers prepare list of equipment and
procedural guidelines for HSS operations under NBC/TIM conditions.
(_Provide a list of radiological detection devices, chemical agent
detection/identification kits/devices, components of biological
sample/specimen collection, and shipping containers. Provide
guidelines/references for operating detection/identification
devices._)
_b._ Planning actions for use before an NBC/TIM event. (_Provide
preventive/protective measures that the leadership can employ
to reduce the health effects of a NBC/TIM event. Also, provide
preventive/protective measures that leadership can employ to reduce
the health effects of existing NBC/TIM hazards/contamination in an
AO. Provide HSS leadership with procedures that can be employed to
protect their unit and patients._)
_c._ Planning action for use during an NBC/TIM event. (_Provide
preventive/protective measures that the leadership can employ
to reduce the health effects of a NBC/TIM event. Provide HSS
leadership with procedures that can be employed to protect their
unit and patients._)
_d._ Planning actions for use after an NBC/TIM event. (_Provide
preventive/protective measures that line leadership can employ
to reduce/mitigate the health effects of an NBC/TIM event on the
force. Provide HSS leadership with procedure that can be employed
to mitigate the effects on their unit and patients._)
_e._ Planning actions for preventive medicine support for NBC/TIM
events. (_Provide types and numbers of PVNTMED units/personnel
required to perform PVNTMED missions during such events. Describe
mission requirements for units/personnel preparing for and reacting
to the event. Describe types of samples required and how samples
must be collected, preserved, packaged, and shipped to supporting
medical laboratory for analysis. Describe detection/monitoring
equipment required for the event; such as AN/PDR77, AN/VDR2 radiac
meter, chemical agent monitor (CAM), and M272 water test kit._)
_f._ Planning actions for veterinary support for NBC/TIM events.
(_Provide types and numbers of veterinary units/personnel required
to perform the veterinary service missions during such events.
Describe mission requirements for units/personnel preparing for and
reacting to the event. Describe types of samples/specimens required
and how samples/specimens must be collected, preserved, packaged,
and shipped to supporting medical laboratory for analysis. Describe
food contamination and decontamination procedures. Describe
detection/monitoring equipment required for the event; such as
AN/PDR77, AN/ VDR2 radiac meter, and CAM._)
_g._ Planning actions for medical laboratory support for NBC/TIM
events. (_Provide requirements for medical laboratory support for
an NBC/TIM event. Describe types of laboratory test/ procedures
required to provide command verification on the use of an NBC
device/weapon. Provide medical laboratory reporting requirements;
example: provide report to command surgeon; Joint Task
Force/theater commander; senior commander in affected operational
area._)
_h._ Planning actions for combat health logistics support for
NBC/TIM events. (_Provide requirements for combat health logistics
support units and personnel. Describe types of Class VIII supplies
required to support HSS response to an event. Examples: Numbers of
chemical agent patient decontamination MESs, chemical agent patient
treatment sets, number of packets of chemical agent pretreatment
tablets required, and chemoprophylaxis required for personnel
exposed to a biological agent._)
_i._ Planning actions for combat stress control/mental health
support for NBC/TIM events. (_Provide requirements for COSC/mental
health support units/personnel. Describe where and how COSC/ mental
health personnel will provide their support in response to the
event._)
_j._ Planning for medical treatment of NBC/TIM event casualties.
(_Provide requirements for medical evacuation and treatment
(including emergency dental care) support units/personnel.
Provide requirements for nonmedical personnel to perform patient
decontamination at the MTF. Describe where and how evacuation and
treatment personnel will provide their support in response to
include supervision of patient decontamination procedures._)
3. COORDINATION REQUIREMENTS. (_Provide requirements for support
such as who should transport/escort samples/specimens from unit
of origin to support medical laboratory and on to the CONUS gold
standard laboratory. Example: The Technical Escort Unit normally
provides transportation and escort for suspect NBC samples, in
their absence describe who will provide this service. Provide
requirements for numbers of personnel required to perform patient
decontamination at supporting MTFs. Describe decontamination
support requirements for medical units; especially hospitals and
major combat health logistics facilities._)
4. REPORTS. (_Describe types of reports required and frequency
of reporting on HSS aspects of NBC/TIM events. Reports should
provide, at a minimum, aspects of event and recommended preventive/
protective actions needed to prevent or minimize casualties._)
APPENDIX F
EMPLOYMENT OF CHEMICAL AND BIOLOGICAL COLLECTIVE PROTECTION SHELTER
SYSTEMS BY MEDICAL UNITS
Section I. INTRODUCTION
F-1. General
To continue the HSS mission under CB conditions, MTFs must search
out contamination free areas or employ CPS systems. Levels I and
II MTFs may be able to locate contamination free areas; however,
due to the mobility limitations of hospitals, they must always
be prepared to operate under CB conditions if the area is under
attack. Systems that can be employed as an MTF (Levels I, II, III,
and IV) are described in this appendix.
F-2. Types of Collective Protection Shelter Systems
_a._ The CBPS system is employed at the BAS, DCS, and FST. The CBPS
is attached to the hard-walled box on the rear of a high mobility
multi-purpose wheeled vehicle (HMMWV). The BAS will have one CBPS
system per treatment team; the DCS will have four CBPS systems; the
FST will have three CBPS systems. Also, systems will be issued to
other selected medical treatment teams. When employed at the DCS,
the patient holding team will also require GP tents to hold their
required number of patients (see Chapter 4). Patients held inside
the CBPS will be those that have been decontaminated and admitted
into the system for treatment and are recovering from the treatment
procedures and are awaiting evacuation. Any patients held in the
GP tent must remain in MOPP Level 4 (the GP tent will not have
collective protection); these patients are those that are expected
to RTD within 72 hours.
NOTES
1. Normally, patients will not be held at the DCS under NBC
conditions unless evacuation cannot be accomplished. They
should be RTD or evacuated to a clean MTF, as soon as the
mission permits.
2. The CBPS can also be employed as the DCS in the conventional
mode. Employment in either mode still requires GP tentage for
patient holding to meet total patient holding requirements.
_b._ The DEPMEDS-equipped patient care areas of the US Army Force
XXI hospital and the hospital unit base (HUB) of the Medical
Force 2000 (MF2K) will employ the CP DEPMEDS. It will not protect
personnel or patients from the thermal, blast, and initial
radiation effects of nuclear weapons; however, it will provide
some protection against fallout effects. Areas of the hospital
that are not included in the chemically protected (CP) DEPMEDS
are MF2K general hospital unit medical (HUM), MF2K field hospital
unit holding (HUH), MF2K combat support and general hospital unit
surgical (HUS), minimum care wards, administrative areas, food
service, supply (including Class VIII), and staff quarters. The
system includes--
· Chemically/biologically protected liners for tent,
expandable, modular, personnel (TEMPER) and passageways.
· CB-filtered and conditioned (heated or cooled) air (field
deployable environmental control unit [FDECU] or H80 Army
Standard Heater).
· Chemically/biologically protected ambulatory, litter, and
supply air locks.
· Chemically/biologically protected latrines.
· Chemically/biologically protected seals for ISO shelters.
· Chemically/biologically protected water supply system.
_c._ The M20 simplified collective protection system is another
system that is available. It consists of a chemically protected
room liner, a CB filter blower, and an ambulatory air lock.
However, it does not have a litter air lock making it unsuitable
for litter patient care. The M20 may be used to protect medical
staffs at the DCS, FST, and hospitals, patients held in the GP
tents at the DCS and in the minimum care wards and staff quarters
of the hospitals. Thus providing additional CB protection for
staffs and patients.
Section II. EMPLOYMENT OF THE CHEMICALLY BIOLOGICALLY PROTECTED
SHELTER SYSTEM
F-3. Establish a Battalion Aid Station in a Chemically Biologically
Protected Shelter
To establish a BAS in a CBPS, use one CBPS per treatment team
for conventional operations in a split-team mode. When operating
in a squad configuration and in the conventional mode, the two
CBPS systems may be complexed to provide more workspace. However,
keep in mind that the treatment squad is not staffed to operate
the two systems in the CB mode. Therefore, when the two systems
are complexed and the treatment squad must convert and operate
in the CB mode, they may want to close the complexing door and
only use one system. When initially setting up the CBPS for
operations in the CB mode, only one CBPS is setup; see Note 2
below. Set up the system as described in TM 10-5410-228-10. To
be operational as a BAS, set up medical supplies and equipment
as required or as designated in the TSOP. A PDS consisting of
a contaminated ambulance point, contaminated triage point, a
patient decontamination area, and a contaminated treatment area is
established on the downwind (prevailing wind) side of the CBPS. An
overhead cover of plastic sheeting (approximately 20 feet wide by
50 feet long) is set up over the PDS, the hot line, and the clean
treatment/waiting area; the cover overlaps the air locks. The clean
treatment/waiting area should have an area at least 20 feet wide by
15 feet long to allow space for placing patients into the litter
air lock without crossing the hot line. A second area covered with
20 × 25 feet of plastic sheeting (the evacuation holding area) is
set up beside the shelter on the opposite side from the generator.
The clean treatment area is separated from the decontamination area
by a hot line with a shuffle pit. Only clean (decontaminated)
patients or personnel are allowed to cross the hot line into the
clean treatment area, or are admitted into the CBPS. Figure F-1
presents one layout of a BAS using the CBPS. See TM 10-5410-228-10
for complete details on setting up, operating, and maintaining the
CBPS. Each CBPS provides 300 square feet of work area.
NOTES
1. The overhead cover is not needed when the wind speed exceeds
10 knots per hour. The plastic will not stay in place.
2. Although each treatment team of the BAS has a CBPS; only one
system is set up when operating in the CB mode. This is due to
the lack of authorized personnel to operate all systems at one
time in the CB mode. =Eight medical= personnel are required to
operate the BAS (employing one CBPS) in the CB mode. At least
eight nonmedical personnel are required to perform patient
decontamination =under medical supervision=. Also, only setting
up one system in the CB mode provides the BAS the ability to
retain its flexibility in order to maintain its support mission
of being where it is needed and when it is needed. The CBPS can
be used as the treatment shelter in the conventional mode as
well. When the treatment squad is operating in the split-team
mode, each team will have a CBPS for use as its treatment
shelter. When operating one system in the CB mode, the other
system provides a replacement in the event the one in use in
the CB mode is damaged beyond repair. This ensures continued
HSS to the command.
[Illustration: _Figure F-1. Battalion aid station using the
chemically biologically protected shelter._]
F-4. Division Clearing Station in a Chemically Biologically
Protected Shelter
To establish a DCS using the CBPS, set up four shelters as
described in the TM. To be operational, medical supplies and
equipment are set up as outlined in the unit TSOP. The four
shelters are complexed as shown in Figure F-2. With four CBPS
systems set up and operational, a total of 1,200 square feet of
work area is available. The contaminated triage, decontamination,
and contaminated treatment areas are separated from the clean
treatment/waiting area by a hot line with a shuffle pit. Overhead
covering is provided as described for the BAS. Patients are
admitted through the EMT litter or ambulatory air lock. Patients
are released through the patient holding air locks. This aids in
controlling entry and exits; thus preventing the introduction
of contamination into the systems. At least eight nonmedical
personnel from supported units are required to perform patient
decontamination under medical supervision at the DCS.
NOTE
In the event that the overpressure system fails on a system
that is in use with entry/exit air locks, move to the available
shelter with an entry/exit air lock in the same direction
for use as the entry/exit until the failed system can be
restored. Example 1: At the DCS the EMT system fails, move to
the ATM shelter to receive patients until the EMT system has
been restored. Example 2: At the DCS the patient hold system
fails, move exits to the dental/lab/x-ray shelter until the
patient hold system can be restored. Example 3: At the FST the
postoperative system fails, use the preoperative shelter until
the postoperative system can be restored. These options will
allow patient care operations to continue until the failed
systems can be restored.
[Illustration: _Figure F-2. Chemically biologically protected
shelter configuration as a division clearing station._]
F-5. Forward Surgical Team in a Chemically Biologically Protected
Shelter
To establish a FST using the CBPSs, follow the procedures for the
DCS except set up three CBPSs. All equipment is set up inside the
CBPS as required by your unit TSOP. With three CBPSs set up and
operational, a total of 900 square feet of work area is available
(Figure F-3). When the FST is forward in support of a medical
company and operating in the CB mode, the FST systems are connected
to the DCS of the supported medical company. Figure F-4 shows the
FST and DCS connected. When operating in the CB mode with the
medical company, all patients are received through the EMT air
lock of the DCS. The patients are triaged in the DCS and, based
upon their injuries, they are routed to the DCS treatment area or
to the FST for surgical care. Patients released from the FST for
evacuation are placed in a PPW and processed through the litter
air lock in the FST recovery section. Patient decontamination is
performed at the PDS operated by the DCS. The FST cannot operate in
a CB environment without being complexed with the DCS. They do not
have any patient decontamination capabilities.
[Illustration: _Figure F-3. Forward surgical team configuration for
operations in conventional mode._]
[Illustration: _Figure F-4. Forward surgical team and division
clearing station configuration for operations in a nuclear,
biological, chemical environment._]
Section III. EMPLOYMENT OF THE CHEMICALLY PROTECTED DEPLOYABLE
MEDICAL SYSTEMS AND SIMPLIFIED COLLECTIVE PROTECTION SYSTEMS
F-6. Collective Protection in a Deployable Medical System-Equipped
Hospital
_a._ When the threat of NBC action is anticipated in the AO, the
CP DEPMEDS components must be set up as the hospital is being
established. The system cannot be set up in a hospital that has
already been established; to do so requires the hospital to be
closed, all TEMPERs be struck, and erected with the M28 liners
installed during the erection process. To establish CPS in a
DEPMEDS-equipped hospital, follow the procedures as described in
TM 10-5410-283-14&P. Training Circular 8-13 provides instructions
on establishing a US Army DEPMEDS-equipped hospital (without CPS).
Figure F-5 presents one layout of the DEPMEDS-equipped patient
care area of a MF2K CSH HUB employing the CP DEPMEDS with an
internal water supply system. Figure F-6 presents a layout of the
patient care area of the DEPMEDS-equipped portion of an 84-bed MRI
hospital. Figure F-7 presents a layout of the patient care area of
the DEPMEDS-equipped portion of a 164-bed MRI hospital.
_b._ When employing CP DEPMEDS, provisions for waste disposal
and protected water and food supplies within the system are
established. Additionally, Class VIII supplies must be protected
from contamination. Supplies not in use or needed in the protected
operational areas are stored in medical chests, shipping
containers, or wrapped in layers of plastic that are inside
covered areas, such as closed MILVANs or tents. When contamination
is present, only open these storage areas for operational area
emergency resupply. Use plastic sheeting or other leak-proof
material to provide an additional barrier between the supplies
and the contamination. Wrap supplies in plastic or other barrier
material for movement from the storage area to the resupply air
lock of the CP DEPMEDS.
· A water supply system with distribution hoses is established
inside the CP DEPMEDS areas (Figure F-5). Pumps continuously
circulate the water from the storage tank through the hose
system back to the storage tank. The continuous circulation
ensures that the chlorine residual is maintained in the water
supply. Personnel in areas that are not included in the
continuous flow system must draw water from the system and
carry it to their work areas in 5-gallon water cans or other
containers. Water resupply is accomplished by passing a hose
through the utility port at the end of the TEMPER and M28 liner
for a connection to the water transport vehicle. The ends of
both hoses must be decontaminated with a 5 percent chlorine
solution before connecting them together. The vehicle must
have a tank or water supply container that is NBC protected to
ensure that the water supplied is free of NBC contamination.
· Rations, as determined by the hospital commander, should be
available within the protected area for personnel and patients.
Under emergency conditions the commander can authorize feeding
patients MRE rations for limited periods of time (up to 72
hours), if they are able to chew and swallow. However, attempts
must be made to ensure the required types of rations for
patient feeding are available in the CPS. The rations can be
stored in any available space; however, the rations must be
protected from exposure to possible contaminants, especially
liquids. Ration control measures are established to ensure that
the rations are only consumed as provided for in the hospital
TSOP.
· Two CB protected latrine systems are included in the CP
DEPMEDS. The latrines contain bedpan wash areas. The waste from
the latrines is collected in an outside receiving container.
The waste is removed from the container and disposed of as
outlined in the unit TSOP.