FM 4-02.51 COMBAT AND OPERATIONAL STRESS CONTROL (JULY 2006) - page 2

 

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FM 4-02.51 COMBAT AND OPERATIONAL STRESS CONTROL (JULY 2006) - page 2

 

 

Combat and Operational Stress Control Support Operations
headquarters. Interface between the unit and higher headquarters staff elements will include the
following subject areas—
ƒ The COSC operations.
ƒ Assignment or attachment of the medical detachment, CSC elements.
ƒ Daily personnel and equipment status reports.
ƒ Class VIII (medical supply) status and resupply requirements.
ƒ Casualty feeder reports.
ƒ Operation orders.
ƒ Personnel replacement for the detachment.
ƒ Medical intelligence information.
ƒ Behavioral health/COSC consultation tasking and results.
ƒ Maintenance requirements and requests.
ƒ Replacement and reconstitution operations.
ƒ Civil-military operations.
ƒ Communications (signal operation instructions [SOI], access to message centers and nets,
and transmission of COSC messages through medical, land, and other channels).
ƒ Mass casualty plan.
ƒ Road movement clearances.
ƒ Tactical updates.
ƒ Contingency operations.
ƒ Return-to-duty and non-RTD procedures.
ƒ Medical evacuation procedures (air and ground ambulances).
ƒ Changes in locations of supported unit.
z
Interface and coordination with unit to which attached. The headquarters of the unit to which a
medical detachment, CSC is under operational control (OPCON) or attached is responsible for
providing the administrative and logistical support requirements of the detachment. These
requirements are normally identified in the attachment order. The higher headquarters will be
identified in the attachment order and the medical detachment, CSC will be coordinated with this
headquarters prior to deployment. The medical detachment, CSC must coordinate with the
headquarters staff according to the tactical standing operating procedures (TSOP) of the unit of
attachment. The staff shares information with the detachment commander or his representative
pertaining to the threat, tactical situation, patient/COSR casualty status, and changes in FHP
requirements. Coordination activities and subject area information exchange should include—
ƒ Command and control procedures.
ƒ Status of FSMCs/BSMCs and CSCPs.
ƒ Communications and SOI.
ƒ Operational support requirements.
ƒ Civil-military operations.
ƒ Soldier restoration operations.
ƒ Reinforcement and personnel replacement.
ƒ Road movement and clearances.
ƒ Casualty reporting and accountability.
ƒ Patient-holding procedures.
ƒ Force protection.
ƒ Convoy operations.
ƒ Geneva Conventions.
ƒ Detainees/EPW.
ƒ Improvised explosive devices (IEDs).
ƒ Religious and cultural considerations.
6 July 2006
FM 4-02.51
3-7
Chapter 3
RECONDITIONING CENTERS
3-31. The medical company, CSC task-organizes CSC elements to staff separate small reconditioning
centers in locations that are relatively secure. However, under some circumstances, the company may
consolidate teams to establish a large reconditioning center, which supports two or three divisions.
Reconditioning facilities normally locate near a CSH. See Chapter 12 for definitive information on
reconditioning center operations.
3-8
FM 4-02.51
6 July 2006
Chapter 4
Unit Needs Assessment
SECTION I — PRINCIPLES AND TENETS OF UNIT NEEDS ASSESSMENT
GENERAL PRINCIPLES
4-1. The UNA is a systematic process for identifying the COSC needs of units. The UNA allows COSC
personnel to identify priorities for interventions and activities and for allocating resources. The UNA is not
a clinical screening to identify individuals who have or are at risk for BH disorders problems, but rather
evaluates the needs of the Soldier population and leads to more effective preventive COSC activities and
early interventions. The UNA allows COSC personnel to—
z
Identify and describe specific areas of COSC need.
z
Discover factors contributing to the needs.
z
Provide an assessment of the BH training needs of Soldiers, leaders, UMT, and medical
personnel within the unit.
z
Develop plans to meet or improve the COSC needs of Soldiers and units through prevention and
early intervention activities.
SCOPE
4-2. Unit needs assessments can be conducted at various command levels from small to large units. The
COSC personnel at each level should conduct UNAs for their supported units. Larger-unit UNAs can
include the composite findings and recommendations of one or more UNAs completed at subordinate
levels. For example, a brigade UNA may include the results of several subordinate battalion UNAs
(consolidated for confidentiality). Generally, UNAs are not conducted below the company level, though
exceptional circumstances may dictate a platoon or lower UNA.
TENETS
4-3. Tenets of UNAs―
z
Gain commander approval and support prior to conducting the UNA.
z
Protect anonymity and ensure confidentiality of Soldiers and commanders. This includes the
protection of unit identification from higher headquarters.
z
Provide the commander with an unbiased assessment.
z
Consider the social, political, and organizational factors of the environment.
z
Ensure that information sources represent the entire unit.
z
Select an assessment method that is consistent with the operational situation.
z
Limit overgeneralizing the findings from one unit to another or from one time or situation to
another.
z
Recognize that UNAs provide population-level assessments of COSC needs, not clinical
screening tools to identify individuals who may benefit from COSC interventions.
z
Distinguish between what respondents report they need and what interventions are required.
z
Ensure the UNA is planned and coordinated at a level commensurate with the complexity of the
assessment and/or situation before starting.
6 July 2006
FM 4-02.51
4-1
Chapter 4
SECTION II — FOCUS AND METHODS OF DETERMINING UNIT NEEDS
ASSESSMENT
AREAS OF FOCUS FOR A UNIT NEEDS ASSESSMENT
4-4. A UNA involves the systematic assessment of numerous areas of Soldier and unit functioning. A
typical UNA includes, but is not limited to, the following areas:
z
Major stressors impacting the unit.
z
Level of unit cohesion.
z
Well-being of unit Soldiers.
z
Soldier concern about home-front issues.
z
Soldier knowledge and skill for controlling combat and operational stress.
z
Soldier ideas for addressing COSC needs.
z
Soldier knowledge of accessing COSC resources.
z
Barriers and stigma that prevent Soldiers from accessing COSC services.
z
Training needs of Soldiers, leaders, UMT, and medical personnel on topics of COSC importance
(such as buddy aid, suicide awareness, or suicide prevention). See FM 6-22.5, FM 22-51, and
US Army Training and Doctrine Command (TRADOC) Pamphlet 600-22 (available at:
http://www.tradoc.army.mil/tpubs/pamndx.htm ) for additional information on suicide awareness
and prevention.
METHODS OF UNIT NEEDS ASSESSMENTS
4-5. The UNA takes advantage of all available information. Various methods can be used to assess
general unit needs and to identify issues that differ among subgroups (for example, gender, rank, or
race/ethnicity). The use of multiple assessment methods is recommended. These methods may include—
z
Interviewing Soldiers to hear their perceptions and concerns. Information gathered during the
casual conversation, although informal, may afford valuable anecdotal information (as well as
developing trust and familiarity).
z
Reviewing policy documents (standing operating procedures [SOPs]).
z
Interviewing key unit personnel (chain of command, chaplain, and medical personnel).
z
Conducting structured group interviews (focus groups or unit survey interviews).
z
Administering standardized surveys and questionnaires (paper/pencil or web-based).
z
Monitoring trend indicators (such as high rates of BH referrals, sick call, or misconduct, Soldier
suicide, sexual assault, fratricide or disciplinary actions).
z
Using multiple methods for gathering information when possible to ensure different viewpoints
are considered.
Planning Considerations for Unit Needs Assessment
4-6. The UNA varies in complexity and formality depending on the purpose of the assessment and the
needs of the supported unit commander. Many factors determine the complexity and formality of a UNA,
which in turn influence its feasibility.
Complexity
4-7. Complexity equates to the requirements and cost to complete a UNA. Complexity is influenced by
factors such as—
z
The size and number of units to be assessed.
z
Geographic dispersion of the units and time constraints.
4-2
FM 4-02.51
6 July 2006
Unit Needs Assessment
Formality
4-8. Formality equates to the degree that scientific principles and methods are employed in the conduct of
the UNA. An example of a UNA with low formality is one where the assessing team uses nonstructured
group and individual interviews and perhaps brief questionnaires they have developed. The information is
obtained from key individuals and a convenience sample of troops. That may be sufficient to quickly
identify problems and make recommendations to resolve them. A UNA with high formality is one that
uses professionally validated questionnaires and structured focus group interviews according to standard
protocols. The data is collected from a scientifically selected sample of the larger population. The data is
analyzed by standard analysis programs, so that statistically selected samples of valid comparisons can be
made with other similarly sampled units in other geographical locations and across time. The OSAT
expertise and assistance may be necessary for some UNA instruments and methods. In general, increasing
formality increases the complexity of the UNA. The UNA requires a higher level of formality as the need
for objective data and scientific precision increases (such as when results from multiple units are to be
merged or compared with other UNAs).
Feasibility
4-9. Feasibility is the ability to accomplish a UNA with available resources. In developing a particular
UNA, trade-offs are made to achieve an acceptable level of data quality (formality) for an affordable cost
(complexity).
UNIT NEEDS ASSESSMENT PROCESS
4-10. All UNAs are conducted following a three phase plan.
PREASSESSMENT
4-11. Preassessment is an initial phase to obtain command support, determine target issues, and select
appropriate methods to use.
ASSESSMENT
4-12. Assessment is the phase for gathering, integrating, and analyzing information to identify the COSC
needs of the unit.
POSTASSESSMENT
4-13. The principal task of the postassessment phase is to determine the COAs to present to the
commander which address the identified COSC needs. These findings are then linked to a plan of action.
WHEN TO CONDUCT UNIT NEEDS ASSESSMENTS
4-14. Unit needs assessments may be conducted at various times throughout the deployment cycle. A
UNA may be conducted—
z
Prior to initiation of COSC interventions and activities while COSC personnel and units
establish their support relationships.
z
To assess the effectiveness of COSC interventions and activities that are in the process of being
conducted or that have been completed.
z
At the request of supported commanders.
z
To monitor trend indicators (see Paragraph 4-5).
z
After serious traumatic events and significant unit transitions.
z
To collect unit information for COSC planning.
4-15. Unit needs assessments should be conducted during all types of deployments, including stability and
reconstruction operations, and combat operations.
6 July 2006
FM 4-02.51
4-3
Chapter 5
Consultation and Education
SECTION I — PRINCIPLES AND TENETS OF CONSULTATION AND
EDUCATION
GENERAL PRINCIPLES
5-1. Combat and operational stress control consultation is defined as the transmission of information
through an interactive relationship between the consultant and consultees. Education is used here in a
broader sense in that it is the transmission of information by any means. Examples of consultation include
providing COSC advice, coaching, training, and planning assistance. During this process, the consultant
learns about the consultees and their needs, and tailors the interactions accordingly. Examples of education
include distributing flyers, video and radio broadcasts, and news articles. The consultation and education
functional area supports the other COSC functional areas.
CONSULTANTS
5-2. The term BH consultant is used in the general sense to describe any person performing COSC
consultation or education. In addition to those theater or subordinate commander COSC consultants
identified in Chapter 3, all BH/COSC personnel may serve as consultants at their level. Familiarization
training with other BH disciplines enriches the ability to serve as a consultant.
CONSULTEES
5-3. Depending on the units in the area of support, broad types or categories of personnel may be
consultees. These personnel are involved in recognition and control of stress as a result of their position or
duty assignments. Consultation and education consultees may include―
z
The command or unit surgeon and his staff.
z
Staff chaplain and UMT.
z
The senior commander and the senior NCO of a battalion, brigade, division, or corps.
z
Staff officers and NCOs, including adjutant and personnel
(S1/G1), intelligence
(S2/G2),
operations (S3/G3), civil-military affairs (G9), and the Judge Advocate General (JAG).
z
Medical personnel such as PVNTMED teams that have missions that often complement the
COSC mission.
z
Company grade leaders, especially company commanders, executive officers, first sergeants
(1SGs) platoon leaders, platoon sergeants, company NCOs, and Soldiers that are trained to be
peer mentors.
SOLDIER-PEER MENTORS
5-4. Soldiers selected by their commanders may be trained to provide COSC help-in-place assistance for
COSC information to peers. They may also serve as a POC between fellow Soldiers and the COSC and
UMT teams. Selected Soldier-peer mentors with additional training could assist commanders with
conducting COSC training in mission risk assessments.
6 July 2006
FM 4-02.51
5-1
Chapter 5
TENETS FOR CONSULTATION AND EDUCATION
5-5. Consultation and education are ongoing processes that are performed across the deployment cycle
and the continuum of operations. They may be provided in response to a specific request by command or
recommendation of COSC personnel. Consultation and education may be provided during routine
scheduled meetings such as a commander’s weekly update or a leader professional development class.
5-6. Effective consultation is accomplished by the consultant’s active outreach. Consultation is best
conducted through recurring face-to-face contact, preferably at the consultee’s location. Telephone and
radio may be used to setup initial meetings and provide follow-up consultation. Consultation may be
conducted one-on-one or in small groups where interaction is feasible. When necessary and feasible, audio
or video teleconference may suffice. Active outreach supports the functional areas particularly COSC
triage and traumatic event and transition management.
5-7. Successful consultation depends on the consultant’s credibility, and the trust and familiarity
established with consultees. In addition to sound professional knowledge base and clinical skills, the
consultant must have military bearing and knowledge of the military (including the units, missions,
vocabulary, acronyms, and skills involved). Rapport is enhanced by the demonstration of the consultant’s
genuine interest in the consultee and the unit. There are some situations when consultation and education
are more effectively provided by the COSC officers, the NCOs, or the junior enlisted personnel.
SECTION II — CONSULTATION, EDUCATION, AND PLANNING
CONSULTATION PROCESS
5-8. The following six steps outline the process for most consultations:
z
Initiate the process by introducing yourself and your capabilities to key leadership and get
approval to continue.
z
Assess the needs of consultees and formulate ways to address them.
z
Present COA to consultee and define goals and feasibility of alternative actions.
z
Implement approved COA.
z
Evaluate outcomes or progress.
z
Plan follow-up actions.
5-9. Consultation and education encompasses a broad range of topics, extending from prevention to
treatment. The process of consultation and education assists the consultee with anticipation, identification,
and control of stressors (environmental, physiological, cognitive, and emotional) and stress reactions
(adaptive and maladaptive stress reactions). The following list of COSC functions, resources and their
availability provides examples of consultation and education topics:
z
Operation risk factors.
z
Individual risk factors.
z
Stress moderators.
z
Unit cohesion, esprit de corps, and morale.
z
Critical event management.
z
Barriers to care and overcoming stigma.
z
Operations planning.
z
Integration of new personnel to unit.
z
Trust in equipment and supporting units.
z
Tough realistic training.
z
Home-front stressors.
z
Indicators of unit stress level.
z
Combat and operational stress behaviors.
z
Combat and operational stress reactions.
5-2
FM 4-02.51
6 July 2006
Consultation and Education
z
Misconduct stress behaviors.
z
Mental disorders.
z
Suicidal and homicidal behaviors.
z
Command referral processes.
z
Scapegoating behaviors.
z
Rumor control.
z
Physical needs (such as sleep, nutrition, and hygiene).
z
Social/emotional needs (such as morale, welfare, recreation push package).
z
Communication with home.
z
Reintegration of Soldiers into unit.
z
Alcohol and substance abuse.
z
Procedures for COSC triage.
z
Care provider stress (such as compassion fatigue, vicarious trauma, moral dilemma).
z
Long-term consequences of COSR and mental disorders.
z
Medical evacuation policy and procedures.
z
Leadership.
z
Fear management.
z
Rest and relaxation (R&R) considerations.
5-10. Additional details about some of these topics may be found in FM 22-51.
5-11. From theater staff level down to the MH sections, BH personnel are involved in the consultation and
planning process for COSC support. Their support may be either through providing situational updates,
developing staff estimates, or being directly involved and assisting with the development of the FHP plan.
Planning starts with mission analysis. The mission analysis is the first step of the military decision making
in abbreviated planning for a time-constrained situation, see FM 5-0. A part of mission analysis is based on
the commander’s intent and guidance. A medical battalion headquarters staff may receive addition
instructions from the MEDBDE headquarters staff. During the planning process, command surgeons and
medical planners
(S3/G3) may seek information from the BH/COSC consultant or task medical
company/detachment, CSC for COSC estimates.
MISSION ANALYSIS
5-12. The COSC planning is an essential part of every medical estimate and operations plan. Ensure that
the command surgeon involves the COSC consultant in all medical planning. Mission analysis includes―
z
Assessing COSC capabilities (organic and attached assets with current status and location).
z
Gathering information from the commander’s guidance regarding the upcoming operations.
(See the S2 for intelligence, the S3 for scheme of maneuver and forces involved; the S1 for
casualty estimates, personnel status issues, and units supported, and the logistics staff officer
[S4/G4] for logistical considerations). Surgeons provide disease and nonbattle injuries (DNBI)
estimates and status of medical units. Unit needs assessments, organic medical personnel, and
UMT can provide additional information.
z
Developing the COSC estimate based on the gathered information. The COSC estimate helps
medical planners to anticipate demands on medical and COSC resources and to prepare
accordingly. See FM 3-0, FM 5-0, and FM 8-55 for methods to develop the COSC estimate.
z
Assessing limitations (specify reasons that BH assets are not available).
z
Identifying specified, implied and essential COSC task in the FHP annex of the OPORD.
z
Providing COSC COA.
z
Presenting estimate and COA to command surgeon. Define goals and feasibility.
z
Implementing approved COA. Consult with implementing COSC personnel about estimate and
operational details.
6 July 2006
FM 4-02.51
5-3
Chapter 5
z
Evaluating outcomes or progress.
z
Providing estimate and COA for fragmentary order (FRAGOs) and planning follow-up actions.
REHEARSAL
5-13. To achieve optimal synchronization, the FHP plan is rehearsed as an integral part of the combined
arms plan at the combined arms rehearsal. Medical leaders provide input to the over all plan and develop
the concept for the FHP plan. During the decision-making/orders process, they identify critical events and
synchronize the FHP plans. In addition to medical locations on the CSS overlay, these plans indicate the
triggers for FHP events. At the rehearsals, leaders practice their synchronized plans that include FHP.
5-14. The CSS/FHP annex of the OPORD that includes map overlays is the conclusion of the medical
planning efforts; the rehearsal is the culmination of the preparation phase for an operation. The medical
platoon leader has the responsibility for rehearsing FHP operations. Rehearsals are done to achieve a
common understanding and a picture of how the plan will be implemented. The following leads to a
successful rehearsal—
z
All plans must be completed prior to the rehearsal.
z
The FHP portion of the battalion rehearsals should focus on the events that are critical to mission
accomplishment. A successful rehearsal ensures explicit understanding by subordinate medical
personnel of their individual missions; how their missions relate to each other; and how each
mission relates to the commander’s plan. It is important for all medical units to understand the
complete FHP concept.
z
Rehearsing key FHP actions allows participants to become familiar with the operation and to
visualize the “triggers” which identify the circumstances and timing for friendly actions. This
visual impression helps them understand both their environment and their relationship to other
units during the operation. The repetition of critical medical tasks during the rehearsal helps
leaders remember the sequence of key actions within the operation and when they are executed.
z
The OPORD is issued through effective troop leading procedures.
SECTION III — TRANSITION MANAGEMENT AND SUPPORT IN THE
DEPLOYMENT CYCLE
SUPPORTING TRANSITION AND PHASES OF A DEPLOYMENT
5-15. Transition and phases of a deployment cycle may have different and sometimes unique stressors.
These stressors may be subjects for consultation and education. Needs assessment may be necessary to
redistribute COSC assets and change the means for delivering COSC activities and interventions.
5-16. The COSC personnel conduct transition (change of command) workshops, especially after relief of
commanders. These workshops are normally requested by the incoming commander. The purpose of these
workshops is to―
z
Facilitate staff discussion of what the staff sees as the unit and staff’s strong points and the areas
needing more work.
z
Provide the new commander the opportunity to discuss his leadership style and his expectations
and set priorities for the staff.
5-17. The change of OPTEMP may include―
z
Going from deployment to combat (offensive or defensive operations).
z
Conducting battle handover in place by turning the battle over to another unit.
z
Going from high intensity combat to stability and reconstruction operations.
PREDEPLOYMENT SUPPORT
5-18. Medical support in predeployment is mainly the responsibility of MEDDAC personnel or of a US
Army Reserve (USAR) mobilization site augmentation unit (which has no BH personnel assigned).
5-4
FM 4-02.51
6 July 2006
Consultation and Education
Division and brigade COSC BH personnel are involved with their unit’s Soldiers who are being treated for
mental disorders, and with general COSC prevention of the unit members and families. The CSC units that
are not deploying may be tasked to support predeployment COSC activities and interventions. Combat and
operational stress control screening of individuals during predeployment may include—
z
Secondary BH screening for Soldiers who are referred by primary care providers that flagged
positive on DD Form 2795 (Pre-Deployment Health Assessment).
z
Health screening of medical and BH records.
z
Fitness for duty evaluations according to AR 40-501.
z
Evaluations and recommendations to leadership about Soldiers who are fit for duty overall, but
should not be deployed at this phase of the operation for BH reasons.
5-19. Other predeployment functions may be provided on request. These functions may include—
z
Briefings, consultation and education on deployment cycle stressors and how to cope, and on
specific stressors that Soldiers may encounter in the AO.
z
Unit assessments at request of commanders.
MID-TOUR REST AND RECUPERATION OR EMERGENCY LEAVE
5-20. Leaders must be aware and alert for Soldiers who exhibit a need for COSC screening prior to mid-
tour R&R. Other Soldiers may only require some education briefings and handout cards on handling their
transition from a hostile CZ to R&R environments. In some cases, prior to emergency leave, some
screening for domestic violence risk may also be necessary in any potential high-risk Soldier. This COSC
screening is done for ensuring the safety of the Soldier and of others. One protocol has unit commanders
referring those Soldiers that have requested leave for the purpose of addressing marital, legal, or other
highly charged difficulties at home, to the BH officer. The BH officer explores the situation and the
Soldier’s reactions to it and checks for history with the rear detachment of the MH section,
MEDDAC/MEDCEN and FAP. If the BH officer finds the Soldier to be at high risk, the commander can
deny leave. Another option is to escort the Soldier to home base. At home base, he is kept by his unit’s
rear detachment until a meeting is held under safe conditions with the Soldier, BH, FAP personnel, his
family, and the others involved in the difficulty. At this meeting the situation is defused or resolved before
the Soldier is permitted to leave the rear detachment area.
REDEPLOYMENT
5-21. For Soldiers, redeployment is the process of getting orders to redeploy, embarking towards the
demobilization site, or deploying to another out-of-the-theater mission. Screening of these individual
Soldiers may be a requirement and have established criteria that should be used to ensure appropriate
screening is conducted. The theater or specific units may require that all primary care providers who
perform screening interview, postdeployment health assessment have a designated BH consultant.
Available COSC/BH personnel provide secondary one-on-one BH screening for Soldiers who are referred
by primary care providers because they flagged positive on DD Form 2795. Some Soldiers may require
brief treatment or referral may be required as a result of the screening.
END-OF-TOUR STRESS MANAGEMENT
5-22. End-of-tour stress management is essential to reduce mental problems with Soldiers returning to their
home station and/or families. This also promotes Soldiers seeking help early when problems occur.
Mental health/COSC personnel consult with command on activities during redeployment and for
postredeployment. Issues may include—
z
Common mental disorders and potential misconduct may result when Soldiers are relieved of the
stress and the focus of dangerous missions and are looking towards and preparing to go home.
z
Memorial services for those Soldiers who died during the deployment.
z
Recognition of outstanding performance and the equitable awarding of decorations.
z
Closure ceremonies.
z
Homecoming-reunion education briefing and training.
6 July 2006
FM 4-02.51
5-5
Chapter 5
5-23. The end-of-tour debriefings (EOTDs) are like leader-led after-action debriefings, except that the time
period covered extends from predeployment through to this point in redeployment. The EOTD should be
conducted while the unit is still in the theater or at some place where transportation home pauses for one or
more days. For each phase of the operation, the participants review what were the significant events and
the problems or stressor that bothered the group (including critical events, if any). Equally important the
group recalls what went well, how problems and stressors were overcome (at least by some members), and
what positive memories and feelings they had and will take home.
FACILITATORS
5-24. The COSC or UMT facilitators should be invited to advise the leader and sit in if there are likely to
be many negative memories and feelings that have disrupted or threaten unit cohesion. Advise leaders and
troops on the importance of sustaining unit identity and contact with teammates beyond postdeployment
and in the future.
POSTDEPLOYMENT
5-25. Postdeployment covers that period of time from embarking from theater, through scheduled
postdeployment activities, and return to work after block leave. As with predeployment, medical support in
postdeployment is mainly the responsibility of installation MTF, often augmented by a USAR mobilization
site augmentation unit. Division and brigade COSC/BH personnel and CSC units that are themselves
demobilizing as their units are deactivating will have limited involvement with the BH and COSC needs of
fellow Soldiers. These personnel continue to provide, as needed, consultation to the command and to key
personnel of the unit that they were assigned/attached. They consult with the installation MTF about BH
and coordinate COSC needs that should be met. The CSC units that were not deployed may be tasked to
support postdeployment COSC activities and interventions. The COSC personnel who are not
demobilizing provide reintegration education. Screening of individuals postdeployment will continue and
secondary screening will continue in postdeployment and be recorded on a DD Form 2796 (Post-
Deployment Health Assessment). Each primary screener should have a designated BH consultant from the
MEDCEN/MEDDAC. Secondary screening and treatment of referrals are provided by the installation
MTF. Recent research with a returning division indicated that a secondary postdeployment screening from
90 and 120 days after returning from the theater may be necessary. This seems to be the time when
persisting or delayed symptoms, problems, and perhaps impairment show need for intervention. All
Soldiers should be advised about follow-up BH support resources. Soldiers that are leaving active service
should also be informed about deployment-related entitlements and benefits.
READINESS PHASE OF THE DEPLOYMENT CYCLE
5-26. Division/brigade MH sections and medical units, CSC, of Active Army and Reserve Component
(RC) must use their training opportunities to the fullest. During these training exercises, they should
provide COSC consultation, education, and training to supported units the same as they would in an actual
deployment. Mental health personnel will perform many of their critical mission functions and should not
just simulate them. The management of real COSR occurs in field and garrison/home-station settings.
Triage and emergency stabilization may be required. Restoration may be appropriate in some field
exercises. Even reconditioning can sometimes be provided as a multiday “course” at Active Army posts
where CSC units are stationed. Further, TEM and transition management are also potential major roles for
organic MH sections and medical units, CSC in peacetime. The RC as well as Active Army medical units,
CSC have been used extensively to respond to traumatic events and to assist units that are in the
premobilization, mobilization, or postdeployment phases of their deployment cycles.
5-6
FM 4-02.51
6 July 2006
Chapter 6
Traumatic Event Management
OVERVIEW OF TRAUMATIC EVENT MANAGEMENT
TAILORING TRAUMATIC EVENT MANAGEMENT
6-1. Traumatic event management blends other COSC functional areas to create a flexible set of
interventions specifically focused on stress management for units and Soldiers following potentially
traumatizing event (PTE). Like other functional areas, COSC providers must tailor COSC and TEM
support to the needs of the unit and Soldier.
6-2. An event is considered potentially traumatic when it causes individuals or groups to experience
intense feelings of terror, horror, helplessness, and/or hopelessness. Guilt, anger, sadness, and dislocation
of world view or faith are potential emotional/cognitive responses to PTEs. Studies of Soldiers in Operation
Iraqi Freedom (OIF) and Operations Enduring Freedom (OEF) have shown a correlation between exposure
to combat experiences and BH disorders, most particularly acute stress disorder and PTSD. The following
events should be monitored as PTEs for Soldiers and units:
z
Heavy or continuous combat operations.
z
Death of unit members due to enemy or friendly fire.
z
Accidents.
z
Serious injury.
z
Suicide/homicide.
z
Environmental devastation/human suffering.
z
Significant home-front issues.
z
Operations resulting in the death of civilians or combatants.
Scope of Traumatic Events Management
6-3. In this chapter, TEM is discussed as it applies to military units and personnel to support readiness.
Traumatic events management can be adapted to nonmilitary groups or individuals brought together by a
PTE. Traumatic events debriefing should be conceptualized as an ongoing process and not an acute
intervention. For military units and personnel, TEM is active in all phases of the deployment cycle and
across the continuum of military operations.
Traumatic Events Management Functional Mission Area
6-4. Successful TEM relies on a solid foundation of other COSC functional area activities such as UNA
that may require the COSC provider to—
z
Establish a credible working relationship with supported unit leadership.
z
Understand the unit’s needs via previously conducted UNAs.
6-5. In the absence of preexisting relationships and UNA, COSC providers should secure command
support and recommend a UNA as the first step in TEM. Subsequent UNAs will clarify unit responses to
other TEM interventions and to ongoing unit needs.
Unit Needs Assessments
6-6. When conducting a UNA after a PTE the COSC providers need to take under consideration the
following—
z
Ensure a timely arrival that does not disrupt unit operations but facilitates the UNA.
6 July 2006
FM 4-02.51
6-1
Chapter 6
z
They should not interrupt or intrude on the people who are attending to the acute crisis when
arriving at the unit, unless asked. Presence without intruding will gain trust information and
POC.
z
Understanding that the UNA may be limited by the urgency of the unit’s return to action, the
difficulty of data collection, and having limited resources. Sufficient knowledge must be gained
to tailor the interventions to the unit before initiating them. It is better to defer the intervention
to the next opportunity if the unit must return to action immediately after replenishment and/or
before necessary data is collected.
z
Know that the UNA is a unit-level assessment and does not substitute for individual-level
screenings or COSC triage. See Chapter 4 for a detailed discussion of UNA.
Consultation and Education
6-7. The COSC provider should conduct unit leader consultation and education activities prior to a PTE.
Consultation and education topics should include—
z
The impact of PTE on unit and Soldier readiness.
z
Common PTEs for units and Soldiers.
z
An overview of TEM.
z
Components of TEM.
z
Normal responses to PTEs.
z
Triggers to refer Soldiers for BH evaluation.
z
Development of SOPs for responding to PTEs when they occur.
6-8. Preemptive consultation and education prepare unit leaders to institute TEM interventions following
a PTE. The 5 R’s are a good model to build on. In acute TEM interventions, leaders should consider
interventions that target—
z
Safety, security, and survival.
z
Food, hydration, clothing, and shelter.
z
Sleep.
z
Medication (replace medications destroyed or lost).
z
Orientation of unit/Soldiers to developing situation.
z
Restoration of communication with unit, dependents, friends, and community.
z
Location should be at a secure site that provides protection from ongoing threats, toxins, and
harm.
6-9. Consultation and education to Soldiers should emphasize normalizing the common reactions to
trauma, improving their coping skills, enhancing self-care, facilitating recognition of significant problems,
and increasing knowledge of and access to COSC services. Post-PTE UNAs guide further consultation and
education efforts. Combat and operational stress control providers should be aware that leaders may not
have experienced the PTE in person, but have experienced the PTE through their Soldiers and may require
support.
6-10. For an in-depth discussion of consultation and education, refer to Chapter 5.
Combat and Operational Stress Control Triage
6-11. The COSC provider should be prepared to provide COSC triage in the aftermath of the PTE.
Consultation and education is important to ensure appropriate and timely referrals for triage. The COSC
provider can offer the following guidelines in referral of Soldiers for COSC triage:
z
Persistent or worsening traumatic stress reactions
(such as dissociation, panic, autonomic
arousal, and cognitive impairment).
z
Significant functional impairments (such as role/work relationships).
z
Dangerousness (suicidal or violent ideation, plan, and/or intent).
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FM 4-02.51
6 July 2006
Traumatic Event Management
z
Severe psychiatric comorbidity (such as psychotic spectrum disorder, substance use disorder, or
abuse).
z
Maladaptive coping strategies (such as pattern of impulsivity or social withdrawal under stress).
z
New or evolving psychosocial stressors.
z
Poor social support.
z
Failure to respond to acute supportive interventions.
z
Exacerbation of preexisting psychiatric conditions.
z
Soldier request for assessment.
Stabilization
6-12. The COSC provider should be prepared to provide or coordinate stabilization services following the
PTE. Pre-PTE coordination with medical unit personnel promotes safe management.
Soldier Restoration
6-13. The measures below are applicable to Soldiers with COSR following a PTE. The COSC provider
should be familiar with the 5 R’s and with BICEPS. In keeping with restorative efforts, the COSC provider
focuses on the following measures through leadership consultation, Soldier education, and/or direct
management:
z
Minimizing exposure of Soldiers with COSR to further PTE.
z
Reducing physiological arousal.
z
Mobilizing support for those who are most distressed.
z
Providing information and fostering communication and education.
z
Using effective risk communication techniques.
z
Proving assurance/reassurance.
z
Mitigating fear and anxiety.
z
Encouraging sleep hygiene.
z
Reestablishing routines.
z
Promoting exercise and nutrition.
z
Encouraging self-paced emotional ventilation.
z
Discouraging use of alcohol/substances.
Behavioral Health Treatment
6-14. Given the correlation between PTE and development of traumatic stress disorders the COSC
provider must be familiar with the best current practices for evaluation and treatment. The Veterans Health
Administration (VHA)/DOD Clinical Practice Guidelines website (http://www.oqp.med.va.gov/cpg/cpg.htm )
offers clinicians evidence-based assessment and treatment algorithms for acute stress disorder, PTSD, and
many other BH disorders.
6-15. In recent years, the use of early interventions in response to PTE has come under critical review. The
focus of much of this debate is on the use of psychological debriefing (PD) and more specifically, the
critical incident stress debriefings provided to individuals or groups exposed to PTEs. Current research
suggests that PD/critical incident stress debriefings can be harmful to participants, while failing to reduce
traumatic stress reactions or to prevent the progression to PTSD. As PD/critical incident stress debriefings
undergo definitive study, COSC providers should adhere to current evidence-based best practices.
6-16. In accordance with the VHA/DOD Clinical Practice Guidelines (http://www.oqp.med.va.gov/cpg/cpg.htm )
for PTSD, COSC providers should—
z
Consider alternative methods to PDs for individuals affected by PTEs.
z
Avoid PD as a means to reduce acute posttraumatic distress (acute stress reaction or acute stress
disorder) or to slow progression to PTSD.
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6-3
Chapter 6
z
Understand there is insufficient evidence to recommend for or against conducting structured
group debriefings.
z
Be aware that compulsory repetition of traumatic experiences in a group may be counter-
productive.
z
Consider group debriefings with preexisting groups (such as teams, units, emergency medical
treatment [EMT] teams, coworkers, family members) may assist with group cohesion, morale,
and other important variables that have not been demonstrated empirically.
z
Emphasize that group participation must be voluntary.
LEADER-LED AFTER-ACTION DEBRIEFING
6-17. A leader-led after-action debriefing is lead by a platoon, squad, or team leader and is not normally
conducted above platoon level. The leader-led after-action debriefing should be conducted after all
missions especially when the maneuvers did not go according to plan. A leader-led after-action debriefing
may even be sufficient for PTEs involving injury or death. For the leader to conduct a PD, his personnel
should have received previous PDs; and normally provide peer support and validation for showing and
talking about their emotional reactions during and after the debriefing. The best time to conduct this
debriefing is as soon as is feasible after the team/squad/platoon has returned to a relatively safe place and
members have replenished bodily needs and are no longer in a high state of arousal. Usually a well-
conducted leader-led after-action debriefing is the best option to manage PTEs during a mission. The
exception to this type of debriefing is when the event evoked reactions that seriously threaten unit cohesion
and/or have a high likelihood of arousing disruptive behavior and emotions. In these situations the leader
should ask himself the following—
z
Should I conduct the debriefing?
z
Should a trained facilitator be present?
z
Should a request for COSC TEM be submitted for his team/squad/platoon?
CONDUCTING A LEADER-LED AFTER-ACTION DEBRIEFING
6-18. These debriefings require the leader to extend the lessons-learned orientation of the standard AAR.
He uses the event reconstruction approach or has the individuals present their own roles and perceptions of
the event, whichever best fits the situation and time available. See Training Circular (TC) 25-20 for
definitive information on AARs. When individuals express or show emotions, the leader and the
teammates recognize and normalize them; they agree to talk about them later and support the distressed
Soldier through personal interactions. The group then returns to determining the facts. Lessons-learned
discussion is deferred until all the facts are laid out. See FM 22-51 for additional information. The leader
may provide education about controlling likely reactions or referral information at the end, depending on
his knowledge and experience.
6-19. When a PTE is likely to create individual or collective guilt, distrust, or anger, the unit leader should
be encouraged to request COSC assistance. Either a COSC or a UMT person trained in TEM sits in with
the leader-led debriefing as a familiar and trusted friend of the unit. The COSC or UMT facilitator helps
the unit/team leader rehearse and mentors the leaders on the debriefing process. During the PD, the
facilitator can ask questions of the group to clarify the facts and steer the process away from divisive anger,
blaming, and scapegoating toward a positive, cohesion-restoring outcome. This method is halfway
between a simple leader-led after-action debriefing and a PD and is referred to as a facilitated leader-led
after-action debriefing. The leader conducting the debriefing must be attentive to identify individuals
needing COSC follow-up.
6-20. Leaders in positions above platoon level also have a role in leader-led after-action debriefing.
Company commanders and 1SGs may conduct leader-led after-action debriefing with their subordinate
leaders. Battalion commanders and higher may conduct leader-led after-action debriefings with their staff
after distressing actions and may include subordinate leaders when time allows bringing them together.
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FM 4-02.51
6 July 2006
Traumatic Event Management
COOL DOWN MEETINGS
6-21. A cool down meeting is referred to as an immediate, short meeting when a team or larger unit/group
returns from the battlefield or other missions. These cool down meetings are held after heavy/intense
battles with the enemy or a shift in the mission has occurred which is highly arousing and/or distressing.
This is especially important after critical events. The cool down meeting is an informal event and occurs
before the participants fully replenish their bodily needs and precedes any other activities including more
COSC interventions, or return to the mission.
6-22. Personnel who coordinate and wait for the return of the unit that has been in a heavy intense battle,
include leaders or supporting officers or NCOs from the command, UMT, and COSC providers.
(In
domestic support operations the same personnel identified above or other trained personnel from
governmental or nongovernmental organizations such as the Red Cross may be waiting on the return of the
unit after a PTE. These personnel may be present at the cool down meeting.)
COMPONENTS OF A COOL DOWN MEETING
6-23. Components of a cool down meeting may include—
z
Assembling all of the unit personnel at a safe and relatively comfortable location for a brief
period of time (about 15 minutes).
z
Receiving or sharing nonstimulating beverages and convenient food (comfort foods if available).
z
Providing personnel the opportunity to talk among themselves.
z
Giving recognition and praise for the difficult mission they have completed.
z
Providing information to unit personnel on where and how they will rest and replenish.
z
Previewing the immediate agenda for the unit on what will happen after the cool down meeting
including plans for further debriefing and/or other available stress control or morale/welfare
intervention.
z
Providing announcements pertaining to further preparations and expected time of return to the
mission.
6-24. The COSC personnel may have a role in cool down meetings. In consultation and education, COSC
consultants emphasize the value of cool down meetings and the simplicity of the components, which are
easily neglected in crisis situations. When feasible, they unobtrusively attend the cool down meeting,
showing “presence” while learning of the event, getting familiar with the key people, and observing anyone
showing signs of distress and being available to them. If requested, they may give a very brief introduction
and review of normal stress reactions that unit personnel may have in the next few hours.
6 July 2006
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6-5
Chapter 7
Combat and Operational Stress Control Support for Units
Undergoing Reconstitution
UNIT RECONSTITUTION SUPPORT
7-1. Unit reconstitution support is defined in FM 100-9 as extraordinary actions that commanders plan
and implement to restore units to a desired level of combat effectiveness commensurate with mission
requirements and available resources. Besides normal support actions, reconstitution may include—
z
Removing the unit from combat.
z
Assisting the unit with external assets.
z
Reestablishing the chain of command.
z
Training the unit for future operations.
z
Reestablishing unit cohesion.
7-2. When tasked as part of a reconstitution task force, COSC personnel are responsible for providing
units with Soldier restoration, performing the COSC functions of the UNA, and providing consultation and
education, as required. They provide triage, stabilization, Soldier restorations, and short time-constrained
COSC treatment, when needed. Reconstitution is a time-constrained process, but Soldier restoration may
be provided at the reconstitution site if several days are available. The focus of consultation and education
efforts include—
z
Rebuilding unit cohesion.
z
Integrating new Soldiers or groups of Soldiers into the unit.
z
Facilitating assumptions of command by replaced leaders.
z
Facilitating the building of Soldiers’ confidence in their leaders and themselves.
z
Mentoring unit leaders in leader-led after-action debriefing process.
z
Advising on COSC aspects of bereavement memorial services and communication with the
family support group and unit families. The COSC personnel also facilitate leader-led after-
action debriefings and lead or serve as observers in TEM interventions.
RECONSTITUTION PROCESS
7-3. Reconstitution of units transcends normal day-to-day force sustainment actions. Reconstitution is a
total process. Its major elements are reorganization, assessment, and regeneration, in that order. All COSC
personnel should be thoroughly familiar with FM 100-9.
Reorganization
7-4. Unit reorganization primarily involves a shifting of internal resources and is accomplished as either
immediate or deliberate reorganization. The commander of the attrited unit decides to reorganize when
required and may consider the following—
z
Immediate reorganization is the quick and usually temporary restoring of degraded units to
minimum levels of effectiveness. Normally, the commander implements immediate
reorganization at his combat location or as close to that site as possible to meet near-term needs.
The COSC personnel provide consultation with key POC in the unit (leaders, UMTs, and
trauma/health care specialist, usually by telecommunication).
z
Deliberate reorganization is done to restore a unit to the specified degree of combat
effectiveness. Usually, more time and resources are available further to the rear. Procedures are
similar to immediate reorganization except that some personnel and weapons system
6 July 2006
FM 4-02.51
7-1
Chapter 7
replacement resources may be available, equipment repair is more intensive, and more extensive
cross- leveling is possible. When used in reorganization, cross-leveling involves the movement
of personnel and/or equipment between units to achieve equalization. The process is
accomplished while maintaining or restoring the combat effectiveness of the units involved.
z
The role of COSC personnel in deliberate reorganization may require a COSC team to deploy to
the reorganization site. They assess the stressors and stress reactions and advise the
commanders on supportive actions, (such as those for the reorganization of small unit-level
elements), assists command with transitions and integration of new replacements.
z
When the reorganization involves battalion size or larger units the process becomes more like
the coordinated operation described for unit regeneration, provided below. It is likely to draw
upon fitness team expertise and Soldier restoration assets from rearward as well as on the
forward deployed teams.
REGENERATION
ASSESSMENT PHASES
7-5. The defining characteristic of regeneration is the massive infusion of personnel, equipment, and
assistance under the directions of higher headquarters. Assessment measures a unit’s capability to perform
its mission. It occurs in two phases. The unit commander conducts the first phase. He continually assesses
his unit before, during, and after operations. If he determines it is no longer mission-capable even after
reorganization, he notifies his commander. The higher headquarters either changes the mission of the unit
to match its degraded capability or removes it from combat. External elements may also have to assess the
unit after it disengages. This is the second phase. These elements do a more thorough evaluation to
determine regeneration needs. They also consider the resources available.
7-6. The second phase of assessment begins with an initial survey by a team sent by the higher
headquarters. This team determines the status and needs of the attrited and exhausted unit as it moves to
the regeneration site. Some of the key issues in estimating the COSC needs of the unit include the—
z
Percentage and nature of casualties.
z
Duration of operations and environmental exposure.
z
Status of hydration, nutrition, and sleep.
z
Loss and current effectiveness of leaders.
z
Attitudes, perceptions, and level of confidence of unit survivors.
z
Traumatic events.
7-7. The COSC consultants at every level must provide consultation to all command surgeons on the
importance of including BH/COSC personnel in all reconstitution operations. The initial evaluation team
should include a subordinate commander COSC consultant. Task-organized CSC teams normally deploy
to the unit during the second phase to provide UNA, consultation, and other COSC activities and
interventions. Unit needs assessment with high formality may be requested by the higher headquarters for
decision-making purposes. These assessments are feasible for selected units, with prior coordination, as
much of the logistical complexity is reduced by the orchestrated planning at higher command echelons.
Conducting Regeneration
7-8. Regeneration involves rebuilding a unit through large-scale replacement of personnel, equipment,
and supplies. If required, it includes internally reorganizing; reestablishing or replacing essential C2 and
conducting mission-essential training for the reconstituted unit. Regeneration is required when heavy
losses of personnel and equipment leave a unit combat-ineffective and unable to continue its mission. The
commander controlling assets to conduct regeneration decides whether to use resources for this purpose.
Regeneration has two variations: incremental regeneration or whole-unit regeneration. Incremental
regeneration is the massive infusion of individual personnel replacements and single items of equipment
into the surviving unit elements. Whole-unit regeneration is the replacement of whole units or definable
subelements, such as squads, crews, and teams. The S1/G1, S4/G4, and medical staffs coordinate the
7-2
FM 4-02.51
6 July 2006
Combat and Operational Stress Control Support for Units Undergoing Reconstitution
dispatch of the regeneration task-force teams. These teams occupy the reconstitution site before arrival of
the exhausted unit. The COSC assets that perform the indicated initial assessment are needed as part of this
task force. The reconstitution task force guides each element of the arriving units into its designated areas.
The regeneration task force provides for the immediate needs of the survivors. This should include
personal gear and equipment to replace lost or damaged items, food services, personnel services,
maintenance teams, and medical teams to provide sick call services while organic medical personnel rest.
Replacement personnel are sent to the reconstitution site. The COSC personnel assist with their
assimilation into the regenerated unit.
RECONSTITUTION RESOURCE REQUIREMENTS FOR COMBAT
AND OPERATIONAL STRESS CONTROL
7-9. Factors which influence the resource requirements for COSC in reconstitution
(deliberate
reorganization and regeneration) include the size of the unit, number of subunits which have suffered heavy
casualties, the extent of emotional trauma, and time available. The focus of COSC for reconstitution
support was provided in Paragraph 7-2. A guideline is provided in Table 7-1 for COSC personnel
requirements. This staffing should not overly rely on organic COSC staff that will be in need of rest.
Table 7-1. Reconstitution operations guideline for combat and operational stress
control personnel requirements
Size of Unit
Personnel Required
Company/Troop
2 to 4
Battalion/Squadron
6 to 12
BCT/Brigade Regiment
12 to 30
Division
30 to 60
6 July 2006
FM 4-02.51
7-3
Chapter 8
Combat and Operational Stress Control Triage
SECTION I — THE TRIAGE PROCESS FOR COMBAT AND OPERATIONAL
STRESS CONTROL
SOLDIER TRIAGE
8-1. The COSC triage process is the sorting of Soldiers based on an assessment of their needs and
capabilities, and the location where they can best be managed in keeping with BICEPS principles. Triage
is applicable at every level of care. The two key components of COSC triage are assessment and
disposition.
8-2. Assessment is an evaluation of the Soldier’s physical and BH needs, potential medical emergencies,
and other safety risks. Assessment is performed by COSC personnel according to their professional
training, expertise, and standards.
8-3. Disposition is the COSC intervention plan to address the needs identified in the assessment.
Disposition has two components that include—
z
Determining what intervention techniques best address the Soldier’s needs and functional
capabilities.
z
Selecting the best location where the Soldier can be managed. The personnel conducting COSC
triage should consider the needs, abilities, and the safety of the Soldier. They should also
consider the unit’s capacity to provide COSC interventions based on its OPTEMPO mission,
resources, response to prior consultations, and willingness to participate in COSC interventions.
TRIAGE ALGORITHM FOR COMBAT AND OPERATIONAL STRESS
CONTROL
8-4. Like surgical triage categories, COSR also uses triage categories. Each of the COSR triage
categories are discussed in detail in the below paragraphs. The COSC triage algorithm presented in Table
8-1 uses some of the triage categories.
6 July 2006
FM 4-02.51
8-1
Chapter 8
Table 8-1. The combat and operational stress control triage algorithm
Step
Is this a medical emergency?
1
Yes
Refer to nearest MTF
No
Go to Step 2
Step
Does the Soldier require medical/behavioral observation?
2
Does Soldier have presumptive COSR
or MH disorder?
Yes
Go to Step 3 A
No
Yes
Go to Step 3 B
No
Help-in-place
A. Can the Level II MTF or CSC Soldier
Step
B. Can the Soldier’s unit support the 5 R’s or other treatment
Restoration Center provide adequate evaluation
3
interventions?
and intervention?
Yes
HOLD*
Yes
UNIT
Is there a suitable support unit?
No
REFER
No
Yes
REST
No
HOLD*
* When deciding between two or more potential Level II MTFs or CSC Restoration Centers, refer the Soldier to the one
closest to his unit that meets his COSC needs.
Step
Use on subsequent triages. Has the Soldier improved after appropriate duration of intervention?
4
TRIAGE CATEGORIES FOR COMBAT AND OPERATIONAL STRESS
REACTION CASES
8-5. The following are triage categories that may be used for COSR cases. Help-in-place (HIP), rest,
hold, and refer cases are discussed below.
HELP-IN-PLACE CASES
8-6. Help-in-place is used to identify those cases that do not have severe COSR or BH disorders. They
are provided COSC consultation and education, as appropriate, and remain on duty. These interactions
may occur in any setting (for example, dining facility, workplace, or the post exchange). Individual
identifying information is not retained or documented. There is no implicit or explicit therapist-patient or
therapist-client relationship in HIP interactions.
8-7. The unit identifies those cases that remain with or return to their original unit, either for full duty
with their section/platoon or for light duty with extra rest and replenishment within a headquarters element.
This option depends on the unit’s mission, resources, and the Soldiers symptoms. Personnel performing
triage must, therefore, be familiar with the unit’s situation and take that into account. When the Soldier’s
condition improves, the Soldier and/or unit may not feel that additional triage is necessary.
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FM 4-02.51
6 July 2006
Combat and Operational Stress Control Triage
Note. Help-in-place is a new triage category that replaces the old duty category and is also used
for unit cases.
REST CASES
8-8. Rest identifies those cases that are provided rest and replenishment in a nonmedical support unit,
usually one that is in support of their unit. These Soldiers do not require close medical or BH observation
or treatment. They are unable to return immediately to their own unit either because their unit cannot
provide an adequate environment for the 5 R’s; or transportation is not available for at least a day; or the
5 R’s can best be coordinated from the nonmedical support unit. This option depends on the resources and
mission of the available CS/CSS units, as well as on the Soldier’s symptoms. Someone must be designated
to be in charge of the Soldier and ensure that the
5 R’s are provided. There must be a reliable
transportation link to return the Soldier to his original unit after a day or two. When the Soldier’s condition
improves sufficiently for him to return to his unit, the Soldier and/or the supporting unit may feel that
additional triage is necessary.
HOLD CASES
8-9. Hold refers to those cases that require close medical/BH observation and evaluation at a Level II
MTF or COSC Soldier restoration center because the Soldiers symptoms are potentially too disruptive or
burdensome for any available CSS unit or element. Soldier’s symptoms may be caused by a BH disorder
that could suddenly turn worse and require emergency treatment. The Level II MTF or COSC Soldier
restoration center must have the capability to provide the necessary medical observation, diagnostic tools,
and adequate stabilization for emergency treatment. When deciding among capable Level II MTFs or
COSC Soldier restoration centers, refer the Soldier to the one closest to his unit that meets his COSC needs.
Assessment of closeness considers speed and reliability of transportation and back. Consider transferring
to another Level II MTF or COSC Soldier restoration center with increased capabilities before changing a
Soldier’s triage category to refer. All hold cases will be triaged again by COSC personnel or other trained
medical personnel after they have been placed in this category.
REFER CASES
8-10. Refer cases are similar to the hold cases, except that refer cases are too disruptive and burdensome
for the MTF or the COSC Soldier restoration center that is not resourced to care for this particular case.
The MTF or COSC Soldier restoration center cannot provide the necessary level of diagnostic and
treatment capabilities. Refer cases requiring care at a COSC reconditioning center, a Level III MTF or
higher levels of care will be triaged by COSC or other trained medical personnel prior to being transferred
to these facilities.
TRIAGE PERSONNEL FOR COMBAT AND OPERATIONAL STRESS
CONTROL
8-11. All COSC personnel participate in the triage process according to their professional training,
experience, and standards. Familiarization training among BH disciplines extends the effectiveness of all
COSC personnel in triage skills. Medical care providers must be mentored to use the COSC triage process.
A commander providing the 5 R’s and placing a Soldier in a support unit for a temporary break does not
equate to COSC triage.
TRIAGE CONSIDERATIONS
8-12. Triage should be initiated when the
z
Soldier is a self-referral.
z
Chaplain has referred the Soldier.
z
Medical personnel have requested a COSC consultation and referred the Soldier.
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FM 4-02.51
8-3
Chapter 8
z
Unit member/buddy has referred the Soldier.
z
Leader has requested an informal referral.
z
Soldier is a command-directed referral
(see DODD 6490.1 and DOD Instruction [DODI]
6490.4).
z
Combat operational stress control personnel observe a Soldier’s behaviors which indicate
possible COSR or a BH disorder.
8-13. Factors that influence an assessment may vary in depth and duration due to several other factors.
These factors may include the
z
Referral source.
z
Nature of the complaint.
z
Observed needs.
z
Medical/psychiatric history.
z
Availability of resources.
z
Amount of privacy for conducting assessment.
z
Operational Tempo.
z
Environmental conditions.
z
Professional training of the person making the assessment.
z
Command interest.
z
Soldier cooperation.
Note. Regardless of these factors, COSC personnel are responsible for conducting the
assessment in a timely manner within professional standards of practice.
DOCUMENTATION
8-14. An assessment is documented according to AR 40-66 whenever the Soldier—
z
Is diagnosed with a BH disorder.
z
Has a condition (or suspected condition) requiring emergency medical evaluation or treatment.
z
Is prescribed medication.
z
Is assessed to be a high safety risk (for example, homicidal or suicide, cognitive impairment,
substance abuse, and impulsivity).
z
Requests that documentation of his assessment be made in his medical records.
z
Is evacuated beyond Level II MTF for further assessment or treatment.
z
Is command-referred for a BH evaluation.
TRANSFER AND EVACUATION
8-15. All COSC personnel are responsible for knowing the transfer/evacuation policies and procedures
within their AO. Policies and procedural information are available through the command surgeon, medical
regulating officer (MRO) of the medical command, control, communications, computers, and intelligence
(C4I) headquarters or major MTF. All relevant background and/or clinical documentation must accompany
the Soldier during the transportation or evacuation process.
MODE OF TRANSPORTATION
8-16. Nonambulance transport is the preferred mode of transportation for COSR and nonurgent BH cases.
Examples of nonambulance transportation include the Soldier’s unit vehicles, supporting supply/logistics
vehicles, and nonambulance medical vehicles. Ambulances convey patient status on Soldiers and often
must be reserved for medical emergency. Under the provisions of the Geneva Conventions, ambulances
must be used exclusively in the performance of humanitarian duties, therefore, they cannot be used to
return Soldiers to duty and transport must be provided by the supported unit.
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FM 4-02.51
6 July 2006
Combat and Operational Stress Control Triage
ESCORT
8-17. Depending on a Soldier’s condition, an escort (either medical or nonmedical) may be necessary to
provide safety, monitoring, and accountability during transportation or evacuation. The escort should be an
NCO or officer of equal or greater rank/grade as that of the escorted Soldier. Escorts must be emotionally
mature, responsible, and capable of conducting their escort duties. Frequently escorts carry the Soldier’s
clinical documentation to the destination MTF.
FEEDBACK
8-18. Good communication is essential for effective continuity of care during the transportation/evacuation
process. The Soldier’s unit must be informed about his location and status throughout the process. The
sending party must provide sufficient documentation about the Soldier’s condition, history, and
administered interventions. The receiving party must provide feedback to the sending party regarding
receipt of the Soldier and his documentation.
SECTION II — PRECAUTIONS AND DIFFERENTIAL DIAGNOSTIC PROBLEMS
ASSOCIATED WITH COMBAT AND OPERATIONAL STRESS CONTROL
TRIAGE
PRECAUTIONS FOR COMBAT AND OPERATIONAL STRESS
CONTROL TRIAGE
8-19. Medical emergencies must be identified during COSC triage. Medical emergencies consist of
physical illnesses or injuries and/or BH disorders that can result in permanent injury, disability, or death.
Early identification of a medical emergency avoids unnecessary delay in definitive treatment. Medical
emergencies can cause emotional and/or BH changes and may resemble COSR in presentation. The
following conditions and behaviors could be medical emergencies. Therefore, it is important to ensure
medical examinations and disposition of Soldiers that display the following conditions
z
Psychosis.
z
Mania.
z
Alcohol withdrawal.
z
Substance intoxication.
z
Delirium.
z
Suicidal gesture, attempt, or high risk for suicidal behavior.
z
Catatonia.
z
Significant paresis, paralysis, and/or sensory loss.
8-20. Assessing for physical illnesses or injuries is a critical part of COSC triage. The COSC personnel
must always consider physical illnesses or injuries that resemble COSR or BH disorders. Physical illnesses
or injuries may not reach the threshold of a medical emergency, but must be recognized and appropriately
treated. Assessing for physical illnesses or injuries requires an adequate review of body systems and a
quick physical examination. The examination includes vital signs, examination of head, eyes, ears, nose,
throat, chest, abdomen, and extremities with simple testing of reflexes and muscle strength. In field
situations (Level I and II), negative or normal findings need to be documented on DD Form 1380 (US Field
Medical Card). Refer to AR 40-66 for detailed information on patient accountability and management of
individual health records. Any positive findings from the physical examination must be evaluated further.
If the examiner has not checked various body systems, it is not reassuring to tell a Soldier that his physical
or BH complaints are only COSR. All COSC personnel should receive familiarization training on basic
medical examination techniques and in documenting medical information. Whenever a physical illness or
injury is suspected, personnel should consult with their medical peers for further assistance. Some cases
will require direct medical examination by a physician or physician assistant (PA). The COSC personnel
should not order tests or procedures that do not directly influence case management. Medical tests may
6 July 2006
FM 4-02.51
8-5
Chapter 8
promote the patient role in the mind of the Soldier. Needless tests may delay a Soldier’s RTD and
encourage secondary gains.
DEFER DIAGNOSIS OF BEHAVIORAL DISORDERS
8-21. During assessment, COSC personnel must always consider BH disorders that resemble COSR, but
defer making the diagnosis. The COSC personnel favor this default position to preserve the Soldier’s
expectations of normalcy (according to BICEPS). This is also done to avoid stigma associated with BH
disorders and to prevent the Soldier identifying with a patient or sick role. Deferral is also preferred
because some diagnoses require extensive history collection or documentation that is unavailable during
deployment situations (such as personality disorders and attention deficit hyperactive disorder). It is
possible that a Soldier can have a combination of COSR, BH disorders and physical illnesses/injuries at the
same time. In such cases, COSC personnel must rely on their clinical experiences, training, and
consultation with peers and medical personnel to distinguish among these sometimes overlapping
conditions. Physical injuries/illnesses are treated at a MTF, however, the Soldier may return for further
COSC interventions and activities. Deferral of diagnosis is preferred, but diagnosis can be considered if
the Soldier—
z
Presents for reemerging symptoms of a previously diagnosed and/or treated BH disorder.
z
Presents for refill prescription of psychotropic medication.
z
Has a medical condition or BH disorder listed above in paragraph 8-19.
z
Is enrolled in a reconditioning program.
z
Fails to improve after having received four to five days of continuous COSC interventions and
activities at hold or refer status.
z
Requires individual BH treatment.
z
Is referred for multiple episodes of COSR.
DIAGNOSTIC CONSIDERATIONS FOR DIFFERENTIAL DIAGNOSTIC DISORDERS
Low-Grade Environmental or Stress-Related Illnesses
8-22. Low-grade environmental or stress-related DNBI illnesses can drain the Soldier’s strength and
confidence. For example, chronic diarrhea and slight fever may exhaust, demoralize, and contribute to
COSR among Soldiers. These conditions should be treated medically, concurrently with physical
replenishment, rest, reassurance and organized activities, which restore the Soldier’s confidence. If they
persist in spite of rest and symptomatic treatment, a more aggressive workup and treatment may be
indicated.
Dehydration
8-23. Dehydration deserves special mention because it can be very insidious. Soldiers under battlefield or
heavy work conditions become extremely dehydrated without feeling thirsty. This is especially likely in
CBRN equipment, or in a desert/arctic environment. Refer to FM 4-25.10 for additional information on the
prevention of dehydration and FM 4-25.11 for first aid measures.
Hyperthermia
8-24. Hyperthermia (overheating) in an otherwise healthy individual often first causes mild elation and
excessive energy. This may be followed by irritability, disorientation, and confusion. When core body
temperature climb above 106º Fahrenheit (F) or 41º Centigrade (C), the Soldier may become belligerent,
combative, and have visual hallucinations. If brain temperature rises further, the Soldier collapses and
convulses in heatstroke. Refer to FM 4-25.11 for first aid measures and FM 4-25.10 for additional
information on prevention and first aid measures for heat injuries.
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FM 4-02.51
6 July 2006
Combat and Operational Stress Control Triage
Hypothermia
8-25. Hypothermia may cause an individual to become disoriented when core body temperature falls below
95°F (34.6°C). The person may move and speak slowly. His skin looks and feels warm, leading him to
take off clothing. He becomes disoriented, then unresponsive and may appear to be dead. Hypothermia is
as likely in cool or even warm, wet climates as it is in extremely cold ones. Refer to FM 4-25-10 for
additional information on prevention and FM 4-25.11 for first aid measures.
Overuse Syndromes
8-26. Overuse of muscles, joints, and bones that have not been prepared for the strain of field duties can
lead to persisting stiffness, pain, swelling, and orthopedic injuries. If severe, these injuries may require
evacuation to a hospital for evaluation. Even if these injuries are avoided, the unfit person who overexerts
has days of stiffness, aching, and weakness. Such cases are likely to develop COSR if further demands are
made on them.
Rhabdomyolysis
8-27. Rhabdomyolysis is one potentially dangerous complication of severe muscle overuse
(and of
heatstroke or crush injuries) in which myoglobin from damaged muscle cells injures the kidneys. It can
cause fatigue, seizures, muscle tenderness, and muscle aches. A warning sign is dark (tea-colored) urine,
but without laboratory testing, this is not easily distinguished from the concentrated urine of dehydration.
Rhabdomyolysis is a medical emergency.
Head Trauma
8-28. Concussion may stun the individual and cause amnesia, residual confusion, and/or impulsive
behavior. For any case of suspected head trauma or for any case of significant memory loss (especially for
a discrete period of time), check scalp, eyes, ears, nose, cranial nerve signs, and vital signs for evidence of
head injury. Cases with deteriorating mental status are medical emergencies. If one pupil becomes larger
than the other, it is an extreme emergency requiring immediate hospitalization. Left untreated, the
condition can progress rapidly to coma and respiratory arrest within hours. If a head injury is suspected,
monitor mental status and vital signs periodically, especially respiration, even though physical findings are
negative. Awaken the Soldier periodically to check mental status and pupil size (allowing sufficient time to
recover from any grogginess on awakening). Continuous monitoring is appropriate if there are serious
concerns about the risk.
Spinal Cord Trauma
8-29. Pressure, bruising, and hematomas of the spinal cord, as well as severing of the spinal cord, can
cause spinal shock, with loss of sensory and/or motor functions below the level of the injury in the affected
dermatome and muscle group patterns. The loss of function may be bilateral, unilateral, or partial. These
cases could be confused with paralysis or sensory loss presentations of COSR. Further manipulation of a
fractured spine can worsen or make permanent the spinal cord damage. Information from the history of
onset, a cautious physical and neurological examination, or complete relief of symptoms following
hypnosis or strong positive suggestions could demonstrate convincingly that this is only COSR. It is best
to be cautious and keep the spine immobile during care and transportation.
Postconcussion Syndromes
8-30. Postconcussion syndromes may persist weeks to months beyond the period of acute concussion.
Postconcussion syndromes may include perceptual or cognitive impairment, poor impulse control, and
difficulty in planning ahead. These are often accompanied by cranial nerve deficits or soft neurological
signs.
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FM 4-02.51
8-7
Chapter 8
Abdominal Trauma
8-31. Ruptured spleen or other intraperitoneal bleeding may cause shock. The Soldier may arrive in a fetal
position and be unresponsive but have reflex guarding due to peritonitis.
Air Emboli and Focal Brain Ischemia
8-32. High blast overpressures from incoming high explosive ordnance can produce air emboli (bubbles in
the blood) and focal brain ischemia (small areas in the brain which cannot get oxygen because the blood
flow has been interrupted). Nuclear explosions can do this, as can high explosives when shock waves are
magnified by reflection within bunkers, buildings, and trenches. Ruptured eardrums, general trauma, and
evidence of pulmonary damage should be detectable. Cases may have stroke symptoms (loss of muscle
strength, loss of sensation in parts of the body, and/or speech disturbances), which may be subtle and
mistaken for COSR.
Laser Eye Injury
8-33. Laser range finders/target designators cause small burns on the retina if they shine directly into the
eye, even at great distances and especially if viewed through optics. If the laser beam causes a small retinal
blood vessel to bleed inside the eyeball, the person will see red. If blood inside the eye is confirmed on
examination, the Soldier should be evacuated to a hospital with verbal reassurance that he may RTD soon.
If the laser does not hit a blood vessel, the Soldier may see only flashes of light, followed quickly by some
painless loss of vision. If the laser damage areas of the eye responsible for peripheral vision, the Soldier
may never recognize a visual deficit. If the Soldier was looking directly at the laser source however, there
will likely be a major loss of visual clarity. With simple retinal burns in the retina’s periphery, most of the
visual symptoms recover with hours to days of rest, reassurance, and nonspecific treatment the same as
with COSR. Calm, professional treatment at each level of medical care should emphasize that the injury is
not vision-threatening and the chances for some, if not total, recovery is good. Soldiers with the simple
retinal burns should provide self-care to decrease the risk of assuming a patient mind-set and to promote
their chances of RTD. For additional information on the management of laser eye injuries, refer to
FM 8-50.
Middle Ear Injuries/Diseases
8-34. Temporary loss of hearing can be cause by a decreased acoustic sensitivity following a brief
extremely intense noise (explosive) or less intense, longer duration noise. Tinnitus (ringing in the ears) can
also result from acoustic nerve damage or irritation, as well as from high doses of certain drugs, such as
aspirin. Distinguishing physiologic from psychogenic hearing loss may require consultation with an
otolaryngologist (ears, nose, and throat specialist).
Peripheral Neuropathies
8-35. Peripheral neuropathies include compression neuropathies, which are especially likely in military
settings
(for example, rucksack palsy). Depending on severity, they may require temporary job
reclassification during convalescence. As these injuries are not life-threatening, a hasty diagnosis should
not precede a trial of Soldier restoration treatment.
Uncommon Endemic Neurologic Disorders
8-36. These physical diseases can first manifest with cognitive emotional and/or behavioral symptoms. A
comprehensive neurological examination is required for the definitive diagnoses. Examples include—
z
Guillain-Barre Syndrome manifests with muscle paralysis, usually without sensory loss, which
ascends the legs and arms, then the trunk, over hours to days. It is sometimes triggered by
immunizations, as might be given to troops deploying overseas. It often progresses to a
life-threatening situation as the muscles of respiration become involved. This requires
evacuation to EAC and continental United States (CONUS). Fortunately, recovery is usually
complete, but it takes months to years.
8-8
FM 4-02.51
6 July 2006
Combat and Operational Stress Control Triage
z
Multiple sclerosis is a disease that can mimic many types of COSR/BH disorders with its
sometimes transitory, shifting motor, sensory, speech, and cognitive/emotional symptoms. It is
made worse by stress and may be difficult to diagnose. Once confirmed, multiple sclerosis cases
should be evacuated to CONUS, as should other rare, progressive diseases like Lou Gehrig’s
disease (amyotrophic lateral sclerosis).
z
True convulsive seizure can manifest after head injury or a sublethal or chronic nerve agent
exposure. These are treated with normal anticonvulsant medications. Fear of nerve agent
exposure may lead some Soldiers to experience psychogenic seizures. These psychogenic
seizures are also called pseudo-seizures. In addition to falling unconscious and convulsing,
urinary and fecal incontinence can occur during a pseudo-seizure.
SUBSTANCE ABUSE/DEPENDENCE
ALCOHOL
8-37. Substance abuse is an example of misconduct stress behaviors and not necessarily COSR. Drug and
alcohol abuse may occur in active CZs and nearby areas where use is explicitly prohibited and severely
punished. Personnel performing the COSC assessment should be familiar with evaluation and treatment of
substances abuse and dependency. Combat operational stress control providers should consider the
following:
z
Heavy habitual use of alcohol, even by otherwise capable officers and NCOs, may go unnoticed
in peacetime. However, alcohol abuse it may degrade necessary mission performance demanded
by combat and may result in withdrawal symptoms when access to alcohol is interrupted.
Alcohol withdrawal is potential medical emergency; consultation with medical personnel is
essential.
z
Intoxication or withdrawal from alcohol, barbiturates, and tranquilizers may be mistaken for
COSR or another BH disorder. Intoxication or withdrawal requires medical treatment.
Withdrawal seizures or impending or ongoing delirium tremens need emergency medical
treatment.
OVERUSE OF STIMULANTS
8-38. Stimulants may cause panic attacks, hyperactivity, mania, rage attacks, psychosis or paranoia.
Cessation of amphetamines after prolonged use causes a crash characterized by extreme sleepiness,
lethargy, overeating depression and suicidal thinking. This condition may require one to two weeks of
hospitalization to assure safe recovery.
HALLUCINOGENIC DRUGS
8-39. Hallucinogenic drugs cause sensory distortion, panic, bizarre thoughts, and potentially dangerous
behaviors. These drugs may be employed by the enemy as chemical or biological warfare agents.
Phencyclidine hydrochloride (PCP) is especially problematic since it also blocks pain and tends to make
those under its influence paranoid, violent, and abnormally strong. Hallucinogenic drug psychosis should
not be treated with antipsychotic drugs. Physically restrain and sedate patients as necessary.
INHALATION OF FUMES
8-40. Inhalation of fumes (either by accident or as deliberate abuse) and carbon monoxide poisoning can
cause disoriented, abnormal behavior. Supportive treatment and, specific antidotes/medication may be
needed.
ANTICHOLINERGIC DELIRIUM
8-41. In combat, atropine delirium may occur. Soldiers are equipped with atropine injectors to use as first
aid against nerve agents. Two milligrams (mg) (one atropine injector) without nerve agent challenge can
cause rapid pulse, dry mouth, slightly dilated pupils, decreased sweating (hot, dry, flushed skin), and
6 July 2006
FM 4-02.51
8-9
Chapter 8
urinary retention. In some individuals, 6 mg of atropine (equal to three atropine injectors) may cause
hallucination and disorientation in the absence of a nerve agent challenge. Such side effects may be more
pronounced in sleep-deprived Soldiers. Overheated Soldiers are more susceptible to the atropine side
effects. Atropine compounds the complications of overheating by diminishing the body’s ability to lose
heat through sweating. One dose (2 mg) of atropine can reduce the efficiency of heat-stressed Soldiers.
Two doses (4 mg) will sharply reduce combat efficiency, and 6 mg will incapacitate troops for several
hours. Some plants can also cause anticholinergic delirium when eaten.
ANTICHOLINESTERASES
8-42. A nerve agent is an anticholinesterase similar to many insecticides. Low-dose nerve agent exposure
may produce miosis (pinpoint pupils) without other signs. Miosis decreases vision except in very bright
light and may cause eye pain when attempting to focus. This miosis may take hours to days to improve
spontaneously, depending on the degree and type of exposure. Evidence gathered from farm workers
poisoned by insecticides suggests that mild personality changes, insomnia, nightmares and chronic
persistent depressive symptoms may be seen even after use of an antidote. Low-dose nerve agent exposure
may lower the seizure threshold of many Soldiers. True epileptic seizure cases must be distinguished from
those Soldiers who may have pseudo-seizures.
BEHAVIORAL DISORDERED PATIENTS IN THE THEATER
PRIMARY BEHAVIORAL DISORDERS
8-43. Primary BH disorders (especially schizophrenic-form/schizophrenic disorder, major depression, and
bipolar disorder) will continue to occur at approximately the same rate as in peacetime. Some Soldiers may
hide their disorders by receiving care through civilian channels. Once in the theater they may experience a
relapse or self-refer to a MTF when their medication supply is exhausted.
PERSONALITY DISORDERS
8-44. Preexisting personality disorders may make a Soldier unable to adapt to military life. However,
studies have failed to show a relationship between personality disorders and the likelihood of breakdown in
combat. Once Soldiers with personality disorders have developed COSR or a BH disorder, they may have
greater difficulty recovering and RTD. Diagnosis should never be made in haste; diagnostic criteria must
be supported with adequate historical information.
8-10
FM 4-02.51
6 July 2006
Chapter 9
Combat and Operational Stress Control Stabilization
SECTION I — EMERGENCY STABILIZATION
STABILIZATION
9-1. Emergency stabilization is the acute management of disruptive behavior resulting from COSR and/or
a behavioral disorder. The disruptive behavior severely impacts unit functioning by posing a danger to self
and/or others. In some cases, an underlying medical condition leads to the disruptive behavior and may
present an additional threat to the Soldier’s life. Emergency stabilization consists of interventions that
temporarily reduce a disturbed Soldier’s threat of self or others, thereby allowing further medical
evaluation and/or treatment. Some behavioral disorders are associated with violent behavior, such as
psychotic disorders, bipolar manic disorders, antisocial personality disorder, and borderline personality
disorder. Violent behavior is also associated with disruption of brain functioning due to organic factors
such as intoxication, hyperthermia, metabolic imbalance, or CBRN exposure.
9-2. The COSC triage process will be repeated throughout the emergency stabilization and will determine
the disposition of the Soldier. After emergency stabilization, subsequent triage could result in an
immediate RTD, transfer to a COSC Soldier restoration program for observation, or further evacuation.
METHODS USED FOR EMERGENCY STABILIZATION
9-3.
Methods that may be used for emergency stabilization include—
z
Providing verbal reassurance and reorientation are the best methods for controlling an agitated or
disruptive Soldier. If these fail, a nonthreatening show of strength or force may suffice, or
sedating medications may be offered to the Soldiers. If all other means fail to reduce the threat
to self and/or others, physical restraint must be considered. Given the risk for violence, it is
inadvisable to attempt subdue/restraint method one-on-one.
z
Applying physical restraints is reserved for subduing and restraining agitated or disruptive
Soldiers who fail to respond to safer and less restrictive forms of restraint (for example, verbal
warnings or show of strength). Placing a disturbed Soldier into physical restraint increases the
risk of injury to the Soldier and restraint team. Prolonged or improper application of physical
restraint can cause injury to the disturbed Soldier. Given the potential for injury, it is paramount
that COSC personnel receive training in proper physical restraining methods. Safe medical
evacuation by ground (preferred) or air ambulance.
z
Regardless of the method, the restrained Soldier must be checked frequently to guard against
nerve injuries or impaired circulation, which may lead to skin ulcers or gangrene. It is important
to check periodically to ensure the Soldier is not secretly escaping from restraints. The Soldier
is provided verbal reassurances with positive expectations for his recovery each time he is
checked.
z
Chemical restraints (such as medication) can be administered to a disturbed Soldier to reduce the
risk of harm to self or others. Medication may be offered to the Soldier in conjunction with
verbal reassurances and reorientation. Chemical restraints may only be ordered by a medical
professional who is authorized to prescribe medication when a Soldier is incompetent to make
medical decisions for himself and/or when the Soldier’s behavior places himself or others in
danger. Once administered, medical personnel must observe for side effects and adverse
reactions, and must consider administering additional medications as needed. When a Soldier is
in physical restraints, medication may no longer be essential, but may serve to reduce the risk of
escape, limb damage, and overheating. As a secondary benefit, once the medications reduce the
6 July 2006
FM 4-02.51
9-1
Chapter 9
Soldier’s agitation, others in the vicinity may feel safer and calmer. Before prescribing an
antipsychotic medication, there are a few things to consider. First, some antipsychotic drugs may
take several hours or days to take effect. Second, early administration of an antipsychotic drug
may confuse the clinical picture for the next evaluator in the evacuation chain. The
recommendation for most cases is to use no medication unless it is truly necessary for
management.
SECTION II — COMBAT AND OPERATIONAL STRESS CONTROL FULL
STABILIZATION
FULL STABILIZATION
9-4. Full stabilization is normally the mission of the Level III MTF such as a CSH specialty clinic’s
psychiatric service. Full stabilization goes beyond securing the safety of the Soldier and those around him.
It provides a safe environment for the Soldier to receive treatment interventions, continued evaluation, and
assessment for RTD potential. If RTD within the evacuation policy is not feasible, the full stabilization
process helps to prepare the patient for a safe, long-distance evacuation. If a Level III MTF is not
available, full stabilization may be accomplished by COSC personnel when appropriately supported or by
using equipment diverted from the COSC Soldier restoration capability. Considerations for full
stabilization may include—
z
Conducting full stabilization for NP patients is desirable for the sake of the Soldier’s future
treatment and for the potential of returning some Soldiers to duty. However, full stabilization is
personnel intensive with a relatively low RTD payoff. Providing only sufficient stabilization to
allow evacuation from the theater may be acceptable in order to maintain the other COSC
functions.
z
Ensuring appropriate timely evacuation of Soldiers with NP/behavioral disorders according to
the theater evacuation policy. It is preferred that full stabilization is achieved for all NP patients
to facilitate appropriate and timely evacuation according to the theater evacuation policy.
z
Assessing and triaging of COSR Soldiers undergoing full stabilization is an ongoing process. In
subsequent triages, if a Soldier becomes stable the potential for RTD, they may be transferred to
a COSC Soldier restoration or reconditioning program, or may be RTD directly.
TENETS OF FULL STABILIZATION
9-5. The COSC full stabilization includes ongoing evaluation of RTD potential. This requires assessment
of mental status and performance capability overtime without excessive drug effects or limitation on
activity. Contact with the Soldier’s unit may be needed to get information on prior history and functioning.
The further from the unit the Soldier has been evacuated, the more difficult it may be to contact the
Soldier’s unit. Full COSC stabilization normally takes several days. To the extent compatible with safety,
the stabilization program should adhere to the principles and methods for treating COSR and behavioral
disorder (such as BICEPS and 5 R’s).
9-6. During full stabilization, special efforts should be made to maintain and reinforce the Soldier’s
identity as a Soldier. Techniques that may be helpful in maintaining the Soldier mind-set include—
z
Keep Soldiers in duty uniform, not pajamas, as soon as they can be allowed.
z
Maintain rank distinctions and appropriate military courtesy.
z
Encourage self-care and helping behaviors.
z
Engage in military work activities appropriate to the Soldiers’ level of function and MOS.
9-7. Initial and ongoing assessments are essential to tailor the treatment to the Soldier’s individual needs.
It is essential that clinical documentation is available for these assessments. The Soldier’s condition is an
evolving one, and must be monitored throughout full stabilization. If assessed capable to RTD, efforts
should be made to return the Soldier to duty.
9-2
FM 4-02.51
6 July 2006
Combat and Operational Stress Control Stabilization
9-8. Ongoing treatment and/or therapeutic modalities are essential to improving a Soldier’s chances to
RTD whether in theater or after evacuation. Therapeutic modalities are similar to those used on inpatient
units, but must remain consistent with COSC principles. These modalities include medication, individual
psychotherapy, group psychotherapy, and appropriate therapeutic occupations. Observed responses to
therapeutic modalities allow informed recommendation for RTD status.
FULL STABILIZATION FACILITIES
9-9. Full stabilization is commonly conducted in the CSH. The CSH can provide more sophisticated
procedures, laboratory and x-ray capabilities than are available at a medical company MTF. If a medical
unit, CSC is providing emergency or full stabilization, the Soldier must be kept separate from other
Soldiers in Soldier restoration or reconditioning.
9-10. If the Level III MTF (CSH) cannot provide sufficient inpatient psychiatric treatment for Soldiers
requiring stabilization and preparation for evacuations, the theater/AO COSC consultant may recommend
up to two temporary COA until the shortfalls resolve. He can recommend to the higher medical command
that COSC personnel from one or more medical unit, CSC augment the Level III MTF psychiatric service
until the caseload decrease or until replacements or additional COSC personnel are brought into theater or
the MTF. Lastly, the medical C2 headquarters may direct that a COSC Soldier restoration or
reconditioning assets be collocated with the Level III MTF to provide an “overflow” ward as well as
augmenting staff. Definitive information is provided on the CSH NP ward staff capabilities in FM 4-02.10.
9-11. The MF2K CSH has a psychiatrist, three psychiatric nurses and a medical/surgical nurse, a social
worker, nine mental health specialists and an OT sergeant at full strength. It has a modular hospital tent to
provide a 20-bed hospital ward. The MF2K hospitals were designed to be at one location, but may follow
the MRI doctrine of splitting off a portion to a remote site, taking with it some of the psychiatry service
personnel. One portion would not have the psychiatry ward module, and would need to function similarly
to the MRI CSH psychiatry service.
9-12. The MRI CSH has a psychiatrist, a psychiatric nurse, and two MH specialists. The service does not
have an organic psychiatric ward where NP patients are admitted. There is normally an intermediate care
ward with medical ward staff designated to receive NP patients. Some of these patients seen by the NP
clinic will already be stable, and are being evaluated and prepared for RTD or evacuation. Most patients
who are admitted for emergency or full stabilization will be on the designated ward, although a few with
serious medical complications could require the intensive care ward. If the hospital has a high census of
medical and surgical patients, most of the NP patients will need to occupy beds on the intermediate care
ward. The MRI hospital may be augmented by staff from a medical company/detachment, CSC to operate
a NP ward, as required.
9-13. Full stabilization facilities in theater can be categorized into two types:
z
Mobile facilities use general purpose (GP) large or medium tents as used in medical units, CSC
and can also be available to a CSH or a tent, expandable, modular, personnel (TEMPER) tent as
used in a CSH.
z
Fixed facilities use buildings that were previously hospitals or buildings converted to hospitals.
9-14. Facilities used for full stabilization include tents, Deployable Medical Systems
(DEPMEDS)
TEMPER tents, and fixed facilities. The adaptation of these facilities have both advantages and
disadvantages that include—
z
The principal advantage of the (hospital) TEMPER tents, as assembled into DEPMEDS hospital,
is their climate control capability. This may be a significant safety advantage for treating
seriously disturbed patients in restraints with high-dose medication, which can disrupt body’s
ability to regulate normal body temperature. The TEMPER and standard tents both pose greater
problems for security than do fixed facilities. The staff may, therefore, have to rely more than is
ideal on physical restraints and medications for sedation of some cases. Blankets or screens can
be used to isolate or segregate problem patients from others. Such partitions reduce mental
contagion but provide little true protection.
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FM 4-02.51
9-3
Chapter 9
z
Standard hospital beds are on high, lightweight metal legs with wheels. For full stabilization
purposes, these should be replaced with standard low, stable cots to hold strong, agitated patients
in restraints. The cots also make a more “military” setting and can be used as seats for group
activities.
z
When feasible, it is best to have a separate
“closed”
(high security) and
“open”
(moderate/minimal) security area. The latter could be a standard GP large tent (the same as
those of the minimal care wards [MCWs] located close to the TEMPER tent of the official NP
ward). The specialists (MOS 68WM6 [practical nurse] and 68W [health care specialist]) of the
MCW could be given on-the-job training in supervision and military group activities for the
moderate/minimum security cases if the NP staff is too small.
9-4
FM 4-02.51
6 July 2006
Chapter 10
Combat and Operational Stress Control Soldier
Restoration
SECTION I — SOLDIER RESTORATION
SOLDIER RESTORATION PROGRAM
10-1. Soldier restoration is normally a 24- to 72-hour (1- to 3-day) program in which Soldiers with COSR
receive treatment. Soldier restoration is accomplished using the principles of BICEPS and the 5 R’s as
discussed in the previous chapter. The 5 R’s are tailored to the needs of the Soldier. Soldier restoration is
conducted as close to the Soldier's unit as possible. Soldier restoration can be conducted by medical
units/elements throughout the theater with the assistance of organic and/or augmented COSC personnel.
The medical company/detachment, CSC is staffed and equipped to establish Soldier restoration programs.
Soldier restoration may also be accomplished at a Level III MTF (CSH). The tenets remain the same but
implementation may differ in the duration of Soldier restoration and the specialized skill and knowledge of
available providers. There are three subcategories of Soldier restoration (referred to as lines of Soldier
restoration) based on location and available resources that are discussed in Section II of this chapter.
SOLDIER RESTORATION PROCESS
10-2. The process of Soldier restoration involves several steps that include screening, assessment, and
interventions, reintegration/coordination, and movement of Soldiers. A discussion of each of the steps in
the process is provided below.
SCREENING
10-3. Adequate medical screening and treatment as necessary must be done before the Soldier begins the
Soldier restoration program. Minor medical conditions can be treated during routine sick call. Soldiers
entering a Soldier restoration program should be only those hold cases that require continuous medical
and/or BH evaluation and observation for 24 hours or more. The criteria for hold cases are discussed under
COSC triage in Chapter 8. Tending to and restoring physiological status (such as sleep and hydration) is a
priority. Some Soldiers who need Soldier restoration will also have a mental disorder. Treatment for the
mental disorder may continue or be initiated during the Soldier restoration process.
ASSESSMENT AND INTERVENTION
10-4. Initial assessment and subsequent COSC interventions depends upon the severity of the COSR and to
what extent the reactions interfere with the Soldier’s ability to function. More thorough interviews are
conducted only after the Soldier’s physiological status has been restored.
REINTERGRATION
10-5. Coordination is required to assist Soldiers with reintegration back into their units. Soldiers are
reassessed regularly. When a Soldier experiencing COSR begins to improve, the COSC interventions shift
toward the reintegration of the Soldier back into his unit. The COSC personnel must work with the COSC
consultant of their area or other resources to assist with this reintegration.
6 July 2006
FM 4-02.51
10-1

 

 

 

 

 

 

 

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