FM 4-02 FORCE HEALTH PROTECTION IN A GLOBAL ENVIRONMENT (FEBRUARY 2003) - page 3

 

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FM 4-02 FORCE HEALTH PROTECTION IN A GLOBAL ENVIRONMENT (FEBRUARY 2003) - page 3

 

 

FM 4-02
and augmentation sets for those frequently used consumables that are needed for early operational capability.
The resupply sets are developed using Service-unique patient streams.
(2) In order to develop, analyze, and refine patient workload, a careful examination of major
groupings and subgroupings of patients types must be accomplished.
b. The categories of patient types used to refine patient workload data are: wounded in action
(WIA), COSC casualties, disease (DIS), and nonbattle injuries (NBI). The actual PC code numbers and
a description of medical conditions which comprise each group are contained in the DEPMEDS Admin-
istrative Procedures, Clinical and Support Guidelines, and Patient Treatment Briefs located at the JRCAB
website.
c.
The patient estimates used to drive the quantity of consumables placed in DEPMEDS are at
some variance with historical precedence. The major difference is the relative proportions of WIA versus
DIS and NBI. In previous wars, disease admissions have exceeded WIA admissions. Current rates may be
explained by the time in the war that the casualty estimate is taken. The three highest periods of WIA
casualty generation are time periods 6 through 8 (D+60 through D+89). Disease rates are lower during
this portion of the war, and are also lower for NATO than other theaters. This reverse WIA/DIS/NBI ratio
is acceptable because of the lethality of the modern battlefield, and because the resources needed to provide
care for diseases is significantly less than for injuries. It is recognized that as the war proceeds the rates of
disease will increase and the number of wounded will be proportionally less.
A-5. Changes to Medical Materiel Sets
a. All new and current DEPMEDS sets and subsequent substantive changes to sets are required
to be reviewed and approved by the ASD(HA) prior to acquisition by the military Services. The Director of
the JRCAB is authorized to approve maintenance, substitution, and minor changes.
• Substantive—change or addition of a major component of an MMS or addition of
a new set which enhances mission capability with consideration given to cost, weight, and cube
requirements.
• Maintenance—change to correct administrative error in national stock number (NSN),
nomenclature, weight, cost, or similar changes.
• Substitution—change to replace a major or minor component of an MMS with a
generically equivalent item with consideration given to cost, weight, and cube requirements.
• Minor—change to delete or add a minor end item or quantity of a component to an
MMS.
b. For an in-depth discussion the procedures (to include staffing memorandum for submitting
recommended changes to MMS) refer to the JRCAB website.
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FM 4-02
A-6. Treatment Guidelines
a. The DEPMEDS treatment guidelines provide assistance, clarification, standards, and expecta-
tions of care to providers. They are not expected to be concrete directives nor rigid prescriptions. Patient
care must be individualized for each patient and for each medical condition. Within the MHS, a patient may
be treated at MTFs managed by different Services, the DEPMEDS treatment guidelines therefore facilitate
continuity of care.
b. Current planning incorporates a shortened theater evacuation policy. If patients cannot be
returned to duty within the established theater evacuation policy, they are evacuated to the next level of care
consistent with their medical status (stable, stabilized, or nontransportable) as soon as possible. The theater
evacuation policy currently used for planning is, if from a—
• Level II unit, the patient is not able to RTD within 72 hours.
• Level III unit, the patient is not expected to RTD within 7 days.
• Level IV unit, the patient is not expected to RTD in 15 days.
A-7. Clinical Guidelines
a. Policy. The clinical policy for DEPMEDS supports essential care in theater.
Appropriate health care is considered to be the provision of health service logistics
support which permits the health care provider to render medical care and make necessary decisions.
Consumable supplies required for treatment must be available in a timely manner. Field medical equipment
must be transportable, and be available in sufficient quantity with limitations imposed by the combat
environment.
Adequate health care is sufficient to provide the lowest possible mortality and morbidity
rates for WIA and NBI casualties in the theater forces.
(1) Initial resuscitation should be prompt and at the point of injury or as far forward as
tactically feasible.
(2) Wounded, ill, or injured soldiers should be treated and returned to duty at the lowest
(most forward) level of care possible.
(3) Those soldiers WIA or suffering from NBIs will be treated and evacuated as expeditiously
as possible to the level of care required for initial wound therapy. Initial wound surgery will consist of
those procedures necessary to stabilize neurological, vascular, bone, and joint wounds and injuries. Initial
wound surgery for the less severe injuries may permit RTD within the stated theater evacuation policy. If
not capable of RTD within the evacuation policy, patients should be evacuated to the next level of care.
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FM 4-02
(4) A mass casualty event occurs when numerous casualties are produced in a relatively
short period of time and the numbers exceed the available HSS assets to provide individualized treatment.
In order to maximize the expenditure of scarce resources and to provide the greatest good to the greatest
number, triage (sorting) of casualties is required. Triage requires clinical judgment to evaluate and
categorize casualties for medical treatment and evacuation. Field Manual 4-02.6 and the NATO Emergency
War Surgery Handbook (STANAG 2068) provide an in-depth discussion of mass casualty situations, triage
categories, and the establishment of a mass casualty station. When a disparity no longer exists between the
number of casualties and the available HSS resources, routine treatment emphasis will govern once again.
(5) Due to weight and cube considerations, wherever practical, reusable durable items are
preferable to disposable equipment or consumable supplies, when there is a means to sterilize, clean, and/or
launder them.
b. Nursing Practice Guidelines. The goal of nursing is to provide safe and efficient nursing care
in a deployed setting. The nursing guidelines are designed to provide care at a safe level or maintain life,
limb, or function. Nursing care is comprised of direct and indirect activities.
• Direct nursing care includes those nursing actions that occur to and for the patient in the
OR setting, at the bedside, or in the presence of patients and are observable.
• Indirect nursing care includes those activities that are essential for patient care but are not
done at the patient’s bedside.
In the TO, indirect nursing care is greater than in CONUS due to the austere
environment.
Indirect nursing care includes activities such as obtaining medications; collecting
equipment for procedures; disposing of medical waste; managing soiled linens; resuppling OR or ward
stock; transporting patients; transporting specimens to the laboratory; obtaining x-rays and blood products;
performing operator maintenance on medical equipment, maintaining OR sanitation; and documenting
medical care and patient status in pre- and postoperative areas, ORs, and wards.
(1) Nursing practice incorporates the activities of data collection, assessment, implementation
of a plan of care, and evaluation of patient care outcomes. The nurse must continually adjust priorities to
meet the dynamic requirements of patient care, ancillary support coordination, administrative tasks, and
staff management. The clinical, cognitive, and managerial skills of the nurse are essential to effectively
function under vigorous demands of a wartime, stability operations, and/or support operations scenario.
This environment includes limited numbers of staff, austere facilities, equipment with limited capabilities,
and a higher frequency of acute care requirements.
(2) Food service personnel will deliver food to the wards and nursing personnel will deliver
food trays to patients.
(3) Whenever possible, nonnursing personnel will assist in transporting stable patients to and
from the x-ray, physical therapy (PT), and dining facilities. A nonnursing pool could include ambulatory,
self-care patients, and administrative and supply personnel.
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FM 4-02
(4) Patient holding areas within a hospital are referred to as wards. There are a number of
different types of ward within a hospital. These wards are:
• Intensive care unit. This ward manages surgical and medical patients whose
physiological status is so disrupted that they require immediate and continuous medical and/or nursing care.
Noninvasive physiological monitoring and life support systems are standard items used in this setting.
Invasive augmentation sets may also be available.
• Intermediate care ward (ICW). This ward manages surgical and medical patients
whose physiological and psychological status is such that they require observation for the presence of real or
potential life-threatening disease or injury. The acuity of care may range from those requiring constant
observation to those patients able to ambulate and assume beginning responsibility for their care. The level
of care and acuity of these patients may fluctuate depending upon the intensity of the conflict. Although not
routinely required, ICW patients may need monitoring devises and ventilator support.
• Minimal care ward (MCW). This ward manages surgical and medical patients who
are partially self-sufficient and usually ambulatory. Some patients require limited therapeutic and diagnostic
services and are in the final stages of recovery. Complexity of care includes administering oral medications
and treatments which cannot be done by patients and may also include providing instruction in self-care and
posthospitalization health maintenance. This treatment may include therapy and reconditioning of RTD
patients.
(5) Standards and responsibilities for the following areas are contained in the DEPMEDS
Administrative Procedures, Clinical and Support Guidelines, and Patient Treatment Briefs and are available
at the JRCAB website (paragraph A-1c):
• Intravenous fluid standards and procedures.
• Administration of medication.
• Intake and output documentation.
• Foley catheters.
• Admission procedures.
• Patient assessment and evaluation.
• Documentation requirements.
• Skeletal support systems.
• Patient hygiene.
• Nasogastric tubes.
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FM 4-02
(6) Central materiel supply provides support to hospital activities 24 hours a day and 7 days
a week. The CMS is expected to be in an operational mode early in the establishment of a DEPMEDS
hospital, in accordance with Service-specific plans and operations. Sterile items, trays, and linen packs
should be available as soon as possible.
(7) Nursing care in the OR dictates staffing requirements, administration and management of
the CMS, administration of medications, patient transport, preoperative assessment, documentation of
nursing care, sponge, sharps, and instrument counts, conscious sedations, collection of specimens, and the
positioning of the patient.
(8) Safety procedures in the OR encompass the use of lasers, pneumatic tourniquets, fire
safety, hazardous material (HAZMAT), electrical failures, gas cylinder handling, storage, and disposal, use
of electrosurgical devices, and infection control measures.
(9) Personal protective equipment is available for all OR personnel and its use is required to
prevent contamination by infected blood/body fluids. Personal protective equipment includes gloves, face
shields, goggles, shoe covers, gowns, masks, and head covers, as appropriate.
(10) Only medications will be kept in the medicine refrigerator. Temperature checks will be
performed in accordance with the pharmacy SOP and the refrigerator will be cleaned weekly with a
detergent.
(11) Traffic patterns will be established that preclude the crossing of clean and sterile supplies
and equipment over paths used to move contaminated supplies and equipment and waste disposal.
(12) To ensure the quality of air within the OR, filters should be changed in accordance with
the OR SOP.
c.
Patient Complications. Unfortunately, some patients’ medical conditions will deteriorate or
complications will set in. These adverse events may necessitate a return to intensive care, additional
treatment, and the expenditure of additional medical supplies. A general, nonspecific incidence of
complication rate is applied to those PCs felt to be most liable for complications and is reflected in the
applicable guidelines and treatment briefs. Patients with complication of life-, limb-, or vision-threatening
nature should be stabilized and evacuated as expeditiously as possible.
A-8. Support Guidelines
a. Patient Administration. The patient administration (PAD) division in a DEPMEDS hospital is
responsible for most of the administrative aspects of patient care. These responsibilities encompass:
admission and disposition (A&D) processing; scheduling patient evacuation; collecting, safeguarding, and
accounting for patient’s funds and valuables; custodianship of inpatient and outpatient treatment records, to
include timely redeployment of medical records; maintenance of medical records and files; collecting and
reporting of medical statistical data; management of casualty (reporting) and decedent affairs; initiation of
line of duty investigations; and submission of special reports and other patient related activities (such as
A-12
FM 4-02
very seriously ill [VSI] and seriously ill [SI] listings). The PAD coordinates externally with the higher
headquarters medical regulating office (MRO), the TPMRC, and/or the supporting mobile aeromedical
staging facility (MASF)/aeromedical staging squadron (ASTS), as appropriate for all AE; with the personnel/
casualty affairs officers of patient’s units (to include VSI, SI, stable condition, or deceased information);
with mortuary affairs (MA) for the prompt removal of remains (the DEPMEDS hospital does not have a
morgue); with supporting personnel unit to arrange transportation for RTD patients; and with supporting
personnel and supply units to reequip soldiers who RTD at this level (DEPMEDS hospitals do not stock
additional uniforms and equipment for RTD soldiers). Upon admission of a patient, the PAD must collect,
store, and notify the patient’s parent unit of weapons, ammunition, and explosives evacuated with the
patient. Further, the PAD ensures that baggage belonging to evacuated patients is within the AE weight
guidelines and for making appropriate disposition of excess baggage.
b. Infection Control. Infection control activities within an MTF are critical to the patient care
mission. Infection control considerations include:
• Handwashing which is essential before and after each patient contact.
• Standard precautions and aseptic techniques are used when the patient’s condition requires
invasive procedures.
• Category specific isolations procedures allow for optimal isolation when indicated (FM
4-02.33), especially in a field environment where microbiologic diagnostic capabilities may be limited.
(A
listing of specific diseases and length of isolation required is contained in the DEPMEDS Administrative
Procedures, Clinical and Support Guidelines, and Patient Treatment Briefs located on the JRCAB website
[paragraph A-1c].)
• Intravascular access therapy accomplished at Level II will be considered as not
accomplished under aseptic conditions.
• All open fluid containers will be changed and/or discarded after 24 hours, such as IV and
irrigation fluids.
• All laboratory specimens will be handled using standard precautions, and should be
considered to harbor pathogens.
• Linen and trash must be removed from patient care areas (PCAs) at a minimum of every
12 hours.
• Reusable equipment will be cleaned and disinfected between patients. Disposable
equipment should not be reused.
c.
Waste Disposal. Medical treatment facilities create a significant amount of waste. There are
five categories of waste. These categories are: general waste (including solid waste), hazardous waste,
medical waste, human waste, and wastewater. All military units generate general and hazardous waste.
Medical waste is generated by medical personnel and units during the performance of the health care
A-13
FM 4-02
delivery mission. There are two types of medical waste: nonregulated and regulated. Nonregulated
medical waste consists of solid materials generated from the direct result of patient diagnosis, treatment, and
therapy that requires no further treatment and can be disposed of as general waste. Regulated medical waste
(RMW) is defined as medical or laboratory waste that is potentially capable of causing disease in people and
may pose a risk to individuals or public health if not handled or treated properly. All types of waste must be
disposed of in accordance with US laws, regulations, and policy guidance. If the unit is located outside of
the US, cooperative agreements and HN laws may also affect the proper disposition of waste. For an in-
depth discussion of waste disposal refer to FM 4-02.10, FM 4-25.12, and FM 21-10 and the DEPMEDS
Administrative Procedures, Clinical and Support Guidelines, and Patient Treatment Briefs which are
available at the JRCAB website.
d. Nutritional Care. At Levels I and II there are no resources to provide special diets for
patients. Those soldiers who may be held at the Level II MTF for 72 hours must be capable of subsisting on
the field rations available. At the Level III hospital (and above), dietitians and medical supplemental rations
are available to prepare special diets for hospitalized soldiers; however, nutritionally impaired patients
should be considered for expeditious evacuation to facilities with full nutritional support capability. The
meal, ready-to-eat (MRE) is not authorized for patient feeding at any level within the theater medical
system, except in AE and emergency situations when other rations are not available.
e.
Laboratory Services. Laboratory services are available from Level II through Level V. The
sophistication of laboratory procedures increases with each level of care. The capabilities of a specific
laboratory are based on the MMSs available to the unit. Laboratory capabilities are very limited if only the
basic laboratory MMS (D303—Laboratory [General]) and (D304—Laboratory [Liquid Blood Bank]) are
available. These modules do not allow for the use of frozen blood products, the culture and susceptibility
testing of microorganisms, or anatomic pathology/cytology procedures. Specimens for microbiology and
anatomic pathology/cytology procedures can be collected and referred to another hospital or special function
laboratory that offers the required procedures. Hospital laboratory capabilities can be significantly enhanced
by additional Liquid/Frozen Blood Bank (D404) sets or the addition of the Microbiology (D403) and
Anatomic Pathology/Cytology (D436) modules. One other module, Frozen Blood Bank (D405) can also be
used to increase capability. For a description of these MMSs refer to the DEPMEDS Administrative
Procedures, Clinical and Support Guidelines, and Patient Treatment Briefs which are available at the
JRCAB website.
f.
Blood Bank. The Armed Services Blood Program Office (ASBPO) was established by DODD
6480.5 to coordinate the respective military departments and unified commands’ blood programs to effect
standardization of policies, procedures, and equipment. The ASBPO is the organization authorized direct
liaison with Federal, civilian, and allied or coalition agencies on all blood related matters.
• Each unified command has a separate integrated system for providing blood and
blood products to its various component MTFs. The unified command JBPO serves as the single blood
manager.
• Frozen blood products will be pre-positioned in designated unified commands in quantities
to support blood requirements for the initial days of an armed conflict. The frozen blood products are
shipped to and used in DEPMEDS hospitals and on designated naval vessels. The Food and Drug
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FM 4-02
Administration (FDA) has licensed frozen RBCs for 10 years storage; however, data has shown that it can
be stored up to 21 years and might be used during contingencies.
• The ASBPO directs shipment of liquid and frozen blood products from CONUS to a TO
via a designated Armed Services Whole Blood Processing Laboratory (ASWBPL). In theater, blood
products are received at a blood transshipment center and shipped to a component blood supply unit and
subsequently distributed on a geographical basis to MTFs.
• Although the FDA has approved post-wash storage of deglycerolized RBCs, it may only
be stored up to 3 days post-wash. Therefore, in contingencies, if deglycerolized RBCs are used they may
only be stored for up to 3 days post wash.
• Certain wartime scenarios require the use of frozen deglycerolized RBCs during the
initial phase following the onset of hostilities. In fact, the majority of total RBC requirements will be
obtained from deglycerolized RBCs until liquid RBCs can be obtained from CONUS. Thereafter, liquid
RBCs will be used. Whenever possible, blood products shipped to the theater will have a minimum of 2
weeks remaining before expiration.
• Generally, 20 percent of all RBCs will be given at Level II, 60 percent at Level III, and
20 percent at Level IV. The normal Rh distribution to 85 percent Rh positive and 15 percent Rh negative is
projected.
• The blood planning factors are used by medical planners in calculating the blood product
requirements within the TO. They are to be applied only once per patient admitted. They represent
cumulative requirements for that patient during hospitalization for that specific episode. The planning
factors for blood are—
Red blood cells—4 units for each WIA and NBI patient admitted in a deployed
facility.
Fresh frozen plasma (FFP)—0.08 units for each hospitalized WIA and NBI patient.
Frozen platelet concentrate (PLT)—0.04 units for each hospitalized WIA and NBI
patient.
• The blood planning factors are programmed into the Medical Planning Module (MPM)
and are used by unified medical planners to generate daily product requirements for the theater.
• Except in emergencies, pre-positioned blood products will eliminate blood collection
requirements in the TO during armed conflict. The majority of blood products needed in theater will be
provided from CONUS. All blood products pre-positioned or provided from CONUS will be fully
processed.
• Immediate spin cross-matching of RBCs will be performed at Levels III and IV. It will
not be performed at Level II.
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FM 4-02
• The ABO and Rh group of the patient will be rechecked prior to infusion at Levels III
and IV. The ABO and Rh group of RBCs will be checked unless they have been verified by the ASWBPL
prior to shipment.
• Antibody screens will not be performed in theater.
• Blood collected in the field under emergency conditions will only be tested for ABO and
Rh group. Where theater assets permit, a serum tube will be collected for subsequent infectious disease
marker transmission purposes.
• For specific information on blood requirements for each PC and transfusion procedures
refer to FM 8-70, Technical Manual (TM) 8-227-3, TM 8-227-11, TM 8-227-12, and the patient treatment
briefs available at the JRCAB website (paragraph A-1c).
g. Radiology Services. Radiology support is available at Levels II through V. For acute care at
Level II MTFs, the primary care physician and/or PA are responsible for reading and interpreting x-ray
films taken at this level. The complexity of procedures and studies is limited at this level due to the austere
conditions and equipment limitations. At Levels III and IV hospitals which have an assigned radiologist, the
preliminary interpretation of x-ray films taken for acute care may be performed by the requesting provider.
However, the radiology department is responsible for the final reading and interpretation of all films taken
at the facility. Nuclear medicine and magnetic resonance imaging capabilities are not available within the
TO. For guidelines on specific PCs and standards refer to the DEPMEDS Administrative Procedures,
Clinical and Support Guidelines, and Patient Treatment Briefs which are available at the JRCAB website
(paragraph A-1c).
h. Pharmacy Support. Pharmacy services within a hospital provide support to the PCAs on a 24-
hour basis. The pharmacy should be operational in the early establishment of the hospital. Services
provided by the pharmacy include: providing general pharmaceutical support (for example: restocking of
PCAs on a daily basis, filling valid orders for drugs as received, and operating an issue point where PCA
personnel pick up medication and deliver drugs to using units, if appropriate); providing all controlled
substances; packaging and dispensing medication for AE and discharge to duty patients and/or other
ambulatory patients; providing parenteral admixture services; generating IV quality fluids in the theater;
providing parenteral nutritional solutions at Levels III and IV; providing other compounded miscellaneous
sterile fluids; providing drug information services; and providing guidance on the selection and procurement
of all pharmaceuticals. Unit dose services will not be provided in theater. Other considerations include:
• It is expected that deploying personnel who are taking medication will bring their own
supply for the first 90 days. Medications for long-term administration may not be available until the
resupply system (line order requisitioning) is established.
• Initial pharmacy stockage is contained in MMS D306. Pharmacists should review the D-
Day Significant Item List for alternate drugs for specific drug classes. Within the hospital, the pharmacy
service will request resupply from the MTF logistics division.
• When requesting pharmaceuticals, PCA personnel must have a bulk drug order, duplicate
copy of the physician’s medication order, or the standard prescription form.
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FM 4-02
• A reasonable quantity of medications will be provided by the pharmacy to the PCAs, as
determined by the patient care staff.
• The handling, accountability, and record keeping for controlled substances is required
and it must conform to regulatory requirements. All restricted and controlled items must be stored in a
lockable container in any DEPMEDS module.
A-9. Medical Guidelines
a. Emergency Medicine.
(1) General guidelines. Emergency medicine focuses on the stabilization of life- or limb-
threatening diseases, injuries, and wounds. It is the care provided by the trauma specialist, physicians, and
PAs in forward areas (Levels I and II) and in CZ and EAC hospitals. Each level has an increasing
sophistication of equipment and services provided to ensure the best prognosis, to decrease morbidity and
mortality, and to limit long-term disability. When establishing an MTF, regardless of size or location, the
emergency medicine area should be operational at the earliest possible moment. Patients presenting with
severe traumatic injuries should be administered tetanus toxoid, based upon the individual patient condition.
Further, all patients with suspected head and neck injuries should have the head and neck immobilized with
the best available product. This may necessitate changing the cervical collar to the universal fitting cervical
collar at Level III.
NOTE
The AMEDD is currently reviewing and recommending changes to
existing protocols for the use of resuscitative fluids on the battlefield.
If a casualty with a traumatic injury is coherent, alert, and oriented to
place and time, and has a radial pulse, and all obvious bleeding has
been stopped, resuscitative fluids should not be immediately admin-
istered. The casualty’s wounds are treated and he is monitored to
ensure he does not develop signs of shock.
• Level I. The first medical care an injured, ill, or wounded soldier receives is
provided at this level. Emergency medical treatment at the point of injury or wounding is provided by the
trauma specialist. The patient is then evacuated to the BAS, which is the MTF (established by the treatment
platoon of the maneuver unit) where the soldier receives ATM. At this level the soldier is treated and
returned to duty or stabilized for further evacuation to the rear.
• Level II. Medical treatment at Level II is a continuation of the treatment received at the
BAS. As the MTF is established in a more secure location than the BAS, the physicians and PA have addi-
tional time in which to enhance stabilization of the patient for further evacuation to the rear. If augmented
by a FST, patients requiring far forward resuscitative surgery can receive the required care at this level.
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FM 4-02
• Levels III and IV. The emergency medicine/treatment area of the CSH is the entry
point for patients into the theater hospitalization system (Level III and EAC Level IV). The emergency
medicine/treatment area can be used for triage, emergency treatment (ATM), and as a preoperative area.
The Army Service Component Command (ASCC) may determine that a separate preoperative area is
established in its hospitals based on METT-TC.
(2) Airway management. The establishment of patent airway is essential for resuscitation of
a traumatized patient. Endotracheal tubes (ETs) will be placed by qualified clinicians at whatever treatment
level where the capability exists to support the patient’s airway management needs. Endotracheal tubes are
used for assisted ventilation if required for brief periods of time (up to 7 days). If required for airway
management, cricothyroidotomies can be performed; these are normally performed under emergency
conditions where restorations of a patient airway is an immediate requirement to sustain life. Aeromedical
evacuation does not require a surgical airway; however, one should be considered if the physician determines
that the patient requires assisted ventilation for more than 7 days; if there is a significant risk the ET could
be displaced during transport; and when the upper airway injuries are less than 3 days old.
(3) Control of hemorrhage and bleeding. Extremity hemorrhage should be controlled by
direct pressure. Tourniquets may be of value, but the use of clamps directly into the wound should not be
employed.
(4) Support of circulation (resuscitation fluids). The predominant cause of shock in trauma
patients is hypovolemia. The three most severe classes of hemorrhage (Classes II, III, and IV) require
astute clinical attention and action. Management of these patients require hemorrhage control and fluid
replacement with appropriate monitoring.
• The primary agents for resuscitation are lactated Ringer’s (LR) solution and blood.
Available blood products in various operational theaters are liquid packed (deglycerolized) RBCs, packed
RBCs, FFP, and PLTs.
• Colloid solutions will generally not be needed in most cases of hypovolemic shock.
For DEPMEDS hospitals there is albumin/protein products (25 percent and 5 percent) and a synthetic
colloid preparation
(hetastarch) available for patients with Class III and IV hemorrhage, as deemed
appropriate by the attending physician.
• Hypovolemic shock is not treated by vasopressors, steroids, or sodium bicarbonate.
• Two large bore IVs are established and the infusion of LR is started.
• When possible, patients should have a systolic blood pressure of greater than 100
millimeters (mm) mercury (Hg) and urine output of 30 cubic centimeters (cc)/hour before going to surgery.
This, however, is a matter for clinical decision by the health care provider.
• All crystalloid fluids for resuscitation are contained in the EMT MMS. Those
fluids used in the OR are for the maintenance of anesthesia only.
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FM 4-02
b. Resuscitative Fluids. For an in-depth discussion of types of resuscitative fluids, quantities
required, administration of fluids, and coagulopathy refer to DEPMEDS Administrative Procedures, Clinical
and Support Guidelines, and Patient Treatment Briefs located at the JRCAB website.
c.
Infectious Diseases. Incidence of infectious diseases must be reported in accordance with the
requirements of FM 4-02.33. Infectious disease consultation will be available within the theater and will be
coordinated through the supporting PVNTMED personnel/units. All unexplained febrile patients should be
evacuated. If required, the theater evacuation policy may be amended to meet the specific requirements
imposed by an outbreak of a specific infectious disease. Health hazard assessment and medical surveillance
activities are mandated by DODD 6490.2, DODI 6490.3, and AR 40-66. All infectious disease occurrences
must be documented in the individual soldier’s health record.
d. Medical Aspects of the Biological Threat. Many bacteria, fungi, viruses, rickettsial agents,
and toxins have the potential of being used as BW agents. Despite the very different characteristics of these
organisms, biological agents used as weapons share some of the same common characteristics. They can be
dispersed in aerosols of particle size 1 to 5 microns which may remain suspended (in certain weather
conditions) for long periods and if inhaled will penetrate into distal bronchioles and terminal alveoli of
victims. They may be delivered by simple technology, including industrial sprayers with nozzles modified
to generate the smaller particle size. The aerosol could be delivered from a line source such as an airplane,
or boat traveling upwind of the intended target, or from a point source such as a stationary sprayer or a
missile dispensing agent containing bomb lets in an area upwind of the target. Other possible routes of
exposure for BW agents include oral, by intentional contamination of food and water, and percutaneous. In
general, these routes of exposure are less important than the respiratory route. For an in-depth discussion
on the protection, prevention, and treatment of BW casualties refer to FM 8-284. For an in-depth
discussion of the operational aspects, to include patient decontamination, refer to FM 4-02.7.
e.
Medical Aspects of the Chemical Threat. Chemical agents may exist as solids, liquids, or
gases, depending on temperature and pressure. Except for riot-control agents (which are solids at usually
encountered temperatures and pressures), CW agents in munitions are liquids. Following detonation of the
munitions container, the agent is primarily dispersed as a liquid or as an aerosol, defined as a collection of
very small solid particles or liquid droplets suspended in a gas. The tendency for a CW agent to evaporate
depends not only on its chemical composition and on the temperature and air pressure, but also on such
variables as wind velocity and the nature of the underlying surface with which the agent is in contact.
Volatility is inversely related to persistence, because the more volatile a substance is, the more quickly it
evaporates and the less it tends to stay or persist as a liquid and to contaminate terrain and materiel. For an
in-depth discussion on the protection, prevention, and treatment of CW casualties refer to FM 8-285. For
an in-depth discussion of the operational aspects, to include patient decontamination, refer to FM 4-02.7.
f.
Critical Care. Critical care management (CCM) encompasses the acute medical/surgical care
of the critically-ill patient and is predicated on accurate pre-CCM triage decisions that select patients for
further support. Critical care management includes care for acute cardiorespiratory collapse, pre- and
postoperative care of trauma victims, treatment of disorders of oxygenation and ventilation for circulatory
difficulties (including dysrhythmias and cardiovascular trauma). The process of CCM includes intensive
monitoring with appropriate equipment required to identify life support deficiencies. The provision of
CCM also implies expertise in airway management, skill in hemodynamic monitoring and supportive
A-19
FM 4-02
services including fluid administration, cardiotonic and vasoactive medication administration, and nutritional
support. Evacuation of casualties requiring prolonged CCM must be available and evacuation services
capable of transporting patients with mechanical ventilator (MV) and invasive monitoring should be available
within the TO. Specific guidelines for acute respiratory failure (ARF), shock, and sepsis are contained in
the DEPMEDS Administrative Procedures, Clinical and Support Guidelines, and Patient Treatment Briefs
located at the JRCAB website (paragraph A-1c).
g. Respiratory Care. Respiratory care in a DEPMEDS-equipped MTF focuses on MV support,
supplementation of oxygen, administration of aerosolized medicines, and general care of the patient with
ventilatory compromise. Respiratory care is an integral part of casualty care from the emergency medicine/
triage area through the postoperative ICU and on to the ICW. Its major impact and emphasis is on the
intubated, mechanically ventilated patient. For specific discussions on oxygen administration, airway
management, MV, aerosolized medications, respiratory and nursing care, refer to the DEPMEDS
Administrative Procedures, Clinical and Support Guidelines, and Patient Treatment Briefs located at the
JRCAB website (paragraph A-1c).
h. Optometry. The increasing incidence of eye injuries in war and the incapacitating nature of
such injuries give high priority to vision care. In addition, the loss of glasses, contact lens, or gas mask
inserts can, at the least degrade performance and at worst, make the individual combat ineffective. By
providing the appropriate eye care support, the casualty can quickly RTD without a visual impairment. An
optometrist can effectively manage most anterior segment eye injuries and diseases, freeing the ophthalm-
ologist for surgical repair of eye and adnexal injuries. Optometrists also effectively triage more severe
ocular injuries and ensure prompt treatment of such conditions. Optometrists provide essential support to
the operational aviation community for the aviation contact lens program. Contact lenses should not be
used in theater unless medically or operationally indicated for specific mission purposes. Replacement
spectacles and protective mask inserts requiring standard single vision lenses may be fabricated at optical
support units in theater, afloat, or in fixed facilities. Bifocal lenses and nonstandard single vision lenses
may be requested from the supporting CONUS full service ophthalmic laboratory or from an OCONUS
ophthalmic laboratory which has a lens surfacing capability.
A-10. Surgical Guidelines
a. At Level II, the medical company augmented with an FST is the location where surgical
intervention can first occur to render a nontransportable patient sufficiently stabilized to withstand evacuation
to an Level III hospital. The FST is limited in the number of surgical procedures it can perform.
b. North Atlantic Treaty Organization STANAG 2068 necessitated the publication of the NATO
Emergency War Surgery Handbook. This handbook in concert with the DEPMEDS Administrative
Procedures, Clinical and Support Guidelines, and Patient Treatment Briefs provide the guidelines required
for conducting surgery in a field environment.
c.
Specific guidance on the following areas is provided in the DEPMEDS Administrative
Procedures, Clinical and Support Guidelines: wound management and debridement; antimicrobial
prophylaxis; anesthesia; neurosurgery; ophthalmology; oromaxillofacial/otolaryngology surgery; thoracic
surgery; vascular surgery; abdominal surgery; urological surgery; obstetrics/gynecology; and orthopedics.
A-20
FM 4-02
d. Operational concerns include but are not limited to—
• Health service logistics (to include blood and blood products) must be comprehensively
planned for and supply levels monitored. A shortage or lack of specific medical supplies and/or equipment
may dictate that standard protocols are amended. For example, for wound debridement, if there are not
sufficient quantities of sterile irrigation fluids, potable water can be used as a first stage irrigant. The final
liter of irrigant should be a sterile saline containing antibiotics.
• Once a patient has undergone surgery, he should not be moved until he has recovered
from the anesthetic and his vital signs have been stabilized. Should the hospital (and/or FST) have to move
during this period, a medical holding element with sufficient medical staff, equipment, and supplies should
remain at the location with the patients until they are sufficiently stabilized for transport and medical
evacuation platforms are available to effect the move.
NOTE
In accordance with the provisions of the Geneva Conventions (para-
graph 4-4a[4]), if a patient must be abandoned, we have a moral
obligation to leave behind sufficient medical supplies, equipment, and
personnel to care for the patient.
• Patients with severe neurological injuries should be rapidly resuscitated and evacuated to
a MTF capable of providing the required care. In general, patients with severe head injuries, as defined by
the Glasgow Coma Score (GCS) of less than or equal to 5, will have a lower priority for evacuation in a
triage scenario (mass casualty situation). The presence of certain specific traumatic intracranial processes
(such as acute epidermal hematoma) may significantly alter this guideline. If neurosurgical evaluation is not
available, a GCS higher than 5 should indicate PRIORITY evacuation. A lower GCS may suggest a lower
priority for evacuation, or in the worst case scenario, EXPECTANT management.
• Due to the unpredictability of prognostication in the acute phase of spinal injuries, all
patients with spinal trauma with neural compromise are treated aggressively and given a high priority for
evacuation (URGENT and/or PRIORITY [METT-TC and medical condition dependent]).
• Personnel requiring surgery for obstetrical and gynecological reasons should be evacuated
from the operational theater as soon as possible. When clinical, operational, or logistical reasons preclude
evacuation, the postoperative patient may be evacuated when deemed stable for transport by the attending
health care providers.
• Policies for aeromedically evacuating patients with musculoskeletal injuries include—
All immobilized patients are to be transported on litters to permit elevation of
injured extremities. This requirement includes some upper extremities, and essentially all lower extremity
and spine injured patients.
A-21
FM 4-02
All circular casts must be bivalved prior to entry into the AE system to permit rapid
access to the limb and to allow for swelling at altitude.
Free hanging traction devices are not allowed on medical evacuation aircraft.
Traction may be applied through elastic and spring devices but must fit the litter.
All casts, splints, devices must be no longer than the size of the litter and its
handles.
A-11. Dentistry Guidelines
Although dental health during peacetime/garrison activities is relatively high, many dental problems arise
during deployments. Dental patient conditions can produce symptoms that range from a minor distraction
to severe debilitating pain and are often aggravated by external factors such as stress, fatigue, poor diet, and
temperature extremes. These symptoms have considerable impact on the accomplishment of the military
mission. Prompt and timely dental treatment lends itself to the rapid return of soldiers to duty, since severe
problems can often be treated relatively quickly with minimal equipment and supplies. The two categories
of dental care provided within the TO are emergency dental care and essential dental care. Comprehensive
dental care is provided in the CONUS-support base. Preventive dentistry is a part of essential care. For
additional information on dental activities refer to paragraph 5-7 of this publication, FM 4-02.19, and the
DEPMEDS Administrative Procedures, Clinical and Support Guidelines, and Patient Treatment Briefs
located at the JRCAB website (paragraph A-1c).
A-12. Special Topics
a. Burns. The risk of burn injuries is increased in the military, especially during conflicts. The
presence of large quantities of fuel for both vehicles and aircraft are lucrative targets for the enemy and the
ignition of these flammable liquids (either intentionally or unintentionally) can result in serious injury to
personnel. Additionally, the enemy use of weapons, such as flame-throwers and antipersonnel devices can
also increase the risk factor for burns.
(1) Burns can be caused by flammable materials (flame and flash burns), chemical agents,
and electric sources. In the military, soldiers suffering from severe burns may also have multiple traumatic
injuries or inhalation injuries which complicate the care required.
(2) The first concern of treating patients with thermal (flame or flash) burns is to secure the
airway, control hemorrhage, and to begin initial resuscitative therapy. Once the patient begins to stabilize
(hemodynamic stability), attention is then directed to wound care and care of other traumatic injuries. In
instances of chemical burns and burns resulting from white phosphorous, wound care is immediate in order
to decontaminate the wound to prevent further injury. Burns caused by electric current have special
treatment requirements, as the total body surface area (TBSA) covered by the burn in comparison to the
underlying tissue affected is small.
A-22
FM 4-02
(3) In a combat setting, METT-TC factors, logistical limitations, and limited availability of
health care personnel may necessitate the triage of burn patients. With optimum treatment and appropriate
facilities, approximately 50 percent of patients whose burns involve 60 percent to 70 percent of the TBSA
may survive. With limited resources, burn care resources should be applied to the group of patients which
would benefit the most (20 to 70 percent TBSA burns). This may necessitate that some patients will be
managed as EXPECTANT (over 70 percent TBSA burns) while others, with limited burns (less than 20 per-
cent TBSA burns) receive delayed hospital care. Depending upon the availability of resources and the num-
ber of burn patients, the upper limits may have to be reduced and should be done in increments of 10 percent.
(4) The burn patient best tolerates movement by either ground or air evacuation resources in
the early postburn period; that is after hemodynamic and respiratory stabilization and before the development
of septic complications which may make movement particularly hazardous. Optimally, the patient should
be evacuated to a definitive care facility (CONUS-support base) within 48 hours following the injury.
(5) For an in-depth discussion of treatment protocols for burn patients, refer to the NATO
Emergency War Surgery Handbook and the DEPMEDS Administrative Procedures, Clinical and Support
Guidelines, and Patient Treatment Briefs.
b. Physical Therapy and Occupational Therapy. Physical therapy and occupational therapy (OT)
personnel have complementary backgrounds and training, but are not substitutable for each other. When
providing unit level care (physician extender mission) for neuromusculoskeletal problems, PTs provide
primary care for complaints involving head and neck, spine and trunk, and the extremities; OTs are limited
to primary care of the elbow, wrist, and hand. If both services are available within a facility, they may be
collocated. During mass casualty situations, PT personnel may assist in managing DELAYED and
MINIMAL patients and/or supplement the orthopedic section. Occupational therapy personnel have skills
and training to provide combat operational stress support to patients and staff. These health care providers
may or may not be deployed to the theater depending upon METT-TC, medical troop ceilings, and the
theater evacuation policy. For an in-depth discussion of treatment guidelines for these specialties refer to
the DEPMEDS Administrative Procedures, Clinical and Support Guidelines, and Patient Treatment Briefs.
c.
Preventive Medicine and Occupational and Environmental Health. Preventive medicine, to
include medical surveillance activities is an essential function in both garrison settings and when units are
deployed. For a discussion of PVNTMED services refer to paragraphs 5-6 of this publication, FM 4-02.17,
FM 4-25.12, and FM 21-10. For policy guidance concerning these functions within a DEPMEDS hospital
setting, refer to the DEPMEDS Administrative Procedures, Clinical and Support Guidelines, and Patient
Treatment Briefs and FM 4-02.10.
A-13. Numerical Listing of Patient Condition Codes
a. This paragraph lists the PCs identified in the DEPMEDS clinical database.
b. The following is a list of the PCs for your information. The PCs and their accompanying
treatment briefs are updated on a quarterly basis by the JRCAB. For the most up-to-date information on
PCs and specific treatment briefs, refer to the JRCAB website provided in paragraph A-1 above.
A-23
FM 4-02
0001
Cerebral Concussion, Closed, with/without Nondepressed Linear Skull Fracture, Severe—Loss
of Consciousness from 2 to 12 Hours.
0002
Cerebral Concussion, Closed, with/without Nondepressed Linear Skull Fracture, Moderate—
Loss of Consciousness less than 2 Hours.
0003
Cerebral Contusion, Closed, with/without Nondepressed Linear Skull Fracture, Severe—Loss of
Consciousness greater than 24 Hours, with Focal Neurological Deficit.
0004
Cerebral Contusion, Closed, with/without Nondepressed Linear Skull Fracture, Moderate—Loss
of Consciousness from 12 to 24 Hours, without Focal Neurological Deficit.
0005
Cerebral Contusion, Closed, with Intracranial Hematoma, with/without Nondepressed Linear
Skull Fracture, Severe—Large Hematoma (Including Epidural Hematoma) with Rapidly
Deteriorating Comatose Patient.
0006
Cerebral Contusion, Closed, with Nondepressed Linear Skull Fracture, Severe—Loss of Con-
sciousness greater than 24 Hours, with/without Focal Neurological Deficit.
0007
Cerebral Contusion, Closed with Depressed Skull Fracture, Severe—with Associated Intra-
cerebral Hematoma and/or Massive Depression.
0008
Cerebral Contusion, Closed, with Depressed Skull Fracture, Moderate—No Associated Hema-
toma or Significant Effect from Depression.
0009
Cerebral Contusion with Open Skull Fracture, Severe—with Intracranial Fragments and/or De-
pressed Skull Fracture; Eyelid and Eyeball Laceration with Retained Intraocular Foreign
Body.
0010
Cerebral Contusion with Open Skull Fracture, Moderate—without Intracranial Fragments and/or
Depressed Skull Fracture.
0011
Intracranial Hemorrhage, Spontaneous, Nontraumatic, All Cases.
0012
Patient Condition Code Not Assigned.
0013
Wound, Scalp, Open without Cerebral Injury or Skull Fracture, Severe—Scalped with Avulsion
of Tissue.
0014
Wound, Scalp, Open without Cerebral Injury or Skull Fracture, Moderate—Scalp Laceration.
0015
Fracture, Facial Bones, Closed, Exclusive of Mandible, Severe—Multiple Fractures.
0016
Fracture, Facial Bones, Closed, Exclusive of Mandible, Moderate—Single Fracture.
0017
Wound, Face, Jaws, and Neck, Open, Lacerated with Associated Fractures, excluding Spinal
Fractures, Severe—with Airway Obstruction.
0018
Wound, Face, Jaws, and Neck, Open, Lacerated with Associated Fractures, excluding Spinal
Fractures, Moderate—without Airway Obstruction; Eyelid and Eyeball Laceration with Re-
tained Intraocular Foreign Body.
0019
Wound, Face and Neck, Open, Lacerated, Contused without Fractures, Severe—with Airway
Obstructions and/or Major Vessel Involvement.
0020
Wound, Face and Neck, Open, Lacerated, Contused without Fractures, Moderate—without
Airway Obstruction or Major Vessel Involvement.
0021
Eye Wound, Severe—Loss of Intraocular Fluid, with/without Retinal Detachment, with Severe
Lid Laceration, Eye Not Salvageable.
0022
Eye Wound, Lacerated, Moderate—without Retinal Detachment or Retinal Injury, No Foreign
Body Retained, without Loss of Vitreous Fluid, Patient has Hyphema, Eye Salvageable.
0023
Hearing Impairment, Severe.
0024
Hearing Impairment, Moderate.
0025
Fracture, Spine, Closed, without Cord Damage, Unstable Lesion.
A-24
FM 4-02
0026
Fracture, Spine, Closed, without Cord Damage, Stable Lesion.
0027
Fracture, Spine, Closed, with Cord Damage, Cervical Spine with Respiratory Involvement.
0028
Fracture, Spine, Closed, with Cord Damage, Below Cervical Spine (Progressive).
0029
Fracture, Spine, Open, with Cord Damage, Cervical Spine with Respiratory Distress.
0030
Fracture, Spine, Open, with Cord Damage, Below Cervical Spine (Progressive).
0031
Intervertebral Disc Disorders with Nerve Root Compression Resistant to Bed Rest/Traction.
0032
Intervertebral Disc Disorder with Nerve Root Compression, Responding to Bed Rest/Traction.
0033
Strains and Sprains, Sacroiliac Region, Severe—Nonambulatory.
0034
Strains and Sprains, Sacroiliac Region, Moderate—Ambulatory.
0035
Burn, Thermal, Superficial, Head and Neck, greater than 5 percent but less than 10 percent of
Total Body Area and/or Eye Involvement.
0036
Burn, Thermal, Superficial, Head and Neck, less than 5 percent of Total Body Area and No Eye
Involvement.
0037
Burn, Thermal, Partial Thickness, Head and Neck, greater than 5 percent but less than
10 percent of Total Body Area and/or Eye Involvement.
0038
Burn, Thermal, Partial Thickness, Head and Neck, less than 5 percent of Total Body Area an
No Eye Involvement.
0039
Burn, Thermal, Full Thickness, Head and Neck, greater than 5 percent but less than 10 percent
of Total Body Area with Eye Involvement.
0040
Burn, Thermal, Full Thickness, Head and Neck, less than 5 percent of Total Body Area and No
Eye Involvement.
0041
Fracture, Clavicle, Closed, All Cases.
0042
Wound, Shoulder Girdle, Open, with Bone Injury, Severe—Joint Involvement.
0043
Wound, Shoulder Girdle, Open, with Bone Injury, Moderate—No Joint Involvement.
0044
Fracture, Humerus, Closed, Upper Shaft, All Cases.
0045
Wound, Upper Arm, Open, Penetrating, Lacerated, without Fracture, Severe—with Nerve and/
or Vascular Injury.
0046
Wound, Upper Arm, Open, Penetrating, Lacerated, without Fracture, Moderate—without Nerve
or Vascular Injury.
0047
Wound, Upper Arm, Open with Fractures and Nerve and Vascular Injury, Arm Not Salvageable.
0048
Wound, Upper Arm, Open with Fractures and Nerve Injury, No Vascular Injury, Arm
Salvageable.
0049
Fracture, Radius and Ulna, Closed, Severe—Shafts of Bones.
0050
Fracture, Radius and Ulna, Closed, Moderate—Colles Fracture.
0051
Wound, Forearm, Open, Lacerated, Penetrating, without Bone, Nerve or Vascular Injury, with
Major Loss of Muscle Tissue, Severe—Requiring Major Debridement.
0052
Wound, Forearm, Open, Lacerated, Penetrating, without Bone, Nerve or Vascular Injury,
Moderate—Not Requiring Major Debridement.
0053
Wound, Forearm, Open, Lacerated, Penetrating, with Fracture and with Nerve and Vascular
Injury, Forearm Not Salvageable.
0054
Wound, Forearm, Open, Lacerated, Penetrating, with Fracture and with Nerve and Vascular
Injury, Forearm Salvageable.
0055
Fracture, Hand or Fingers, Closed, Severe—Requiring Open Reduction.
0056
Fracture, Hand and/or Fingers, Closed, Moderate—Not Requiring Closed Reduction.
A-25
FM 4-02
0057
Wound, Hand and/or Fingers; Open, Lacerated without Fractures, Severe—Superficial and Deep
Tendon Involvement.
0058
Wound, Hand and/or Fingers, Open, Lacerated without Fractures, Moderate—No Tendon
Involvement or Limited to Sublimis Tendon Involvement.
0059
Wound, Hand, Open, Lacerated, Contused, Crushed, with Fracture(s), All Cases—Involving
Fractures of Carpals and/or Metacarpals.
0060
Wound, Fingers, Open, Lacerated, Contused, Crushed, with Fracture(s) of Phalangeals, Re-
quiring Rehabilitation.
0061
Crush Injury, Upper Extremity, Severe—Limb Not Salvageable.
0062
Crush Injury, Upper Extremity, Moderate—Limb Salvageable.
0063
Patient Condition Code Not Assigned.
0064
Dislocation, Shoulder, Closed, All Cases.
0065
Dislocation/Fracture, Elbow, Closed, Acute, All Cases.
0066
Patient Condition Code Not Assigned.
0067
Dislocation, Hand or Wrist, Closed, Acute.
0068
Dislocation, Fingers, Closed, Acute.
0069
Amputation, Hand, Traumatic, Complete, All Cases.
0070
Amputation, Forearm, Traumatic, Complete, All Cases.
0071
Amputation, Full Arm, Traumatic, Complete, All Cases.
0072
Sprain, Wrist, Closed, Acute, All Cases.
0073
Sprain, Thumb, Closed, Acute, Severe.
0074
Sprain, Fingers, Closed, Acute, Moderate—No Thumb Involvement.
0075
Burn, Thermal, Superficial, Upper Extremities, greater than 10 percent but less than 20 percent
of Total Body Area Involved.
0076
Burn, Thermal, Superficial, Upper Extremity, less than 10 percent of Total Body Area Involved.
0077
Burn, Thermal, Partial Thickness, Upper Extremities, greater than 10 percent but less than
20 percent of Total Body Area Involved.
0078
Burn, Thermal, Partial Thickness, Upper Extremity, less than 10 percent of Total Body Area
Involved.
0079
Burn, Thermal, Full Thickness, Upper Extremities, greater than 10 percent but less than 20
percent of Total Body Area Involved.
0080
Burn, Thermal, Full Thickness, Upper Extremity less than 10 percent of Total Body Area In-
volved.
0081
Fracture, Ribs, Closed, Severe—Multiple Fractures.
0082
Fracture, Rib(s), Closed, Moderate.
0083
Injury, Lung, Closed (Blast Crush) with Pneumohemothorax, Severe—One Lung with Pulmonary
Contusion and Acute, Severe Respiratory Distress.
0084
Injury, Lung, Closed (Blast Crush) with Pneumohemothorax, Moderate—One Lung with
Pulmonary Contusion and Respiratory Distress.
0085
Wound, Thorax (Anterior or Posterior), Open, Superficial, Lacerated, Contused, Abraded,
Avulsed, Requiring Major Debridement.
0086
Wound, Thorax (Anterior or Posterior), Open, Superficial, Lacerated, Contused, Abraded,
Avulsed, Not Requiring Major Debridement.
0087
Wound, Thorax (Anterior or Posterior), Open, Penetrating, with Associated Rib Fractures and
Pneumohemothorax, Acute, Severe Respiratory Distress.
A-26
FM 4-02
0088
Wound, Thorax (Anterior or Posterior), Open, Penetrating, with Associated Rib Fractures and
Pneumohemothorax, Moderate Respiratory Distress.
0089
Patient Condition Code Not Assigned.
0090
Burn, Thermal, Superficial, Trunk, greater than 20 percent but less than 30 percent of Total
Body Area Involved.
0091
Burn, Thermal, Superficial, Trunk, greater than 10 percent but less than 20 percent of Total
Body Area Involved.
0092
Burn, Thermal, Partial Thickness, Trunk, greater than 20 percent but less than 30 percent of
Total Body Area Involved.
0093
Burn, Thermal, Partial Thickness, Trunk, greater than 10 percent but less than 20 percent of
Total Body Area Involved.
0094
Burn, Thermal, Full Thickness, Trunk, greater than 20 percent but less than 30 percent of Total
Body Area Involved.
0095
Burn, Thermal, Full Thickness, Trunk, greater than 10 percent but less than 20 percent of Total
Body Area Involved.
0096
Wound, Abdominal Wall (Anterior or Posterior), Lacerated, Abraded, Contused, Avulsed
without Entering Abdominal Cavity, Severe—Requiring Major Debridement.
0097
Wound, Abdominal Wall (Anterior or Posterior), Lacerated, Abraded, Contused, Avulsed without
Entering Abdominal Cavity, Not Requiring Major Debridement.
0098
Wound, Liver, Closed, Acute (Crush Fracture), Major Liver Damage.
0099
Wound, Liver, Closed, Acute (Crush Fracture), Minor Liver Damage.
0100
Wound, Spleen, Closed, Acute (Crush Fracture), All Cases.
0101
Wound, Abdominal Cavity, Open, with Lacerating, Penetrating, Perforating Wound to the Large
Bowel.
0102
Wound, Abdominal Cavity, Open, with Lacerating, Penetrating, Perforating Wound to Small
Bowel, without Major or Multiple Resections.
0103
Wound, Abdominal Cavity, Open, with Penetrating, Perforating Wound of Liver, Major Damage.
0104
Wound, Abdominal Cavity, Open, with Penetrating, Perforating Abdominal Wound with
Lacerated Liver.
0105
Wound, Abdominal Cavity, Open, with Penetrating, Perforating Wound of Spleen.
0106
Wound, Abdominal Cavity, Open, with Lacerated, Perforated Wound with Shattered Kidney.
0107
Wound, Abdominal Cavity, Open, with Lacerated, Penetrating, Perforating Wound with
Lacerated Kidney, Initially Repaired, but Subsequent Nephrectomy.
0108
Wound, Abdominal Cavity, Open with Lacerated, Penetrating, Perforated Wound with Shattered
Bladder.
0109
Wound, Abdominal Cavity, Open with Lacerated, Penetrating, Perforated Wound with Lacerated
Bladder.
0110
Wound, Buttocks, Severe—Open, Lacerated, Penetrating, Perforating, and Avulsed.
0111
Wounds, Buttocks, Moderate—Open, Lacerated, Contused, and Abraded.
0112
Displaced Fracture of Pelvis, Closed, with Associated Soft Tissue Damage and Pelvic Organ
Damage.
0113
Non-Displaced Fracture of Pelvis, Closed, with Associated Soft Tissue Damage.
0114
Wound, Abdomen, Open, with Pelvic Fracture and Penetrating, Perforating Wounds to Multiple
Pelvic Structures (Male or Female).
A-27
FM 4-02
0115
Wound, Abdomen, Open, with Pelvic Fracture and Penetrating, Perforating Wounds to Pelvic
Colon Only (Male or Female).
0116
Wound, External Genitalia, Male, Severe—Lacerated, Avulsed, Crushed.
0117
Wound, External Genitalia, Male, Moderate—Abraded and Contused.
0118
Wound, External Genitalia, Female, Severe—Lacerated, Avulsed, Crushed.
0119
Wound, External Genitalia, Female, Moderate—Abraded, Contused.
0120
Fracture, Closed, Femur, Shaft, All Cases.
0121
Wound, Thigh, Open, without Fracture, Nerve, or Vascular Injury, Requiring Major Debride-
ment.
0122
Wound, Thigh, Open, without Fracture, Nerve, or Vascular Injury, Not Requiring Major
Debridement.
0123
Wound, Thigh, Open, Lacerated, Penetrating, Perforating with Fracture and Nerve/Vascular
Injury, Limb Not Salvageable.
0124
Wound, Thigh, Open, Lacerated, Penetrating, Perforating, with Fracture and Nerve and/or
Vascular Injury, Limb Salvageable.
0125
Wound, Knee, Open, Lacerated, Penetrating, Perforating, with Joint Space Penetration, Shattered
Knee.
0126
Wound, Knee, Open, Lacerated, Penetrating, Perforating, with Joint Space Penetration, Arti-
cular Cartilage Damage, No Bone Injury.
0127
Fracture, Closed, Tibia and Fibula, Shaft, All Cases.
0128
Wound, Lower Leg, Open, Lacerated, Penetrating, Perforating, without Fractures, Requiring
Major Debridement.
0129
Wound, Lower Leg, Open, Lacerated, Penetrating, Perforating, without Fractures, Not Requiring
Major Debridement.
0130
Wound, Lower Leg, Open, Lacerated, Penetrating, Perforating, with Fracture and Nerve/
Vascular Injury, Limb Not Salvageable.
0131
Wound, Lower Leg, Open, Lacerated, Penetrating, Perforating, with Fracture and Nerve and/or
Vascular Injury, Limb Salvageable.
0132
Fracture, Ankle/Foot, Closed, Displaced, Requiring Reduction.
0133
Fracture, Ankle/Foot, Closed, Nondisplaced, Not Requiring Reduction.
0134
Wound, Ankle, Foot, Toes, Open, Lacerated, Contused, without Fractures, but Requiring
Major Debridement.
0135
Wound, Ankle, Foot, Toes, Open, Lacerated, Contused, without Fractures, Not Requiring
Major Debridement.
0136
Wound, Ankle, Foot, Toes, Open, Penetrating, Perforating, with Fractures and Nerve/Vascular
Injury, Limb Not Salvageable.
0137
Wound, Ankle, Foot, Toes, Open, Penetrating, Perforating, with Fractures and Nerve and/or
Vascular Injury, Limb Salvageable.
0138
Crush Injury, Lower Extremity, Limb Not Salvageable.
0139
Crush Injury, Lower Extremity, Limb Salvageable.
0140
Dislocation, Hip, Closed, Acute, All Cases.
0141
Tear, Ligaments, Knee, Acute, Complete Rupture.
0142
Tear, Ligaments, Knee, Acute, Incomplete Rupture.
0143
Dislocation, Toes, Closed, Acute, All Cases.
0144
Amputation, Foot, Traumatic, Complete, All Cases.
A-28
FM 4-02
0145
Amputation, Below Knee, Traumatic, Complete, All Cases.
0146
Amputation, Traumatic, Complete, Requiring Hip Disarticulation.
0147
Amputation, Above Knee, Traumatic, Complete.
0148
Sprain, Ankle, Closed, Acute, with Complete Ligament Rupture.
0149
Sprain, Ankle, Closed, Acute, Grade 2, Incomplete Ligament Rupture.
0150
Burn, Thermal, Superficial, Lower Extremities and Genitalia, greater than 30 percent but less
than 40 percent of Total Body Area Involved.
0151
Burn, Thermal, Superficial, Lower Extremity and Genitalia, greater than 15 percent but less
than 30 percent of Total Body Area Involved.
0152
Burn, Thermal, Partial Thickness, Lower Extremities and Genitalia, greater than 30 percent but
less than 40 percent of Total Body Area Involved.
0153
Burn, Thermal, Partial Thickness, Lower Extremity and Genitalia, greater than 15 percent but
less than 30 percent of Total Body Area Involved.
0154
Burn, Thermal, Full Thickness, Lower Extremities and Genitalia, greater than 30 percent but
less than 40 percent of Total Body Area Involved.
0155
Burn, Thermal, Full Thickness, Lower Extremity and Genitalia, greater than 15 percent but less
than 30 percent of Total Body Area Involved.
0156
Blisters, Hand, Fingers, Foot, Toes, Due to Friction, Acute, Moderate,All Cases.
0157
Insect Bites and Stings (Unspecified Body Area) with Systemic Symptoms and/or Respiratory
Difficulty.
0158
Bites and Stings (Unspecified Body Area), Moderate—Localized Symptoms.
0159
Multiple Injury Wound (MIW) Brain and Chest with Sucking Chest Wound and Pneumo-
hemothorax.
0160
MIW Brain and Abdomen with Penetrating, Perforating Wound, Colon.
0161
MIW Brain and Abdomen with Penetrating, Perforating Wound, Kidney.
0162
MIW Brain and Abdomen with Penetrating, Perforating Wound, Bladder.
0163
MIW Brain and Abdomen with Shock and Penetrating, Perforating Wound, Spleen.
0164
MIW Brain and Abdomen with Shock and Penetrating, Perforating Wound, Liver.
0165
MIW Brain and Lower Limbs Requiring Bilateral Above Knee Amputations.
0166
MIW Chest with Pneumohemothorax and Abdomen with Penetrating Wound, Colon.
0167
MIW Chest with Pneumohemothorax and Abdomen with Penetrating, Perforating Wound,
Kidney.
0168
MIW Chest with Pneumohemothorax and Abdomen with Perforating Wound, Bladder.
0169
MIW Chest with Pneumohemothorax and Abdomen with Penetrating, Perforating
Wound, Spleen.
0170
MIW Chest with Pneumohemothorax and Abdomen with Penetrating, Perforating
Wound, Liver.
0171
MIW Chest with Pneumohemothorax and Limbs with Fracture and Vascular Injury.
0172
MIW Abdomen with Penetrating, Perforating Wound of Colon and Bladder.
0173
MIW Abdomen with Penetrating, Perforating Wound of Colon and Spleen.
0174
MIW Abdomen with Penetrating, Perforating Wound of Colon and Liver.
0175
MIW Abdomen and Limbs with Penetrating, Perforating Wound of Colon and Open
Fracture and Neurovascular Injury of Salvageable Lower Limb.
0176
MIW Abdomen and Pelvis with Penetrating, Perforating Wound of Liver and Kidney.
0177
MIW Abdomen and Pelvis with Penetrating, Perforating Wounds of Spleen and Bladder.
A-29
FM 4-02
0178
MIW Abdomen, Pelvis, Limbs, with Fracture and Neurovascular Injury, Limb Salvageable, and
Penetrating Wound, Kidney.
0179
MIW Abdomen, Pelvis, Limbs, without Fracture or Neurovascular Injury, and Penetrating,
Perforating Wound, Bladder.
0180
MIW Abdomen and Lower Limbs, with Fracture and Nerve Injury, with Penetrating Wound of
Spleen, with Full Thickness Burns to greater than 20 percent of TBSA.
0181
MIW, Abdomen and Limbs, without Fracture or Nerve Injury, with Penetrating Wound of
Liver.
0182
MIW Chest with Pneumohemothorax, Soft Tissue Injury to Upper Limbs, and Penetrating
Wound of Brain.
0183
MIW Chest with Pneumohemothorax, Soft Tissue Injury to Upper Limbs and Abdomen, with
Wound of Colon.
0184
MIW Chest with Pneumohemothorax, Pelvis and Abdomen, with Wound of Colon and Bladder.
0185
MIW Abdomen and Chest with Multiple Organ Damage.
0186
Multiple, Nonperforating Fragment Wounds of Skin and Soft Tissue.
0187
Trench Foot, Immersion Foot, Severe—Vesicle Formation.
0188
Trench Foot, Immersion Foot, Moderate—No Vesicle Formation.
0189
Hypothermia, Moderate.
0190
Frostbite, Full Skin Thickness or Deeper Involvement.
0191
Frostbite, less than Full Skin Thickness.
0192
Hypothermia, Severe.
0193
Heat Stroke.
0194
Heat Exhaustion.
0195
Heat Cramps, All Cases.
0196
Appendicitis, Acute, with Perforation, Rupture, Peritonitis.
0197
Appendicitis, Acute, without Perforation, Rupture, Peritonitis.
0198
Inguinal Hernia, Complicated, Direct or Indirect, Sliding, Incarceration of Bowel.
0199
Inguinal Hernia, Uncomplicated, Direct or Indirect, No Sliding, No Incarceration of Bowel or
Bladder.
0200
Internal Derangement of Knee, Chronic, with Torn Meniscus and/or Ligament Laxity.
0201
Strain, Lumbosacral, Sacroiliac Joint, Chronic, All Cases.
0202
Eczema, Dermatitis, Seborrheic, Contact, Others, Affecting Weight Bearing and Pressure Areas.
0203
Eczema, Dermatitis, Seborrheic, Contact, Others, Not Affecting Weight Bearing Areas.
0204
Boils, Furuncles, Pyoderma, Requiring Surgery.
0205
Boils, Furuncles, Pyoderma, All Other Cases.
0206
Cellulitis, Involving Face or Weight Bearing Areas.
0207
Cellulitis, Other than Face or Weight Bearing Areas.
0208
Dermatophytosis, Severe—Affecting Feet.
0209
Dermatophytosis, All Other Cases.
0210
Pediculosis, All Cases.
0211
Scabies, All Cases.
0212
Pilonidal Cyst/Abscess, Requiring Incision and Drainage.
0213
Pilonidal Cyst/Abscess, Requiring Minor Incision.
0214
Ingrown Toenails, Bilateral, with Secondary Infections, Unresolvable at Level II.
0215
Ingrown Toenails, without Secondary Infection.
A-30
FM 4-02
0216
Herpes Simplex and Zoster, without Encephalitis, All Types, All Cases.
0217
Patient Condition Code Not Assigned.
0218
Patient Condition Code Not Assigned.
0219
Hyperhidrosis, All Cases.
0220
Blepharitis, All Cases.
0221
Conjunctivitis, Severe—All Cases.
0222
Conjunctivitis, Moderate, All Cases.
0223
Corneal Ulcer.
0224
Corneal Abrasion.
0225
Iridocyclitis, Acute, Marked Visual Impairment.
0226
Iridocyclitis, Acute, Minimal Visual Impairment.
0227
Refraction and Accommodation Disorders, Refraction Required.
0228
Refraction and Accommodation Disorders, Replacement of Spectacles Required.
0229
Otitis Externa, All Cases.
0230
Otitis Media, Acute, Suppurative, All Cases.
0231
Patient Condition Code Not Assigned.
0232
Allergic Rhinitis, All Cases.
0233
Upper Respiratory Infections, Acute, All Cases.
0234
Bronchitis, Acute, All Cases.
0235
Asthma, with Disabling Symptoms or Repeated Attacks.
0236
Asthma, Other Cases.
0237
Patient Condition Code Not Assigned.
0238
Patient Condition Code Not Assigned.
0239
Acute Respiratory Disease—Severe.
0240
Acute Respiratory Disease—Moderate.
0241
Patient Condition Code Not Assigned.
0242
Patient Condition Code Not Assigned.
0243
Food Poisoning, All Organisms, Disabling Symptoms.
0244
Food Poisoning, All Organisms, Moderate Symptoms.
0245
Diarrheal Disease, Severe.
0246
Diarrheal Disease, Moderate.
0247
Patient Condition Code Not Assigned.
0248
Gastritis, Acute, All Cases.
0249
Peptic Ulcer, Gastric or Duodenal, Penetrating and/or Perforating.
0250
Peptic Ulcer, Gastric or Duodenal, Uncomplicated.
0251
Regional Ileitis, Disabling Symptoms, Unresponsive to Treatment.
0252
Regional Ileitis, Responds to Treatment.
0253
Helminthiasis, All Cases.
0254
Patient Condition Code Not Assigned.
0255
Patient Condition Code Not Assigned.
0256
Hemorrhoidal Disease, All Cases.
0257
Patient Condition Code Not Assigned.
0258
Severe Hypertension.
0259
Ischemic Heart Disease.
0260
Phlebitis, Deep Vein Involvement.
A-31
FM 4-02
0261
Patient Condition Code Not Assigned.
0262
Tenosynovitis, Elbow, Wrist, Shoulders, and so forth.
0263
Meningo-Encephalitis, Uncomplicated.
0264
Meningo-Encephalitis, Complicated.
0265
Near Drowning without Cervical Spine Injury or Hypothermia, All Cases.
0266
Toxic Inhalation, Including Burn-Related Respiratory Injuries, Severe—All Cases.
0267
Patient Condition Code Not Assigned.
0268
White Phosphorus Burns, Resultant Partial Thickness Burns <40 percent TBSA, All Cases.
0269
Sexually Transmitted Diseases (STD), Urethritis.
0270
Sexual Transmitted Diseases (STD), Genital Ulcers and/or Adenopathy.
0271
Sexually Transmitted Diseases (STD), Complicated.
0272
Glomerulonephritis, Acute.
0273
Glomerulonephritis, Chronic.
0274
Pyelonephritis, Acute, Secondary to Obstruction.
0275
Pyelonephritis, Acute, No Obstruction.
0276
Nephrotic Syndrome, All Cases.
0277
Urethral Calculus, Causing Obstruction, Impacted.
0278
Urethral Calculus, Not Causing Obstruction.
0279
Epididymitis, Cystitis, Prostatitis, Acute, All Cases.
0280
Balanoposthitis, All Cases.
0281
Patient Condition Code Not Assigned.
0282
Infectious Mononucleosis, All Cases.
0283
Hepatitis, Infectious, Viral, All Causes.
0284
Patient Condition Code Not Assigned.
0285
Cholecystitis, Acute with Stones, All Cases.
0286
Pancreatitis, Acute, All Cases.
0287
Upper Gastrointestional (GI) Bleed, All Cases.
0288
Patient Condition Code Not Assigned.
0289
Neoplasms, Malignant.
0290
Neoplasms, Benign.
0291
Abnormal Uterine Bleeding.
0292
Dysmenorrhea.
0293
Pelvic Inflammatory Disease (PID), All Cases.
0294
Cervicitis, Endocervictis, with Symptomatic Leukorrhea.
0295
Vulvovaginitis.
0296
Amenorrhea.
0297
Tubal Pregnancy, All Cases.
0298
Patient Condition Code Not Assigned.
0299
Abortion, Spontaneous with Hemorrhage.
0300
Patient Condition Code Not Assigned.
0301
Psychosis.
0302
Misconduct.
0303
Non-Psychotic Mental Disorders.
0304
Stress Reaction, Severe.
0305
Dangerousness.
A-32
FM 4-02
0306
Alcohol Related Syndromes.
0307
Deleted.
0308
Deleted.
0309
Deleted.
0310
Stress Reaction, Mild/Moderate.
0311
Eye Wound, Lacerated, Penetrated with Retinal Injury, Eye Salvageable.
0312
Wound, Knee, Open, Lacerated, Penetrating, Perforating, with Joint Space Penetration, No
Bone or Articular Cartilage Injury.
0313
Wound, Abdominal Cavity, Open, with Lacerated, Penetrating, Perforating Wound, Kidney,
Moderate—Kidney Salvageable.
0314
Deleted.
0315
Deleted.
0316
Deleted.
0317
Drug Related Syndromes.
0318
Deleted.
0319
Wound, Fingers, Open, Lacerated, Contused, Crushed, with Fracture(s) of Phalangeals, Not
Requiring Rehabilitation.
0320
Patient Condition Code Not Assigned.
0321
Patient Condition Code Not Assigned.
0322
Fracture, Mandible, with/without Oral Laceration without Airway Involvement, Unstable, Severe,
Requiring Open Reduction.
0323
Fracture, Mandible, with/without Oral Laceration without Airway Involvement, Mild Displace-
ment, Stable.
0324
Deleted.
0325
Deleted.
0326
Patient Condition Code Not Assigned.
0327
Patient Condition Code Not Assigned.
0328
Animal Bites and Rabies Exposure.
0329
Trachoma, All Cases.
0330
Schistosomiasis, All Cases.
0331
Malaria, Severe—All Species.
0332
Malaria, Moderate—All Species.
0333
Febrile Illness, Acute, Severe—Except Malaria and Pneumonia.
0334
Febrile Illness, Acute, Moderate.
0335
Snake Bite.
0336
Patient Condition Code Not Assigned.
0337
Patient Condition Code Not Assigned.
0338
Patient Condition Code Not Assigned.
0339
Cutaneous Ulcers, including Leishmaniasis.
0340
Patient Condition Code Not Assigned.
0341
Patient Condition Code Not Assigned.
0342
Patient Condition Code Not Assigned.
0343
Patient Condition Code Not Assigned.
0344
Patient Condition Code Not Assigned.
0345
Patient Condition Code Not Assigned.
A-33
FM 4-02
0346
Eye Wound, Directed Energy Induced (Laser), Severe, of Macula and/or Optic Nerve, with
Vitreous Blood, Severe Visual Loss, One or Both Eyes.
0347
Eye Wound, Directed Energy Induced (Laser/radio frequency radiation [RFR]), Moderate to
Severe, Posterior, Nonmacular, Nonoptic Nerve, Visual Loss Secondary to Vitreous
Blood.
0348
Eye Wound, Directed Energy Induced (Laser), Moderate, Nonmacular, Nonoptic Nerve, No
Vitreous Blood.
0349
Eye Wound, Directed Energy Induced (Laser or RFR), Mild to Moderate, Anterior, Pain with
Photophobia and Disruption of Corneal Integrity.
0350
Eye Wound, Directed Energy Induced (Laser), Mild, Flash Blindness, No Permanent Damage.
0351
Anthrax, Inhalation, Nonvaccinated, Incubating, Asymptomatic.
0352
Anthrax, Inhalation, Nonvaccinated, Prodromal.
0353
Anthrax, Inhalation, Acute.
0354
Anthrax, Inhalation, Vaccinated, Asymptomatic.
0355
Anthrax, Inhalation, Vaccinated, Prodromal.
0356
Anthrax, Inhalation, Vaccinated, Acute.
0357
Plague, Inhalation, Incubating, Asymptomatic.
0358
Plague, Inhalation, Acute.
0359
Plague Meningitis.
0360
Botulism with Respiratory Failure.
0361
Botulism without Respiratory Failure.
0362
Staphylococcal Enterotoxin B with Respiratory Failure.
0363
Staphylococcal Enterotoxin B without Respiratory Failure.
0364
Venezuelan Equine Encephalitis with Central Nervous System Involvement.
0365
Smallpox, Incubating, Asymptomatic.
0366
Smallpox, Symptomatic.
0367
Tularemia, Inhalation, Incubating Asymptomatic.
0368
Tularemia, Inhalation, Acute.
0369
Ricin, Inhalation.
0370
Q Fever, Inhalation, Incubating, Asymptomatic.
0371
Q Fever, Inhalation, Acute.
0372
Botulism Exposure without Symptoms.
0373
Ebola/Marburg Virus Infection.
0374
Brucellosis, Inhalation.
0375
Through 0381 Patient Condition Code Not Assigned.
0382
Nerve Agent Vapor Only (Inhalation) Mild.
0383
Nerve Agent Vapor Moderate.
0384
Nerve Agent Vapor Severe.
0385
Nerve Agent Liquid Mild.
0386
Nerve Agent Liquid Moderate.
0387
Nerve Agent Liquid Moderately Severe.
0388
Nerve Agent Liquid Severe.
0389
Wound, Lower Leg, Open, Lacerated, Penetrating, without Fractures, Requiring Debridement,
Moderately Contaminated with Liquid Nerve Agent.
0390
Nerve Agent Combined Penetrating Abdominal Wound.
A-34
FM 4-02
0391
Mustard Liquid/Vapor Mild.
0392
Mustard Liquid/Vapor Moderate.
0393
Mustard Liquid/Vapor Severe.
0394
HD/Lewisite Combination, Mild.
0395
Phosgene Oxime.
0396
Cyanide (AC) Inhalation, Mild.
0397
Cyanide (AC) Inhalation, Severe.
0398
Pulmonary Agent with Early (<4 hours) Symptoms.
0399
Pulmonary Agent with Delayed (>4 hours) Symptoms.
0400
Anticholinergic Incapacitating Agent.
0401
White Phosphorus Injury, Skin Exposure.
0402
Radiation Exposure at Level R1(0.0 to 0.7 gray [Gy]) without Other Physical Injury. Radiophobia
not Addressed. No Data Available on this Potential Psychiatric Casualty Production Issue.
0402
Radiation Exposure at Level R1(0.0 to 0.7 gray [Gy]) without Other Physical Injury. Radiophobia
not Addressed. No Data Available on this Potential Psychiatric Casualty Production Issue.
0403
Radiation Injury at Level R2(0.7 to 1.25 Gy) without Other Physical Injury.
0404
Radiation Injury at Level R3(1.25 to 3.0 Gy) without Other Physical Injury.
0405
Radiation Injury at Level R4(3.0 to 5.0 Gy) without Other Physical Injury.
0406
Radiation Injury at Level R5(5.0 to 8.0 Gy) without Other Physical Injury.
0407
Radiation Injury at Level R6(8.0 to 15 Gy) without Other Physical Injury.
0408
Radiation Injury at Level R7(15+Gy) without Other Physical Injury.
0409
Patient Condition Code Not Assigned.
0410
Radiation R1/R2(0.0 to 1.25Gy) with Operative Trauma.
0411
Radiation R3/R4(1.25 to 5.0 Gy) with Operative Trauma.
0412
Radiation R5/R6/R7(>5.0 Gy) with Operative Trauma.
0413
Radiation R1/R2(0.0 to 1.25 Gy) with Nonoperative Trauma (Examples include Concussion,
Simple Lacerations, Closed Fractures, Ligamental Injuries, and so forth).
0414
Radiation R3/R4(1.25 to 5.0 Gy) with Nonoperative Trauma (Examples include Concussion,
Simple Lacerations, Closed Fractures, Ligamental Injuries, and so forth).
0415
Radiation R5/R6/R7(>5.0 Gy) with Nonoperative Trauma with Nonoperative Trauma (Examples
include Concussion, Simple Lacerations, Closed Fractures, Ligamental Injuries, and so forth).
0416
Atropine, Self-Injection.
0417
Patient Condition Code Not Assigned.
0418
Patient Condition Code Not Assigned.
0419
Patient Condition Code Not Assigned.
0420
Radiation R1/R2(0.0 to 1.25 Gy) with Mild Burn. Burns 1st and 2nd Degree Not Involving
Genitalia or Eyes.
0421
Radiation R3/R4(1.25 to 5.0 Gy) with Mild Burn. Burns 1st and 2nd Degree Not Involving
Genitalia or Eyes.
0422
Radiation R5/R6/R7(>5.0 Gy) with Mild Burn. Burns 1st and 2nd Degree Not Involving
Genitalia or Eyes.
0423
Radiation R1/R2(0.0 to 1.25 Gy) with Moderate Burn. Burns 2nd Degree 16 to 30 percent Body
Surface Area (BSA) or 3rd Degree 6 to 20 percent BSA Not Involving Head.
0424
Radiation R3/R4(1.25 to 5.0 Gy) with Moderate Burn. Burns 2nd Degree 16 to 30 percent BSA
or 3rd Degree 6 to 20 percent BSA Not Involving Head.
A-35
FM 4-02
0425
Radiation R5/R6/R7(>5.0 Gy)with Moderate Burn. Burns 2nd Degree 16 to 30 percent BSA or
3rd Degree 6 to 20 percent BSA Not Involving Head.
0426
Radiation R1/R2(0.0 to 1.25 Gy) with Severe Burn. Burns 2nd Degree >30 percent BSA or 3rd
Degree >20 percent BSA.
0427
Radiation R3/R4(1.25 to 5.0 Gy) with Severe Burn. Burns 2nd Degree >30 percent BSA or 3rd
Degree >20 percent BSA.
0428
Radiation R5/R6/R7(>5.0 Gy) with Severe Burn. Burns 2nd Degree >30 percent BSA or 3rd
Degree >20 percent BSA.
0429
Patient Condition Code Not Assigned.
0430
Radiation R1/R2 (0.0 to 1.25 Gy) with Operative Trauma and Mild Burn. Burns 1st and 2nd
Degree <15 percent BSA or 3rd Degree <5 percent BSA: Not Involving Genitalia or Eyes.
0431
Radiation R1/R2 (0.0 to 1.25 Gy) with Operative Trauma and Moderate Burn. Burns 1st and
2nd Degree 16 to 30 percent BSA or 3rd Degree 6 to 20 percent BSA: Not Involving Head.
0432
Radiation R1/R2 (0.0 to 1.25 Gy) with Operative Trauma and Severe Burn. Burns 1st and 2nd
Degree >30 percent BSA or 3rd Degree >20 percent BSA.
0433
Radiation R3/R4 (1.25 to 5.3 Gy) with Operative Trauma and Mild Burn. Burns 1st and 2nd
Degree <15 percent BSA or 3rd Degree <5 percent BSA: Not Involving Genitalia or Eyes.
0434
Radiation R3/R4/R5/R6/R7 (>1.25 Gy) with Operative Trauma and Moderate or Severe Burn.
Moderate Burns—2nd Degree 16 to 30 percent BSA or 3rd Degree 6 to 20 percent BSA: Not
Involving Head. Severe Burns—2nd Degree >30 percent BSA or 3rd Degree >20 percent
BSA.
0435
Radiation R5/R6/R7 (>5.3 Gy) with Operative Trauma and Mild Burn. Burns 1st and 2nd
Degree <15 percent BSA or 3rd Degree <5 percent BSA: Not Involving Genitalia or Eyes.
0436
Acute Glaucoma.
0437
Acute Traumatic Optic Neuropathy.
0438
Blunt Trauma to Eye; Retrobulbar Hemorrhage.
0439
Eye Conditions Caused By Herpes.
0440
Chemical Ocular Injury.
0441
Stress Reaction.
A-36
FM 4-02
APPENDIX B
MEDICAL INTELLIGENCE
B-1. Aspects of Medical Intelligence
Medical intelligence is that intelligence produced from the collection, evaluation, and analysis of information
concerning the medical aspects of foreign areas that have immediate or potential impact on policies, plans,
and operations. Medical intelligence also includes the observation of the fighting strength of enemy forces
and the formation of assessments of foreign medical capabilities in both military and civilian sectors. To
develop medical intelligence, information is gathered, evaluated, and analyzed on the following subjects:
• Endemic and epidemic diseases, public health standards and capabilities, and the quality and
availability of health services.
• Occupational and environmental health hazards (to include TIMs, environmental quality, and
industrial operations and/or industries) present in the AO.
• Health service logistics, to include blood products, MTFs, and the number of trained HSL
personnel.
• The location, specific diseases, strains of bacteria, lice, mushrooms, snakes, fungi, spores,
and other harmful organisms (toxic flora and fauna).
• Foreign animal and plant diseases, especially those diseases transmissible to humans.
• Health problems relating to the use of local food and water supplies.
• Medical effects of radiation and prophylaxis for BW and CW agents.
• The possible casualties that can be produced by newly developed foreign weapon systems.
• The health and fitness of the enemy’s force and his use of antidotes and immunizations.
• Areas of operations (such as altitude, extremes of temperature, and difficult terrain [swamps,
mountains, deserts, or urban]) that in some way may affect the health of the command or the conduct of
HSS operations.
B-2. Significance of Medical Intelligence
a. At the strategic level, the objective of medical intelligence is to contribute to the formulation
of national and international policy. The policy will be predicated in part on foreign military and civilian
capabilities of the medical or biological scientific community.
b. At the operational level, the objective of medical intelligence is to develop HSS strategies
that—
• Counter the medical threat. (Refer to FM 4-02.17, 4-25.12, FM 8-10-8, and FM 21-10.)
B-1
FM 4-02
• Are responsive to the unique aspects of a particular theater.
• Enable the commander to conduct his operation.
• Conserve the fighting strength of friendly forces.
B-3. Sources of Medical Intelligence
a. Medical intelligence is provided to the HSS planner by intelligence organizations. The HSS
planner must identify the intelligence requirements and provide that request to the supporting intelligence
element within the command or task force (TF). In an emergency, up-to-date medical intelligence
assessments can be obtained by contracting Director, AFMIC, 1607 Porter Street, Fort Detrick, Maryland
21702-5004. The message address is DIRAFMIC FT DETRICK MD. Medical intelligence elements
and AFMIC can provide Medical Capabilities Studies, Disease Occurrence—Worldwide Reports, Foreign
Medical Materiel Studies, the Disease and Environmental Alert Report, the Foreign Medical Facilities
Handbook, Scientific and Threat Intelligence Studies, Foreign Medical Materiel Exploitation Reports,
Quick Reaction Responses, and the AFMIC Wire. The HSS planner should use all available intelli-
gence elements to obtain needed intelligence to support the military operation. The AFMIC 24-Hour
Service/Request for Information telephone number is commercial (310) 619-7574 or DSN 343-7574. The
e-mail address is afmicops@afmic.detrick.army.mil. Refer to FM 8-10-8 for a discussion of medical
intelligence.
b. A supporting intelligence element should exist at some point in the medical unit’s chain of
command. This element will be the primary source for the HSS planner to access the necessary intelligence
for the execution of HSS operations. The HSS personnel must develop a feedback system with the
supporting intelligence element to provide as well as receive intelligence updates.
c.
For additional information on medical intelligence refer to FM 4-02.17 and FM 8-10-8.
B-4. Medical Intelligence Preparation of the Battlefield
a. Medical intelligence preparation of the battlefield is a systematic process that is designed to aid
HSS planners in analyzing various enemy, environmental, and medical threats in a specific AO. The MIPB
process is the first step in the mission analysis phase of the MDMP. The information derived from
conducting a proper MIPB is the cornerstone to developing detailed and effective HSS estimates and plans.
Some portions of the template will be more or less applicable depending on the assigned mission. The
purpose of MIPB is to—
• Define the battlefield environment.
• Describe the battlefield effects on deployed forces and HSS operations.
• Conduct threat integration (enemy and medical) and information consolidation.
B-2
FM 4-02
b. Some of the categories may seem contrived when applying them to stability operations and
support operations situations. The HSS planner must, therefore, interpret the categories and apply the
pertinent information or modify the category to fit the operational scenario. In some stability operations and
support operations scenarios, there may not be a recognizable enemy; the enemy and friendly situation
paragraphs of the MIPB can be thought of as negative and positive factors impacting on the successful
accomplishment of the HSS mission. For example, in a discussion of opposition groups, it is conceivable
that an organized opposition may not be apparent in a country where a FHA program or disaster relief effort
is being conducted. The HSS planner should, therefore, consider those situations and factors which could
foster an insurgency or the formation of opposition groups and focus the HSS operations to proactively
correct anticipated deficiencies, thereby eliminating the possible threat. For additional information and
considerations for stability operations and support operations refer to FM 8-42. For additional HSS
planning considerations refer to FM 8-10-8 and FM 8-55.
B-5. Medical Intelligence Preparation of the Battlefield Template
a. Define the Battlefield Environment.
(1) Identify significant characteristics of the environment.
(a) Geography. (This includes climate, weather, terrain [to include urban terrain], and
altitude. It may also contain information on possible weather/environmental threats such as earthquakes,
volcanoes, monsoons, or other such conditions.)
(b) Political and socioeconomic situation.
(This includes population demographics
[ethnic groups, religious groups, age distribution, income groups, culture, and language]; living conditions
of the general population; infant mortality rate; anticipated requirements for medical support of the local
population; refugee or displaced persons situation; role of clans, tribes, gangs, opposition groups, or
paramilitary organizations/groups; and, crime rates and the presence of organized crime.)
(c) Threat forces and capabilities.
(This includes enemy ideology, goals, objectives,
and mission; enemy attitude toward the Geneva Conventions; order of battle [in broad terms]; enemy force
structure and weapons systems; enemy capability to generate friendly casualties and the types of wounds/
injuries anticipated; enemy medical doctrine and capabilities [are US forces likely to treat significant
numbers of enemy wounded; what is the overall health status of the enemy such as significant endemic/
epidemic diseases present and/or immunization status]; NBC casualties [include type of weapons/agents,
delivery systems, doctrine for use, and ability to sustain operations in an NBC environment]; medical
logistics structure [quality, quantity, availability, and types of medical equipment]; potential for terrorist
actions and the availability and probability of the use of NBC weaponry/devices; enemy psychological
operations [PSYOP] and unconventional warfare [UW] capability).
(d) Infrastructure.
(The infrastructure includes transportation systems [land, sea, and
air]; communications systems [telephone, cellular, digital, mass media, and electronic means]; and, utilities
[water, electricity, and sanitation].)
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FM 4-02
(e) Medical infrastructure. (This includes location and availability of medical facilities;
quality and type of medical facilities
[names and contact information for practitioners and health
administrators are useful]; capabilities of medical facilities [size, patient capacity, and types of specialties];
education and training levels of health services professionals and ancillary support personnel; will enemy
forces use or have access to civilian medical system; are medical facilities approved for use by US, allied, or
coalition forces; quality and availability of medical supplies and pharmaceuticals [do pharmaceuticals meet
FDA standards?]; availability and quality [to include testing requirements in accordance with the American
Blood Banking Association standards] of blood and blood products; evacuation capability, services, and
availability [to include names and contact information]; location of helipads, railheads, airheads, and sea-
ports; and location of medical waste incinerators, disposal areas, and/or availability of contract support.)
(f)
Medical threat.
(Refer to Table B-1 for a medical threat checklist.)
Table B-1. Medical Threat Checklist
MEDICAL THREAT CHECKLIST
DISEASES
ENDEMIC AND EPIDEMIC
FOODBORNE
WATERBORNE
ARTHROPODBORNE
ZOONOTIC
VECTORS AND BREEDING GROUNDS
OCCUPATIONAL AND ENVIRONMENTAL HEALTH HAZARDS
CLIMATIC (HEAT, COLD, HUMIDITY, AND SIGNIFICANT
ELEVATIONS ABOVE SEA LEVEL)
TOXIC INDUSTRIAL MATERIALS
ACCIDENTAL OR DELIBERATE DISPERSION OF RADIO-
LOGICAL AND BIOLOGICAL MATERIEL
DISRUPTION OF SANITATION SERVICES/FACILITIES
(SUCH AS SEWAGE AND WASTE DISPOSAL)
DISRUPTION OF INDUSTRIAL OPERATIONS OR INDUS-
TRIES
NOISE
POISONOUS OR TOXIC FLORA AND FAUNA
POISONOUS REPTILES, AMPHIBIANS, ARTHROPODS,
AND ANIMALS
TOXIC AND POISONOUS PLANTS
MEDICAL EFFECTS OF WEAPONS
CONVENTIONAL
NUCLEAR, BIOLOGICAL, AND CHEMICAL
DIRECTED ENERGY
WEAPONS OF MASS DESTRUCTION
PHYSIOLOGIC AND PSYCHOLOGICAL STRESSORS
CONTINUOUS OPERATIONS
BATTLE FATIGUE
WEAR OF MISSION-ORIENTED PROTECTIVE POSTURE
ENSEMBLE
STABILITY OPERATIONS AND SUPPORT OPERATIONS
HOME FRONT ISSUES
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FM 4-02
(g) Nongovernmental organizations operating in the AO. (This includes such organiza-
tions as the International Committee of the Red Cross [ICRC] and Doctors without Borders.)
(2) Identify the limits of the command AO. (The command AO is the geographic area where
the commander is assigned the responsibility and authority to conduct military operations.)
(a) Identify the geographic AO.
(This may include the macroview or the microview
depending upon the level of command and the size of the geographic area.)
(b) Identify the total population at risk.
(This should include all US, allied, coalition,
or HN forces, local civilian population, refugees, displaced persons, employees and/or contractors of the
US Government, and NGO personnel. In addition to identifying the total population at risk, the planner
must also determine what the supported population at risk is [those individuals/groups deemed as eligible
beneficiaries for health care provided by US Army HSS assets (refer to Appendix F)].)
(c) Identify all supported US units. (This includes sister Services and elements from US
governmental agencies and contractors.)
(d) Identify all supported allied, coalition, HN, or other multinational units/elements.
(This paragraph should discuss unit troop strengths, locations and missions. It may also include organic
medical resources and capabilities; multinational medical assets [military, paramilitary, and civilian] which
are approved for use for US personnel; identification of multinational [military, paramilitary, and civilian]
requirements; identification of unique medical support requirements [such as endemic diseases in the allied
and coalition forces that are not present in the deployment (HN) AO]; and, the current level of health and
dental fitness among the supported populations.)
(3) Establish limits of the area of interest (AI).
(The AI is a geographic area from which
information is required to facilitate planning. The AI usually falls outside the AO and may or may not be
applicable to a particular operation. The AI would be of interest in instances where portions of the overall
HSS plan fall outside the AO.)
(a) Health service support is being provided by organizations/elements outside of the
AO.
(This can include organizations such as CONUS-support base hospitals, HSL support [DLA or
USAMMA], and global patient regulating support [such as the GPMRC]).
(b) Location and time/distance factors for HSS resources that could be used for
augmenting/reinforcing/reconstituting HSS units/personnel within the AO.
(This can include information
on units/elements in the CONUS-support base or adjacent theaters.)
(c) Coordination and synchronization with C2 assets outside the AO.
(d) Follow-on operations or operations being conducted simultaneously outside the
AO.
(4) Identify the level of detail required and the time available to conduct MIPB.
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FM 4-02
(5) Evaluate existing information/intelligence of medical significance and identify intelligence
gaps.
(Sources include: AFMIC; Defense Intelligence Agency [DIA]; USACHPPM; country studies;
supporting Intelligence Officer, US Army [S2]/Assistant Chief of Staff
[Intelligence]
[G2] or military
intelligence unit; Central Intelligence Agency [CIA] World Fact Book; open source information system
[OSIS]; tourist maps and brochures; PVNTMED resources; WHO; PAHO; Department of State; and,
internet, libraries, and other informational sources.)
(6) Identify and submit collection requirements to support intelligence staff sections/elements/
units.
(7) Collect required information to fill gaps.
NOTE
Should HSS personnel gain information of potential intelligence value
through casual observation of activities in plain view while in the
performance of their humanitarian duties, they are required to report
it to their supporting intelligence element (S2/G2). Refer to FM 8-10-8
for additional information.
b. Describe the Battlefield Effects. The purpose of this phase of the MIPB process is to analyze
and integrate various factors of the battlefield environment (paragraph a above). Detailed analysis of these
factors, to determine the military significant effects, results in medical intelligence upon which the
commander can make informed decisions. The emphasis is on the effects on friendly forces as well as
friendly and enemy actions.
(1) Geography.
(a) Climate and weather effects.
(Information contained here includes the effects of
extreme heat/cold/humidity; effects of the predominant weather patterns [such as monsoons]; effects of
heavy rains or snow; the phase of the moon and its effect on operations [such as fullness/brightness when
military forces are infiltrating an area]; how the weather may be effected by enemy BW and CW agents use;
and, climatic effects on medical supplies and equipment.)
(b) Terrain analysis.
(Terrain analysis includes determining the effect on friendly/
enemy maneuver capability; effect on friendly/enemy ability to sustain health care; effects on timely medical
evacuation; natural lines of patient drift; impact on MTF site selection factors; where the mobility corridors
are located and their effects on friendly/enemy actions; effects of weather conditions on terrain/mobility;
effect of overhead cover [canopy] and vegetation; effect on projected combat action on terrain/mobility;
and, where potential sources of potable water are located.)
(c) Altitude effects.
(This includes effect of high altitude operations on force capability,
rotary wing evacuation assets, and standard medical treatment protocols.)
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FM 4-02
(2) Political and socioeconomic situation.
(a) Population demographics.
(This includes the effect on the delivery of HSS to
supported forces; effect on the HSS system if required to support the local populace and NGOs; what are the
political effects of providing care/not providing care to the HN populace, NGOs, refugees, and displaced
persons; effects of cultural, religious, or language barriers.)
(b) Condition of the general population (and/or supported population).
(This category
includes an analysis of the health of the general population and the impact of it on deployed forces; analysis
of the infant mortality rate as this serves as an indicator of the overall health of the population; status of
nutrition; and, state of advancement of the medical infrastructure [see paragraph (5) below].)
(c) Effect clans, tribes, gangs, opposition groups, or paramilitary organizations/groups
and organized crime on the ability to provide HSS to deployed forces and other eligible beneficiaries.
(d) What affect/additional requirements will refugees, internally displaced persons
(IDPs), detainees/retainees, and EPWs have on the HSS system?
(This is of particular importance for the
PVNTMED arena as camps require sanitation, pest management, and potable water support. Other
requirements include provision of sick call services, outpatient treatment, hospitalization, medical evacuation,
HSL support [to include sorting, repackaging, inventorying, and disseminating donated medical supplies
and equipment], and other functional area concerns.)
(3) Threat forces capabilities/effects.
(a) Effects of enemy ideology, goals, and missions. (This category includes an analysis
of the enemy’s will to fight; what they are trying to accomplish and why [military objectives]; compliance
with the Geneva Conventions; type of enemy forces [such as paramilitary, conventional, special operations
and/or terrorists]; philosophy concerning collateral damage, civilian casualties, disruption of utilities
[sewage, waste disposal, sanitation, water, electricity, and gas], and, generating refugees or displaced
persons.)
(b) Order of battle.
(The order of battle includes the affects enemy doctrine has on
deployed forces, to include medical personnel and units. This information facilitates forecasting what
friendly units/elements/organizations are most likely to sustain heavy casualties.)
(c) Enemy force structure and weapons systems.
(This category includes the analysis
of the accuracy and range of enemy weapons systems; analysis of the size and composition of the enemy
force; and, what types of friendly wounds will be generated by enemy weapons systems [such as piercing,
concussion, blunt trauma, burns, or combined injuries].)
(d) Enemy medical doctrine/capabilities.
(This includes the analysis of enemy medical
doctrine and capabilities; priority and availability of medical care and medical evacuation; do they have the
infrastructure and training to accomplish the HSS mission; and, the potential for them to treat their own
casualties or to leave them for friendly forces to take care of.)
B-7
FM 4-02
(e) Effects of enemy NBC weapons. (This category includes an analysis of enemy NBC
capabilities; effect of enemy NBC use on friendly forces; the likelihood of its use; whether the enemy can
continue the mission in an NBC environment; and whether the enemy’s delivery systems are accurate,
reliable, and effective.)
(f)
Psychological and unconventional warfare capabilities and effects.
(This includes
an analysis of the probable impact of PSYOP on friendly forces; analysis of UW capabilities; probability of
UW forces targeting friendly rear areas and HSS assets/resources; and, the effect UW will have on the
delivery of health care.)
(4) Infrastructure.
(a) Transportation systems.
(Transportation systems include the effect of available
transportation systems on timely medical evacuation and/or CASEVAC, HSL supply/resupply operations;
analysis of likely avenues of approach; effect of the transportation system on mobility and military operations;
effect of military operations on the transportation system; and, impact of transportation networks on enemy/
friendly COAs.)
(b) Communication systems architecture.
(What types of communications networks
currently exist? What is the level of technology for these systems? What is the level of access of the
communications infrastructure by the population [Do families have: Radios? Televisions? Telephones?
Computers?].)
(c) Utilities (water, electricity, and sanitation).
(This includes the analysis of water
quality [potability] and distributions systems; analysis of the reliability of electrical power generation;
effectiveness and efficiency of sanitation systems; effects of enemy/friendly military actions on the utilities
infrastructure; and, the impact a disruption of utilities would have on the health of the general population
and/or deployed forces.)
(d) Industries.
(This includes the types of industry present, their effect on the economy,
and the potential threat from TIMs either used in the manufacturing process or as an end product.)
(5) Medical infrastructure.
(a) Analysis of the overall medical system:
(A checklist for assessing the foreign
medical infrastructure is provided in Table B-2.)
(b) Analysis of indigenous medical facilities.
(A checklist for assessing foreign MTF
capabilities and services is provided in Table B-3.)
(c) Analysis of local medical supply and equipment sources.
(This category includes
an analysis of local quantity, quality, and availability of local medical supplies and equipment; analysis of
the availability of blood and blood products [see paragraph a(1)(e) above]; availability of supplies for use
for local populace, refugees, IDPs, retained/detained persons, and EPWs [to include donated supplies or
those of an NGO/international organization such as the UN]; availability of supplies approved for use by US
B-8
FM 4-02
forces [see paragraph a(1)(e) above]; analysis of local medical supply production facilities; impact of
military operations on the local medical supply infrastructure; and, availability and quality of medicinal
gases.)
Table B-2. Checklist for the Analysis of Foreign Medical System
HEALTH SERVICES
PUBLIC HEALTH SYSTEM/SERVICES.
NUMBER OF PUBLIC HEALTH PERSONNEL, FACILITIES, AND CAPABILITIES.
HOSPITALS BY TYPE AND LOCATION (SUCH AS GENERAL MEDICAL, PSYCHIATRIC, OR ORTHOPEDIC).
NUMBER OF HOSPITAL BEDS BY TYPE (SUCH AS SURGICAL, INTENSIVE CARE, OR GENERAL MEDICINE).
NUMBER OF OR TABLES AND TABLE HOURS.
MEDICAL CLINICS (PRIVATE OR PUBLIC) AND LOCATIONS.
NUMBER OF PHYSICIANS PER POPULATION.
NUMBER OF PHYSICIANS BY SPECIALTY.
ANCILLARY SERVICES AVAILABLE (SUCH AS PT, OT, ORTHOTICS CAPABILITY, COMMUNITY HEALTH
NURSES, MAGNETIC RESONANCE IMAGING, COMPUTED TOMOGRAPHY [CT] SCAN, OR RESPIRATORY
THERAPY).
NUMBER OF NONPHYSICIAN HEALTH CARE PROVIDERS (SUCH AS PHYSICAL THERAPISTS, OCCUPATIONAL
THERAPISTS, NURSE PRACTITIONERS, PODIATRISTS, OR OPTOMETRISTS) BY TYPE.
MEDICAL EVACUATION/CASUALTY TRANSPORT SYSTEMS (PUBLIC, PRIVATE, AND MILITARY GROUND AND
AIR AMBULANCES).
NUMBER OF DENTAL PROVIDERS AND TYPES OF DENTAL CARE AVAILABLE (SUCH AS EMERGENCY AND
ESSENTIAL CARE AND/OR ORAL SURGERY).
NUMBER OF MH CLINICS AND AVAILABLE SERVICES.
NUMBER AND TYPES OF MH PERSONNEL (SUCH AS PSYCHOLOGISTS, SOCIAL WORKERS, AND THE LIKE).
NUMBER AND TYPES OF MEDICAL RESEARCH FACILITIES.
VETERINARY MEDICINE PERSONNEL, FACILITIES, AND CAPABILITIES.
PHARMACEUTICAL MANUFACTURING.
AVAILABILITY AND TYPES OF MEDICAL EQUIPMENT, MEDICAL EQUIPMENT REPAIR, AND MEDICAL SUP-
PLIES.
AVAILABILITY, COLLECTION CAPABILITIES, AND QUALITY OF BLOOD AND BLOOD PRODUCTS.
AVAILABILITY, QUALITY, AND PRODUCTION CAPABILITY OF MEDICINAL GASES.
OPTICAL FABRICATION CAPABILITIES.
NUMBER, TYPES, AND CAPABILITIES OF MEDICAL LABORATORIES.
NAMES AND TITLES OF KEY PERSONNEL WITHIN THE PUBLIC AND PRIVATE HEALTH CARE INFRASTRUC-
TURES.
NUMBER, TYPES, AND LOCATION OF MEDICAL SCHOOLS OR MEDICAL TRAINING CENTERS.
DETERMINE THE LEADING CAUSES OF DEATH OF THE GENERAL POPULATION OR SPECIFIED SUB-
POPULATIONS.
DETERMINE THE PREVALENCE OF ENDEMIC AND EPIDEMIC DISEASES IN THE AO.
DETERMINE THE PREVALENCE OF HUMAN IMMUNODEFICIENCY VIRUS (HIV)/ACQUIRED IMMUNODEFI-
CIENCY SYNDROME (AIDS).
DETERMINE THE ENVIRONMENTAL HEALTH RISK (TO INCLUDE HEAT AND COLD INJURY, EXPOSURE TO
TIMS, AND POISONOUS OR TOXIC FLORA AND FAUNA).
NUTRITIONAL STATUS OF THE GENERAL POPULATION OR SPECIFIED SUBPOPULATIONS.
DETERMINE IMMUNIZATION LEVEL OF GENERAL POPULATION OR SPECIFIED SUBPOPULATIONS.
B-9
FM 4-02
Table B-3. Checklist for the Assessment of a Foreign Medical Treatment Facility
MEDICAL TREATMENT FACILITY CHECKLIST
IS THE MEDICAL FACILITY A PRIVATE, PUBLIC, OR MILITARY INSTITUTION?
IS THE MEDICAL FACILITY A HOSPITAL, CLINIC (SUCH AS OUTPATIENT, EMERGENCY, OR SUBSTANCE
ABUSE), DOCTOR’S OFFICE, LONG-TERM/REHABILITATIVE CARE FACILITY?
WHERE IS THE FACILITY LOCATED? HOW ACCESSIBLE IS IT (SUCH AS ON A MAJOR THOROUGHFARE, ON
SIDE STREETS OR ACCESSIBLE BY AIR)?
WHAT TYPE OF CARE DOES THE FACILITY PROVIDE (SUCH AS EMERGENCY AND GENERAL MEDICINE,
SURGICAL, ORTHOPEDIC, MATERNITY/OBSTETRICS, PEDIATRIC, PSYCHIATRIC, REHABILITATIVE, OR
LONG-TERM CARE)?
WHAT ARE THE NUMBER AND TYPES OF BEDS (SUCH AS SURGICAL, INTENSIVE CARE, OR GENERAL
MEDICINE)?
WHAT ANCILLARY SERVICES ARE AVAILABLE (SUCH AS PT, OT, RESPIRATORY THERAPY, DIAGNOSTIC
X-RAY, NUCLEAR MEDICINE, OR DIAGNOSTIC LABORATORY SERVICES)?
WHAT IS THE STAFFING LEVEL OF THE FACILITY?
DOES THE FACILITY PROVIDE OUTPATIENT SERVICES? IF SO, WHAT TYPES OF CARE?
WHAT IS THE STANDARD OF CARE PROVIDED AT THE FACILITY? HOW DOES IT COMPARE TO US FACILI-
TIES?
HOW ARE MEDICAL PROFESSIONALS CREDENTIALED? WHAT IS THEIR SCOPE OF PRACTICE?
WHAT IS THE NOSOCOMIAL INFECTION DISEASE RATE FOR THE FACILITY?
DOES THE FACILITY HAVE THE CAPABILITY TO ISOLATE INFECTIOUS DISEASE PATIENTS?
WHAT IS THE PATIENT ACCIDENT/INJURY RATE FOR THE FACILITY (SUCH AS FALLING OUT OF BED, INJURY
CAUSED BY FAULTY EQUIPMENT, OR THE LIKE)?
WHAT TYPES OF MEDICAL EQUIPMENT ARE AVAILABLE IN THE FACILITY (SUCH AS DIAGNOSTIC [CT SCAN
OR MAGNETIC RESONANCE IMAGING], REHABILITATIVE, OR PATIENT CARE [VENTILATORS, RESPIRA-
TORS, OR ORTHOPEDIC])?
WHAT TYPES OF SUPPORT SERVICES ARE AVAILABLE (SUCH AS LAUNDRY, HOUSEKEEPING, OR FOOD
SERVICE)? ARE THERE SHARED SERVICES WITH ANOTHER FACILITY? IF NOT, HOW ARE PATIENTS FED
(SUCH AS BY RELATIVES)?
DOES THE FACILITY HAVE AN EMERGENCY ROOM? IS IT STAFFED AND EQUIPPED TO PROVIDE TRAUMA
CARE?
WHAT IS THE CAPACITY OF THE FACILITY TO RESPOND TO A MASS CASUALTY SITUATION (RESULTING
FROM UO, TERRORIST INCIDENTS, MAN-MADE OR NATURAL DISASTERS, OR EMPLOYMENT OF NBC
WEAPONS)?
WHAT IS THE LEVEL OF MEDICAL SUPPLIES MAINTAINED WITHIN THE FACILITY (DAYS OF SUPPLY)?
HOW IS THE FACILITY RESUPPLIED WITH EXPENDABLE AND NONEXPENDABLE MEDICAL SUPPLIES? ARE
MEDICINES READILY AVAILABLE OR MUST THEY BE OBTAINED ON AN INDIVIDUAL CASE BASIS? IS
LOCAL VEGETATION COLLECTED AND USED FOR MEDICINAL PURPOSES?
DOES THE FACILITY HAVE THE CAPABILITY TO COLLECT, TEST, AND STORE BLOOD? WHAT DISEASES IS
THE BLOOD TESTED FOR?
IF THE FACILITY CAN NOT COLLECT AND TEST BLOOD, WHERE DO BLOOD AND BLOOD PRODUCTS COME
FROM? HAS IT BEEN TESTED? DOES THE FACILITY HAVE A REFRIGERATED STORAGE CAPABILITY?
WHAT IS THE MAXIMUM NUMBER OF UNITS OF BLOOD WHICH CAN BE STORED?
DOES THE FACILITY HAVE ITS OWN AMBULANCES (NUMBER AND TYPE [AIR AND GROUND]) OR IS THIS A
SERVICE WHICH IS PROVIDED BY ANOTHER AGENCY/BUSINESS?
IS THE HOSPITAL ACCREDITED BY ITS PARENT NATION AND/OR HOSPITAL ORGANIZATION (SUCH AS IN
THE US BY THE JOINT COMMISSION ON THE ACCREDITATION OF HOSPITAL ORGANIZATIONS [JCAHO])?
DOES THE FACILITY PERFORM ITS OWN MEDICAL EQUIPMENT MAINTENANCE OR MUST BE IT SENT OUT
FOR REPAIR?
B-10
FM 4-02
Table B-3. Checklist for the Assessment of a Foreign Medical Treatment Facility (Continued)
MEDICAL TREATMENT FACILITY CHECKLIST
• DOES THE FACILITY HAVE DEPENDABLE ELECTRIC SERVICE? DOES IT HAVE A BACKUP GENERATOR FOR
POWER OUTAGES?
• DOES THE FACILITY HAVE RUNNING WATER? IF NOT, FROM WHAT SOURCE DOES THE STAFF OBTAIN
WATER? IS IT POTABLE OR DOES IT NEED TO BE TREATED BEFORE USE?
• DOES THE FACILITY HAVE AN OPERATIONAL ENVIRONMENTAL CONTROL SYSTEM? HEAT? AIR CONDITION-
ING?
• WHAT SANITATION FACILITIES ARE AVAILABLE IN THE FACILITY? RESTROOMS FOR PATIENTS AND STAFF?
BATHTUBS/SHOWERS FOR PATIENTS? HAND WASHING STATIONS/CAPABILITIES IN PCAS? DISPOSAL
CAPABILITIES FOR GENERAL, MEDICAL, AND HUMAN WASTE? DISPOSAL CAPABILITIES FOR WASTE
WATER?
• DOES THE FACILITY HAVE A PEST MANAGEMENT PROBLEM (RATS, ANTS, FLIES, LICE, AND/OR OTHER
ANIMALS AND INSECTS)?
• OTHER. ANY OTHER ISSUES, CONCERNS, OR SITUATIONS WHICH AFFECT THE SPECIFIC FACILITY BEING
EVALUATED.
(d) Analysis of medical evacuation services.
(This includes analysis of local medical
evacuation services and capabilities; coordination and synchronization of local evacuation services/resources
to redirect civilian patients; availability of and quality of local MTFs; and, impact of military operations on
local evacuation services.)
(e) Affects of disease and other OEH threats. (This category includes the identification
of disease and OEH threats that affect friendly forces and the delivery of HSS; identification of PVNTMED
measures which are required to counter the medical threat; analysis of the affect of PVNTMED measures on
friendly forces; analysis of the impact that disease and environmental threats have on enemy actions; and,
the identification of additional disease and environmental health hazards which may be created and/or
aggravated by military operations.)
(6) Analysis of services provided by NGOs and other international organizations.
c.
Threat Integration and Information Consolidation. (The object of threat integration is to relate
how essential elements of information [EEI] identified in Phase I and II of the MIPB process will affect the
health of the command, the employment of HSS resources, as well as enemy/friendly COAs as they pertain to
HSS issues. Further, information that is gathered relating to resources and background information, should
be consolidated in a usable format for use as the need arises. Some useful formats for managing information
and medical intelligence include overlays, spreadsheets, matrices, and databases.)
(1) Threat integration can be broken down into three major categories. It is important to
note that in each category the threat relates only to the health of the command or HSS issues. Similarly, the
type of threat can vary greatly with the type of mission or operation (offensive, defensive, stability
operations, and support operations). These categories are—
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FM 4-02
• Friendly COAs.
(What friendly COAs are best supported from a HSS standpoint?
What friendly HSS COAs best support the mission?)
• Enemy COAs.
(What probable enemy COAs could affect friendly HSS units/
resources/services?)
• Geographic-related threat issues.
(This category includes climatic/weather-related
threats and their impact on the need for and delivery of HSS and terrain-related issues that can best be
depicted by creating a modified combined obstacle overlay.)
(2) Consolidation of additional elements of medical information/intelligence into formats that
are user friendly and available for future planning or other possible contingencies. Databases are particularly
useful for managing general information.
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